371. Borderline Personality Disorder

Describe the key feature of Borderline Personality Disorder (BPD).

The key feature of BPD is instability, which manifests across emotions, thinking, behavior, and relationships.

• Emotions

  • Emotions are hard to control, lots of ups and downs; intense/uncontrollable anger, can alternate with periods of hollow emptiness

• Thinking

  • (dissociating (losing time, feeling unreal or in a dream) or suspiciousness/paranoia when stressed; shifting or uncertain identity – changing interests, values goals, or no sense of “who I really am”

• Behavior

  • (impulsive behavior – acting quickly in ways that are risky or self-damaging; suicidal or self-harming behavior)

• Relationships

  • (desperate actions to prevent feared abandonment; idealization/devaluation of relationships)

  • Sudden shifts in how they view relationships

What are some serious mental health problems associated with BPD?

• BPD is associated with a high rate of inpatients, with almost ⅓ of people who have attempted suicide having a history of BPD.

• Additionally, 8-10% ultimately die by suicide, 69-80% self-harm and 75% have attempted suicide.

Describe the reasons for the existence of stigma around BPD

Stigma around BPD exists due to:

• Misinformation

• Media portrayals are often highly stigmatized

• Misunderstanding the causes of BPD

  • Used to be linked to abuse; caused stigmatization and blame towards families

• Symptoms can be frightening, confusing

• Society values being calm, in control, “rational”

Do people with BPD exhibit manipulative and attention-seeking behaviors? Explain.

Yes, people with BPD are manipulative and attention-seeking, but this is because their behaviors are often learned and reinforced, which could explain why they turn back to these behaviours.

Explain the misconception that people with BPD are violent and a high risk for harming others

Research shows that people with BPD are more likely to be victims of abuse rather than being abusers themselves.

Do treatment providers also contribute to the stigma around BPD?

Yes, stigma around BPD exists even among treatment providers.

[STUDY] Zanarini et al. 2004

Describe this graph.

• The graph shows a huge decline in BPD symptoms. Found that 94% of people admitted; people who did not have BPD at year 2 continued to not have symptoms up until year 6

• The sample were specifically receiving very intensive weekly therapy by year 6

  • Meaning, people who were in remission still were receiving therapy

1. What symptoms are most likely to improve in BPD? (3)

2. What symptoms are least likely to improve in BPD? (3)

1. Most likely to improve:

   • Impulsive, risky, and self-damaging behaviours

   • Paranoid thoughts

   • Unstable, stormy relationships

2. Least likely to improve:

   • Emotional symptoms (depression, anger, etc)

   • Dissociative symptoms and negative beliefs

     • Core beliefs don’t just disappear, even with therapy

   • Fears of abandonment and being alone

Describe the available psychological treatments for BPD.

1. Dialectical Behaviour Therapy (DBT; Linehan, 1993)

2. Mentalization-Based Treatment (MBT; (Bateman & Fonagy, 1999)

3. Schema-Focused Therapy (Young, 1994; Giessen-Bloo et al. 2006) 

4. Transference-Focused Therapy (Clarkin et al. 2007)

Define Dialectical Behavior Therapy (DBT) and its creator.

• DBT was created by Marsha Linehan after working with suicidal patients with BPD.

• It focuses on helping patients change their lives and circumstances, rather than trying to change themselves.

How did Marsha Linehan develop DBT?

Marsha Linehan developed DBT after noticing that:

• When she focused on helping patients change their lives, their focus and circumstances, they found that very validating

• Trying to change the individual makes clients feel invalidated and blamed

Why might individuals with BPD not prefer the methods of CBT?

• Clients found unrelenting focus on change invalidating

• Clients found attempts to accept problems invalidating

• Frequent drop-out

• There’s also so many problems presenting in each session

Describe the concept of dialectics in the context of DBT.

• Dialectics in DBT refers to the worldview that reality consists of opposites, where two things can be true at once.

  • e.g.,  I love my mother, but when she calls me in the morning, I can, in that moment, feel some hate. These moments of hate can be very unsettling to feel. These seeming opposites are part of reality

• It emphasizes the need to synthesize seeming opposites and find a continual balance between change and acceptance.

How does DBT address the balance between change and acceptance?

DBT addresses the balance by emphasizing the need to accept reality as it is while also changing what is in the person’s power, finding a middle ground between the two that fosters growth and well-being.

Describe Linehan’s Biosocial Theory of BPD.

