Detailed Notes on Borderline Personality Disorder (BPD) and Dialectical Behavior Therapy (DBT)

Diagnosis of Borderline Personality Disorder

  • Clients with emotional dysregulation or crises may be misdiagnosed with borderline personality disorder (BPD).

  • A client was misdiagnosed with BPD after a difficult period, attended a DBT group, and later sought a new clinician, intentionally omitting the diagnosis due to perceived stigma.

  • Clinicians should ensure clients meet the criteria for BPD, considering pervasive patterns over their lifetime, not just snapshots in time.

Characteristics of Borderline Personality Disorder

  • People with BPD can be lively, energetic, personable, and charming.

  • BPD involves instability in interpersonal relationships, self-image, and affect, with marked impulsivity beginning in early adulthood across various contexts.

  • Diagnostic criteria include five or more of the following:

    • Excessive and unstable emotional responses: intense emotional anguish, high anxiety, panic attacks, irritability, inappropriate anger, and chronic feelings of emptiness and boredom.

    • Impulsive behaviors: self-damaging acts (excessive spending, substance abuse, inappropriate sexual conduct, binge eating).

    • Recurrent suicidal behaviors, gestures, threats, or self-harming behaviors (cutting, hitting, burning).

    • Inaccurate perceptions of self and others; high suspiciousness.

    • Persistent unstable self-image and sense of self.

    • Suspicious thoughts of others that can feel like paranoid ideation or stress-related dissociative episodes.

    • All-or-nothing black-and-white thinking: intense, polarized experiences (e.g., "either you love me or hate me").

    • Frantic efforts to avoid real or imagined abandonment, leading to intense and unstable relationships that alternate between extremes of over-idealization and devaluation.

Application of DBT Skills

  • Even without a BPD diagnosis, DBT skills can support clients presenting with emotion dysregulation, interpersonal problems, or crises.

  • People with BPD crave relationships but struggle with maintaining them and cannot tolerate being alone, leading to frantic behaviors to avoid abandonment.

  • Anxiety increases to the point where clients feel they want to jump out of their skin when disagreement with their partner occurs, or there's a perceived sense of abandonment, resulting in maladaptive interactions to manage their emotional storm.

  • Neurologically, the amygdala (governing emotions and basic needs) may not communicate well with the prefrontal cortex (handling higher-level issues).

    • When the amygdala is not communicating effectively with the prefrontal cortex, individuals respond with higher emotional intensity than the situation actually warrants.

    • The prefrontal cortex responds based upon whatever the amygdala is kicking up once those basic needs around security and survival are being triggered.

    • Explaining this to clients and introducing mindfulness and DBT skills can help them regulate their amygdala and prefrontal cortex.

Perceptions and Compassion

  • People with BPD are good at reading others' emotions but often misread neutral faces as angry or critical.

  • Conceptualizing BPD as having emotions like burns shifts the perspective, promoting compassion and understanding for the client's raw experiences.

  • BPD affects both men and women, though it was historically believed to be primarily diagnosed in females.

    • In men, BPD often presents with comorbid substance abuse disorders.

    • In women, BPD is more likely to present with comorbid post-traumatic stress disorder (PTSD) and eating disorders.

  • BPD is correlated with mood disorders (bipolar), anxiety disorders (panic disorder), and substance use disorders.

  • Statistics: 1.2-6% of the general population is affected; 10% of outpatient service seekers, 20% of inpatient, and 10% meet the criteria to commit suicide. People with BPD have a suicide attempt rate 50 times higher than the general population.

Overlapping Symptoms

  • Symptoms of BPD can overlap with other mental health diagnoses, making accurate diagnosis challenging.

  • Complex PTSD: overlapping symptoms include emotional regulation problems and a sense of badness.

  • Diagnosing and ruling out conditions is not easy; DBT can be used across diagnoses (PTSD, complex PTSD, disorders of extreme stress, BPD, major depressive disorder).

  • Difference between BPD and histrionic personality disorder:

    • BPD: impulsivity and instability.

