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Treatment Goals, Three Etiologic or Underlying Cause Models
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I feel a good place to start with this section is to cover the
basics regarding Borderline Personality Disorder to make sure we are all on the
same page, so to speak.
Borderline Personality Disorder is a severe, chronic,
disabling, and potentially lethal psychiatric condition. People who suffer with
this disorder have extreme and long standing instability in their emotional lives,
as well as in their behavior and their self-image. This is a common disorder affecting
2% of the general population. The best evidence indicates that about 11% of psychiatric
outpatients and 19% of inpatients meet diagnostic criteria for BPD.
♦ Neurotic and Psychotic Characteristics
you know, Borderline Personality Disorder was once associated with schizophrenia.
Stern was the first to coin the term "borderline" to describe a specific
pathological condition that he thought had both neurotic and psychotic characteristics.
Thus in my opinion, I like to think of a client with BPD as being on the borderline
between neurosis and psychosis. However, in the past decade, as you know, BPD
has been detached from that disorder to be associated with affective disorders.
the Borderline Personality Disordered client, relationships with others are intense,
stormy, and unstable with marked shifts of feelings and difficulties in maintaining
intimate, close connections. The person may manipulate others and often has difficulty
with trusting others. There is also emotional instability, with marked and frequent
shifts, to an empty lonely depression or to irritability and anxiety. All too
frequently, 69% to 75% of individuals with BPD resort to self-destructive behaviors.
may be unpredictable and impulsive behavior which might include excessive spending,
promiscuity, gambling, drug or alcohol abuse, shoplifting, overeating or physically
self-damaging actions such as suicidal gestures.
♦ Anger and Deep-Seated Feelings or Beliefs
with BPD may show inappropriate and intense anger or rage with temper tantrums,
constant brooding and resentment, feelings of deprivation, and a loss of control or fear of loss of control over angry feelings. The client with BPD also may display
identity disturbances with confusion and uncertainty about self-identity, sexuality,
life goals and values, career choices, friendships. Do you agree?
For your client
with BPD there is a deep-seated feeling that he or she is flawed, defective, damaged or bad in some way, with a tendency to go to extremes in thinking, feeling or
certain behaviors. Under extreme stress or in severe cases there can be brief
psychotic episodes with loss of contact with reality or bizarre behavior or symptoms.
Even in less severe instances, there is often significant disruption of relationships
and work performance. The sections that follow this will discuss Susan and her rocky
relationship with her husband Dan.
The depression which accompanies this disorder
can cause much suffering and can lead to serious suicide attempts. The completed
suicide rate for BPD individuals is 3% to 9.5% (McGlashan, 1986; Stone,1983),
which is comparable to the other serious psychiatric disorders such as depression,
alcohol dependence, and schizophrenia.
♦ 5 Treatment Goals
greater impulse control, and
stability of relationships.
A positive treatment result for Susan, as you will
see, was increased tolerance of anxiety.
As you know, a general therapy goal is
to alleviate psychotic or mood-disturbance symptoms and generally integrate the
With this increased awareness, and capacity for self-observation
and introspection, it is hoped the patient will be able to change their rigid
patterns, tragically set earlier in life and prevent the pattern from repeating
themselves in the next generational cycle.
♦ Treatment Difficulties
Compounding the seriousness
of Borderline Personality Disorder , as you know, it is difficult to treat.
The very characteristics of the disorder, such as unstable relationships and intense
anger, interfere with establishing the therapeutic relationship that is necessary
to any treatment, whether psychotherapy or medication. Are you reluctant to treat
these individuals because they exhibit two characteristics likely to lead to clinician
" burnout " the BPD person's hostility towards the clinical professional
and their persistent suicidal thoughts and feelings ?
I believe that if there
is in fact a rise of Borderline Personality Disorder in our culture, it is related
to the interplay between child-rearing practices and the effects of social structures
that come into play during early adolescence and young adulthood.
♦ 3 Underlying Cause Models for BPD
to Paris, there are three etiologic or underlying cause models for Borderline
1. Brain Injury: One possibility is brain injury. For example, damage to
the orbital frontal cortex and other limbic sites could skew impulse control,
affective dysregulation, cognitive disability, and predisposition to psychotic
2. The Surrounding Environment: Another trigger or underlying cause for BPD
is the influences of a client's surrounding environment. Parents, for example,
who suffer from developmental disturbances, expose their children to aberrant
behaviors such as alcohol abuse, promiscuity, marital discord, and abuse. As you
are aware, these behaviors can severely damage a client during behavioral development.
3. Impulse Control: In addition to brain injury and environment an underlying
cause of BPD is a primary disorder of impulse control. This leaves a client at
a higher risk for traumatic brain damage and substance abuse. This exacerbates
the impulse control disorder, worsening the client's condition.
to Gunderson and Elliott, in a subgroup of clients, traumatic brain injury or
other CNS illness occurs in the absence of preexisting impulse control disorder
and is the primary cause of impulsivity in BPD clients.
♦ Exploring Connections between MAD and BPD
and Elliott report that there is a 40-60% overlap with major affective disorder
(MAD) and BPD. Others hold that BPD is only a form of MAD and not a separate entity.
What do you think? Does BPD have a separate identity from MAD or a major affective
Those that hold this theory point to the fact that the many detrimental
behaviors of a BPD client such as suicide attempts, poor object relations, and
sexual promiscuity are ways to cope with such emotions as, despair, poor self-esteem,
and efforts to alleviate depression.
In several cases of BPD with MAD, the borderline
symptoms seemed to remit with the remission of affective symptoms. This suggests
that for some of the BPD patients with concurrent MAD, the symptoms of BPD may
have been secondary to the affective disorder.
suggests that affective illness develops as a result of a BPD client's failed
relationships, impulsive behavior, and hypersensitivity to separation and loss.
Finally, one theory stipulates that affective illness and
BPD have no relation and only coincidentally occur simultaneously.
it could be argued that this relationship represents a way of dealing with emotional
pain in a motoric fashion. Also, borderline patients use impulsivity as a means
of self-soothing as well as a way to express their desperation, rage, and intense
frustration. Ultimately, it may well turn out that both are true.
this section, we discussed definitions, symptoms, and treatment challenges regarding
your client who has a Borderline Personality Disorder.
next section, we will examine how schemas affect everyday lives: as a way to view
the world; and a stored response to an emotional trauma. Also, we addressed various
maladaptive schemas that characterize many BPD clients: selective perception,
overgeneralization, and jumping to conclusions.
What disorder might be linked with Borderline Personality Disorder?
To select and enter your answer, go to .