Management of borderline personality disorder

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.

Psychotherapy

There has traditionally been skepticism about the psychological treatment of

DBT draws its principles from behavioral science (including cognitive-behavioral techniques), dialectical philosophy and Zen practice. The treatment emphasizes balancing acceptance and change (hence dialectic), with the overall goal of helping patients not just survive but build a life worth living. Treatment is delivered in four stages, with self-harm and other life-threatening issues taking priority. In the second stage, patients are encouraged to experience the painful emotions that they have been avoiding. Stage three addresses problems of living such as career and marital problems. Finally, stage four focuses on helping clients feel complete and reducing feelings of emptiness and boredom.

DBT encompasses four modes of therapy:

• The first mode is traditional individual therapy between a single therapist and client.
• The second mode of therapy is skills training; a core component of DBT is learning new behavioral skills, including
  social skill), coping adaptively with distress and crises, and identifying and regulating emotional reactions.^[6]
• The third mode of therapy used is skills generalization, which focuses on helping clients integrate the skills taught in DBT into real-life situations.[7] This usually involves coaching in the form of telephone contact outside of normal therapy hours. The calls are usually brief interactions focused on helping clients apply specific skills to circumstances they are experiencing.
• The fourth mode of therapy is the use of a consultation team designed to support the therapists. These teams have several important functions including reducing therapist burnout, providing therapy for the therapists, improving empathy for clients and providing ongoing consultations for client difficulties.

The goal of all DBT treatment approaches is to reduce the ineffective action tendencies linked to dysregulated emotions. DBT is based on a biosocial theory of personality functioning in which the core problem is seen as the breakdown of the patient's cognitive, behavioral and emotional regulation systems when experiencing intense emotions. The etiology of BPD is seen as a biological predisposition toward emotional dysregulation combined with a perceived invalidating social environment.^[8]

DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.^[9]

Several random controlled trials comparing DBT to other forms of cognitive-behavioral treatments have favored the use of DBT to treat borderline patients. Specifically, DBT has been found to significantly reduce self-injury, suicidal behavior, impulsivity, self-rated anger and the use of crisis services among borderline patients. These reductions have been found even when controlling for other treatment factors such as therapist experience, affordability of treatment, gender of therapist and the number of hours spent in individual therapy.^[10][11] In a meta-analysis it was found that DBT was moderately effective. However, none of the studied therapies (including CBT) "fulfilled the criteria for empirically supported treatment."^[12] The additional efficacy in the overall treatment of BPD is less clear; future research is needed to isolate the specific components of DBT that are most effective in treating BPD. Furthermore, little research has examined the efficacy of DBT in treating male and minority patients with BPD. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.^[13]

Schema therapy

Schema therapy (also called schema-focused therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests it is significantly more effective than transference-focused psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after four years, with two-thirds showing clinically significant improvement.^{[14][15][unreliable source?]} Another very small trial has also suggested efficacy.^[16]

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.^[17]

Psychoanalysis

It is in the DSM-IV that the term took two orientations: one psychiatric, and the other behavioral, included in a psychoanalytic psychopathology. According to this split, the diagnosis takes on, or a character of symptoms to be eradicated, or a particular type of patient of psychoanalysts.^[18][19][20]

Psychodynamic psychotherapy generally

Psychodynamic psychotherapy (PP) are different types of psychotherapy derived from psychoanalysis. The duration of psychodynamic psychotherapy ranges from 10 to 25 sessions (short term psychodynamic psychotherapy) to over 200 sessions. The main emphasis of these measures are very different. Similar treatment principles mainly focus on one or several target problems by using the foundation of modern psychoanalytic theory. Results of meta-analysis show that psychodynamic psychotherapy has large effects in the treatment of personality disorders. The results indicate that psychodynamic psychotherapy causes long term changes in personality disorders.^[21]

Transference-focused psychotherapy

Transference-focused psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of

Cognitive analytic therapy combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results.^[26]

Mentalization-based treatment

Marital therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family therapy or family psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.^{[citation needed]}

Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.^[32]

Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.^[3]

Medication

The UK's

Individuals with BPD sometimes use mental health services extensively. People with this diagnosis accounted for about 20 percent of psychiatric hospitalizations in one survey.[44] The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.^[45] Experience of services varies.^[46] Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviours) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.^[47]

Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups.^[48] On the other hand, those with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative label rather than a helpful diagnosis, that self-destructive behaviour was incorrectly perceived as manipulative, and that they had limited access to care.^[49] Attempts are made to improve public and staff attitudes.^[50][51]

Combining pharmacotherapy and psychotherapy

In practice, psychotherapy and medication may often be combined, but there are limited data on clinical practice.^[52] Efficacy studies often assess the effectiveness of interventions when added to "treatment as usual" (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy.

One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing

There can be unique challenges in the treatment of BPD, such as hospital care.[55] In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist can contribute.^[56]

Some psychotherapies, including DBT, were developed partly to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimens is also a problem, due in part to

Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both, and some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area, and that in some cases it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.[59]

Numerous other strategies may be used, including

Psychiatric rehabilitation services aimed at helping people with mental health problems reduce psychosocial disability, engage in meaningful activities and avoid stigma and social exclusion may be of value to people who have BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. Services, or individual goals, are increasingly based on a recovery model that supports and emphasizes an individual's personal journey and potential.^[62]

Data indicate that the diagnosis of BPD is more variable over time than the DSM implies. Substantial percentages (for example around a third, depending on criteria) of people diagnosed with BPD achieve remission within a year or two.^[63] A longitudinal study found that, six years after being diagnosed with BPD, 56 percent showed good psychosocial functioning, compared to 26 percent at baseline. Although vocational achievement was more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, good global functioning and good psychosocial functioning.^[64]

References