What is the first component of Linehan's Biosocial Theory of BPD in the context of DBT?

• First component is emotional vulnerability

  • Emotional SENSITIVITY

    • Smaller things can prompt an emotional response

  • Emotional REACTIVITY

    • How intense the emotional reaction is

    • Someone who is highly emotionally reactive, they have a larger emotional response

  • Slow return-to-baseline

    • Once the emotion is triggered, it takes longer for it to come back down

Describe Linehan’s Biosocial Theory of BPD.

What is the second component of Linehan's Biosocial Theory of BPD in the context of DBT?

• Second component is an invalidating environment:

  • Rejects communication of emotions and thoughts

    • E.g., “You shouldn’t be sad about that there’s worse things happening to others.”

  • Oversimplifies the ease of problem solving

    • E.g., Communication that the child is able to easily get over their problems when in fact, they cannot

  • Intermittently reinforces emotional escalation

    • Child is getting their needs met when they escalate their emotions which reinforces this behavior

    • E.g., Child is in an invalidating environment where they cannot cry.

    • Getting little to no support from parents until you threaten suicide

  • Abuse is not necessary for invalidating environments to come up

Describe Linehan’s Biosocial Theory of BPD.

What is the third component of Linehan's Biosocial Theory of BPD in the context of DBT?

• Third component is a difficulty with emotion regulation.

  • Emotion dysregulation develops as a learned pattern over time, where individuals learn unhelpful short-term coping mechanisms and fail to learn long-term solutions.

  • A1 →← B1: Explains that the biological sensitivity interacts with the invalidating environment

What are the components of comprehensive DBT therapy?

Comprehensive DBT therapy consists of individual therapy, group skills training, phone coaching, and therapist consultation team meetings.

1. Describe the structure of individual DBT sessions.

2. What is the typical duration of each session?

1. Individual DBT sessions typically start with reviewing the Diary Card, checking in on other treatment, setting an agenda using the treatment targets, following the agenda, and wrapping up the session by reviewing the session and homework

2. Typical duration is 60 minutes, once every week

What is stage 1 of DBT and what does it consist of?

Stage 1 – Attaining Basic Capacities

• Focus is on helping the client move from out-of-control to behavioural control

Define the hierarchy of targets in DBT Stage 1.

These targets are prioritized based on the client's level of dysregulation and the severity of their behaviors.

1. Decrease Life-Threatening Behaviors

   • If patient has self-harmed, has intense suicidal ideations, or engaging in behaviors that can put them in serious harm is always targeted FIRST.

2. Decrease Therapy Interfering Behaviors

   • Can happen on client’s end or therapist’s end

   • e.g., Showing up late as a therapist, that’s a therapy interfering behavior

   • e.g., Client is skipping their therapy, that’s a therapy interfering behavior

3. Decrease Quality of Life Interfering Behaviors

   • Relationship functioning, work, money, other mental health problems like depression, EDs, etc.

4. Decrease Skill Deficits, Increase Skillful Behavior

   • Mindfulness

   • Interpersonal Effectiveness

   • Emotion Regulation

   • Distress Tolerance

What is stage 2 of DBT and what does it consist of?

Stage 2 – Escaping Quiet Desperation

• Once client has necessary capabilities and supports, clinician begins exploring posttraumatic (or invalidation-caused) stress patterns

• Reduce extreme emotional pain

• Increase the capacity for normative emotional experiencing

What is stage 3 of DBT and what does it consist of?

Stage 3 – Resolving Problems in Living and Increasing Respect for Self

• The individual is functional in major domains of living.

• The goal here is to reach an ordinary level of happiness/unhappiness + self-respect

• The therapist suggests or pushes for a decrease in sessions, which helps the client be self-reliant.

What is stage 4 of DBT and what does it consist of?

Stage 4 – Attaining the capacity to for freedom and sustained contentment.

• The goals are expanded to self awareness, spiritual fulfillment and the movement into experiencing flow. 

• Added by Dr. Linehan later for clients who find the balance of happiness and unhappiness already achieved does not meet need for spiritual fulfillment

• It’s not typically reached because DBT is expensive

How long does it typically take to complete Stage 1 and maybe Stage 2 of DBT?

Typically, 1 year of DBT includes Stage 1 and maybe Stage 2

T/F: All clients move through all 4 stages of DBT.

False

Identify the 3 strategies of DBT.

1. Dialectical strategies

2. Core strategies

3. Stylistic strategies

What are dialectical strategies?

