Borderline Personality Disorder (BPD) is a disorder of instability: in emotions, thought patterns, beliefs, behaviors, interpersonal relationships and sense of self. There is a lot of stigma around this serious mental health condition which can be difficult to treat. Typically diagnosed from early adulthood on, most of the time BPD symptoms gradually decrease with age. Some people’s symptoms disappear in their 40s. With the right treatment, many people with BPD learn to manage and improve their quality of life [1].

In this article, I explore symptoms of BPD, treatment goals, the importance for people with BPD to obtain treatment and how to help someone with BPD. 

BPD Symptoms and Diagnosis

Emotional dysregulation is a core feature of BPD. Some research suggests BPD patients grow up in homes in which neglect or overtly expressed aggression is more tolerated, or at least more openly experienced. 

People with BPD may have the following symptoms:

• Great emotional instability in reaction to day-to-day events
• Impulsive behavior
• Chronic feelings of emptiness
• Frantic efforts to avoid real or imagined abandonment
• Unstable self-image
• Rapidly switch between idealizing others and devaluing them (“splitting”).
• Intense emotions
• Unstable relationships
• Impulsive behavior that is self-damaging
• Inappropriate, intense anger or difficulty controlling anger
• Suicidal threats and self-harming behavior 
• Periodic paranoid thoughts and dissociative symptoms

Recurrent suicidal behavior is reported in 69-80% of patients with BPD, and suicide rates are estimated to be up to 10% [2].

Treatment of Borderline Personality Disorder

BPD is often misdiagnosed, most commonly as Bipolar Disorder, which also has unstable moods, but lasting weeks or months whereas mood shifts can happen within a day for those with BPD. Misdiagnosis can result in a delay or even prevent recovery.

BPD often co-occurs with other mental illnesses such as post-traumatic stress disorder (PTSD) in about half of people with BPD. Sometimes the symptoms overlap. This can make it harder to diagnose and treat appropriately. Women with BPD are more likely to have co-occurring disorders such as major depression, anxiety disorders, substance abuse or eating disorders. In men, BPD is more likely to accompany disorders such as substance abuse or antisocial personality disorder [1]

Goals of Treatment for BPD

BPD historically has been viewed as untreatable or difficult to treat. But there is hope for those with BPD. Newer evidence-based approaches have changed this reality and begun to diminish the stigma around BPD. Yet, effective treatment takes time. There are no evidence-based medications for BPD but they may help with co-occurring disorders such as depression and anxiety.

Five major approaches have been established as evidence-based treatments, summarized below [3]:

• Dialectical Behavior Therapy (DBT)
• Mentalization-based treatment (MBT)
• Schema-focused therapy (SFT
• Transference-focused therapy (TFP)
• Systems training for emotional predictability and problem solving (STEPPS)

Dialectical Behavior Therapy (DBT) was developed specifically for people with BPD. It is based on some concepts from Cognitive Behavioral Therapy combined with mindfulness, being aware of and attentive to the current situation and moods.

Through individual and group therapy, DBT is designed so individuals with BPD can become more effective in managing their sensitivities and interactions with others. They can do this through learning skills that enhance mindfulness and enable them to:

• Become more mindful of themselves and others
• Be more emotionally regulated with their often very intense emotions
• Better tolerate distress
• Reduce self-destructive behaviors
• Manage relationships 

Mentalization-Based Treatment (MBT), developed in the UK, refers to the ability humans have to learn to imagine (mentalize) one’s own and others’ thoughts in understanding interpersonal interactions. Those with BPD have a history of disorganized and insecure attachment to primary caregivers that leads to problems in emotion regulation, attention and self control.   As a result, they have a reduced ability to mentalize. This leads to issues with their emotional regulation and difficulties managing impulsivity, especially with others.

MBT strengthens a person’s capacity to mentalize in stressful moments of attachment dynamics. Mentalization is how we make sense of each other and ourselves, implicitly and explicitly [2].  MBT therapists support patients to think through hyperactivated states themselves, rather than providing prepackaged or intellectualized explanations, insights, or skills. MBT helps a person note their thoughts and feelings and see things differently. It stresses thinking before reacting. One of the advantages is that it requires less intense training than methods like DBT and is therefore more accessible to a wider audience and at lower cost to health systems.

Schema-Focused Therapy (SFT) is a form of cognitive psychotherapy that focuses on identifying and changing ways of unhealthy thinking. They are called maladaptive schemas, of which there are four:

• Detached protector
• Punitive parent
• Abandoned/abused child
• Angry/impulsive child

SFT is based on the concept that these schemas develop when core childhood needs are met inadequately. SFT focuses on developing healthier alternatives to negative patterns of thinking, feeling and behaving so they no longer control a person’s life. SFT promotes an attachment between therapist and client called “limited re-parenting”.  

Transference-Focused Psychotherapy (TFP) is a psychoanalytically-oriented form of psychotherapy. It focuses on the person’s problematic interpersonal dynamics and their impact giving rise to intense emotional states. Similar to MBT, TFP helps people achieve more balanced, integrated and coherent ways of thinking about oneself and others.

Systems Training for Emotional Predictability and Problem Solving (STEPPS). As a complement to other approaches, STEPPS is composed of cognitive behavioral elements, skills training and a systems component. Structured as a 20-week program, people work in groups with their family members, caregivers, friends or significant others. 

Generalist approaches: There also two generalist approaches developed in the US and UK respectively that require less resources and training to deliver: 

• General Psychiatric Management (GPM)
• Structured clinical Management (SCM)

Group therapy may also help people with BPD interact with others more positively and express themselves effectively.

The Importance of BPD Treatment

Untreated, BPD can be difficult to cope with and hard for loved ones and colleagues as well. So treatment is very important and can be life-changing. Learning to overcome BPD focuses largely on making sense of difficult emotional moments by thinking about what happened in the relationships that led to those moments. Treatment approaches for BPD typically involve one of the above therapies and medication for symptom relief of any co-occurring disorders. 

How to Help Someone Suffering from BPD

Here are a few of the most important ways you can help someone with BPD:

Offer Safety and Respect: People with BPD have an insecure identity. Showing these values can help them feel safer and more connected.

Offer Trust: Due to the attachment issues of people with BPD, it’s important for you to be trustworthy and reliable. 

Manage Conflict: People with BPD may experience a conflict as a rejection or abandonment. let go of the behavior. 

Focus on Strengths: Given the insecurity of people with BPD, it’s important to support their strengths whenever possible. 

Communication: Given the distorted communication patterns of those with BPD, careful listening (with maximum patience) is the first step, especially if they are raging and abusive. 

Recommend Professional Help:  There is therapy for BPD, specifically Dialectical Behavior Therapy which was developed for this purpose as an offshoot and evolution of Cognitive Behavioral Therapy. Individual psychotherapy and medication may also be helpful

Corner Canyon Can Help

Treatment is available in Utah. If you or a loved one are looking for a compassionate space  to heal from mental health issues such as borderline personality disorder with our licensed professional counselors, reach out to our Admissions team now at Corner Canyon Health Centers. We’re in a peaceful setting bordered by the beautiful Wasatch Mountains.

Sources

[1] Treating BPD. National Education Alliance for Borderline Personality Disorder.

[2] Bateman A, et al. 2010. Mentalization based treatment for borderline personality disorder. World Psychiatry. 2010 Feb;9(1):11-5. 

[3] Choi-Kain L. et al. 2017. What Works in the Treatment of Borderline Personality Disorder. Curr Behav Neurosci Rep. 2017;4(1):21-30.