• Teaching dialectical patterns

  • Not “either-or” but “both and”

• Focus is on finding the middle path

Describe the concept of 'extending' in the context of therapy.

Extending involves exaggerating issues to help the client see the other side of the dialectic, making the most of a difficult situation to practice addressing the other side.

What are the 3 core strategies of DBT?

• Cheerleading:

  • Expressing encouragement, hope, praise

• Validation:

  • The therapist communicates to the client that their responses make sense and are understood in light of the situation

  • We don’t want to validate the invalid

  • Rather, clinicians should validate their emotions but NOT maladaptive behavior

• “Finding the kernel of truth”

  • Validate emotions “If I were you, I would feel the same”

  • Validate behaviors “Yelling has worked in the past, so it makes sense that you tried that again”

  • Validate thoughts “When he frowned at you, you remembered your last break up, so naturally you had the thought “maybe we will break up again”.

What are the 6 stages of validation?

• Level 1 – show interest in the person

  • Clinician shows active engagement; helps client feel validated

• Level 2 – accurate reflection

  • Clinician reflects back what the client says in different words; shows they are listening

• Level 3 – articulating the unverbalized

  • Clinician intuiting that they feel a certain way that makes them feel validation for their emotions without explicitly telling the clinician they felt that way

• Level 4 – validating in terms of biology or past behavior

• Level 5 – validating in terms of current events

  • e.g., “Of course you were mad, he was yelling at you!”

• Level 6 – radical genuineness

  • Communicating that you are you as the therapist and you are being fully genuine in the room with the client

  • Can’t be taught or trained, it’s from experience

Describe the core strategy of problem solving in the given context.

Problem solving involves:

• Define the problem (diary card is useful for this)

• Conduct a chain analysis

• Generate solutions (balance of acceptance and change)

• Evaluate solutions

• Commit to a solution

• Troubleshooting

What is a chain analysis of core strategies?

A chain analysis is an exhaustive, blow-by-blow description of the chain of events leading up to and following a behavior, including antecedents and consequences

• What happened before (that day), right before (that hour/minute), during, and after the behavior

• Ask about emotions, thoughts, events

• Non-judgemental

1. How is reciprocal communication defined?

2. What does it include?

1. Reciprocal communication is described as essential for a strong therapeutic relationship in the given context.

2. Includes being responsive to the client by demonstrating that their perspective is important, self-disclosing by sharing personal experience and positive modelling skills (but this is very controversial), and being genuine

1. How does irreverent communication contribute to the therapeutic process?

2. What does it include?

1. Irreverent communication helps keep the client 'off-balance,' attentive, engaged, and open to new points of view, but it must be genuine and built on compassion.

2. Includes:

   • Being straightforward and direct

   • Reframing in unorthodox manner

   • Making lemonade out of lemons

   • Playing devil’s advocate

   • Extending

What is the typical structure of a group skills training session in a clinical setting?

A typical group skills training session includes 10 minutes of mindfulness, 50 minutes of homework review, a 10-minute break, and 50 minutes of learning new skills, usually lasting 120 minutes and held weekly.

Describe the goal of distress tolerance skills.

The goal is for a person to have enough control to avoid making the situation worse.

That are the 5 distress tolerance skills?

• STOP: Refrain from impulsive actions

  • Does not solve the problem, but helps to not make the situation worse

• TIP: Using skills to change body chemistry quickly to counteract emotional arousal

  • e.g., Getting bowl of ice water and dunking face into it; forces your breathing to calm down; cools head for long enough to seek help

• Self-Soothing

  • Using either the 5 senses to calm oneself

• Distracting

  • Can you take your mind off of this for a moment in order to calm down

  • People tend to use this too much, so this skill is taught in moderation

• Improving the Moment

  • Doing little things to make life suck a little less

Define radical acceptance in the context of distress tolerance.

Radical acceptance is the complete and total acceptance of the facts of reality, letting go of fighting reality without necessarily approving or being against change.

• It helps reduce suffering over time

• Helps people to see problems clearly before finding solutions.

What is the purpose of understanding and naming emotions in emotion regulation?

The purpose is to examine the purpose of emotions and learn how to identify them through thoughts, bodily sensations, facial expressions, body language, and action urges.

How can unwanted emotions be changed?

1. Check the Facts – changing beliefs and assumptions can change an emotion

2. Opposite Action – when an emotion does not fit the facts, acting opposite all the way will change the emotion

   • If we evaluate that thought and look for the evidence, there is not enough evidence to fit that thought; helps person act opposite of their urge

3. Problem Solving – when an emotion fits the facts, solving the problem will reduce the emotion

How can an individual reduce vulnerability to the “emotion mind”?

They can do this by:

1. Accumulating positive emotions and mastery

   • Scheduling things that feel like accomplishments can reduce feelings that things are very negative in difficult times

2. Taking care of their bodies

   • Treating physical illness

   • Balanced eating

   • Sleep

   • Regular exercise

   • Avoiding mood-altering substances

What are the three components of interpersonal effectiveness mentioned in the content?

The three components of interpersonal effectiveness are obtaining objectives skillfully, using:

1. The DEAR MAN technique for getting what one wants or saying no

2. Using the GIVE technique for keeping/improving a relationship

3. Using the FAST technique for keeping self-respect.

Describe the DEAR MAN technique.

DEAR MAN

• D - Describe the situation

• E - Express clearly how you feel

• A - Assert wishes

• R - Reinforce the other person

• M - Stay mindful of your objectives

• A - Appear confident

• N - Negotiate

1. What is the purpose of the phone consultation in dialectical behavior therapy?

2. What is the typical structure of phone consultations?

1. Purpose

   • Clients who struggle to ask for help (due to shame, belief they are undeserving, lack of skill etc.) can practice asking for help effectively

   • Clients can get immediate help with suicidal urges (**before they engage in self-harm**)

   • Helps clients generalize skills to everyday life

   • Opportunity to repair following conflict or misunderstanding with therapist

2. Structure

   • Brief (max 15 mins is ideal)

   • Crisis, skill, or relationship focused

   • Focus on brainstorming solutions, troubleshooting, and getting commitment

Describe the 24 Hour Rule in phone consultations.

The 24 Hour Rule in DBT therapy states that a patient must wait24 hours after self-harm before talking to their therapist, except for risk assessment. It aims to prevent inadvertently reinforcing self-harm behaviors by immediate contact with a caring therapist and encourage alternative coping strategies

What are the pros and cons of the 24 hour rule?

• Pros:

  • Allows the patient to utilize the skills they learned in therapy to cope

  • Avoids reinforcing self-harm behavior by giving attention right after self harm incidents

• Cons:

  • May affect therapist and patient relationship negatively

1. What is the therapist's responsibility regarding phone consultations?

2. How can therapists manage the impact of calls on their well-being in DBT therapy?

1. The therapist must monitor personal limits before they're exceeded, communicate limits honestly, and combine with problem-solving and validation.

2. Therapists can work to keep calls brief and communicate their limits honestly to prevent burnout.

How does the consultation team support DBT therapists?

The consultation team provides sustaining motivation, cheerleading, and discusses problems, offering dialectical balance. It helps reduce stress from working with suicidal or self-harming individuals and prevents therapist burnout.

What evidence supports the efficacy of DBT?

Efficacy studies (Linehan et al. 1991) show that DBT is more effective than Treatment As Usual (TAU) in reducing parasuicidal behavior, medical severity of parasuicide, drop out rates, inpatient psychiatric days, and anger. However, DBT shows similar effectiveness to TAU in global social functioning and depression, while it does not reduce suicidal ideation but reduces the behavior.

Why might DBT not reduce suicidal ideation?

The low reduction in suicidal ideation may be caused by comorbid disorders such as struggling with PTSD or complex trauma

How does DBT compare to community therapy by experts in specificity studies?

Specificity studies (Linehan et al. 2006) demonstrate that DBT is more effective than community therapy by experts in reducing suicide attempts, hospitalization rates, angry behavior, dropouts, and ER visits.

What is the cost comparison between DBT and treatment as usual for individual psychotherapy based on efficiency studies?

DBT is found to be significantly more expensive than treatment as usual for individual psychotherapy, based on efficiency studies (Linehan et al. 1991). This cost difference is estimated to be around $5,000, highlighting the financial implications of choosing DBT over traditional treatment methods.

What is the conclusion regarding medication for BPD based on the research?

• The best evidence so far suggests that there is no "Anti-BPD" drug

• SSRIs (e.g. Prozac) show the best evidence for addressing depression, anxiety, and other symptoms.

• Mood stabilizing medications or “anti-psychotic medications” may be helpful but serious side effects

• Medication alone is not recommended