    • Histrionic: excessive emotionality and attention-seeking behavior.

  • BPD often overlaps with bipolar disorder; it is important to differentiate the two diagnoses through assessment.

  • Key feature: Abrupt Shifts. One minute everything seems to be fine, and the next minute there's a lot of hurt and anger and even rejection over something that seems like a nonissue.

Treatment and Validation

  • It is important that you have an open dialogue regarding the diagnosis and BPD with your patients.

  • One minute everything's fine, the next minute there is anger or hurt over something that feels significant

  • Validate the person with BPD so the cycle will stop with validation.

Assessing BPD

  • Be cautious when diagnosing any personality disorder due to associated stigma.

  • Share the diagnosis with the client and explain its implications, guiding treatment.

  • Ensure diagnostic decisions extend beyond the client's presenting issue and look at their past and personal history

  • Engage in open conversations with clients about the stigma related to BPD.

  • Clinicians can provide a sense of relief for clients who are diagnosed with BPD because there is a name for all of their issues and problems

DBT General Concepts and Ideas

  • DBT is focused on the need to learn skills to replace behaviors the do not work.

  • DBT addresses problems that cause difficulty in how we function in life with emphasis being on the therapist having an accepting, non-judgemental, and validating approach to clients.

    • This means that therapists need to work hard to understand their patient's POV and that their feelings, thoughts, and behaviors make sense given their current situation. Sometimes people come up against resistance because they miss this beat of acknowledgement.

  • DBT takes an eclectic approach guided by the dialectical and biosocial theory and addresses safety issues immediately.

  • The goals of DBT are to help people live in the moment, to help people regulate their emotions, to develop coping techniques for stress, and to improve interpersonal relationships using skills developed through DBT.

  • DBT Skills help change unwanted behaviors, emotions, and thoughts.

  • Over the course of treatment clients should experience more stability in actions, moods, and their image of them-self while having more control over their damaging impulses.

  • Difference between DBT and CBT

    • DBT adds mindfulness and acceptance techniques

    • DBG takes the judgement out of CBT

    • DBT uses a principle driven therapy and is administered with various treatment stages and priorities and has more intensive and specific self-monitoring exercises.

  • DBT uses therapist self-disclosure with the goal of relating to a particular problem for the patient

Theories Comprising DBT

  • Biosocial Model

  • Mindfulness Practice

  • Philosophy of Dialectics

  • Marsha Linehan DBT Model of Emotions

    • Emotions are patterned responses to our internal and external environments.

    • Emotions are brief, involuntary, and full system.

Emotional Dysregulation

  • Emotional dysregulation is used to describe the inability to change emotional cues, experiences, actions, verbals responses, or nonverbal expressions.

    • Often presents with anger, sadness, or self-harm or the verbal and nonverbal responses shown.

  • Emotional dysregulation is linked to a variety of mental health problems.

    • 75% of mental illnesses listed in the DSM V have some form of emotional dysregulation

  • Characteristics of emotional dysregulation

    • Excess of painful emotional experiences

    • Inability to regulate a tense arousal

    • Problems turning away from strong emotional cues

    • Impulse control problems

    • Failures in information processing. People might freeze or disassociate when faced with high levels of stress.

  • People who have a hard time regulating also find it hard to ID emotions and understand why they feel the way that they do.

  • Emotional regulation can present as an overcontrol of motions and suppression. This can lead to a pervading negative effect, a really low positive effect, and difficulties with effective comms.

  • Emotional dysregulation is produced by 2 things

    • Emotional vulnerability

    • Inadequate emotional regulation skills

  • Emotional vulnerability happens when patients have a high negative effectivity over all facets of life, leading to being more sensitive over smaller issues and resulting in an intense response that they need more time to recover from emotionally.

  • DBT can help clients return to their baseline using mindfulness and emotion regulation skills in order to avoid an emotional roller coaster.

  • Clients with high rates of emotional deregulation can present as an over abundance of aggressiveness, fear, but also they are highly resilient over time.

Importance of the Environment

  • The video on the next slide showcases a real-world example of an unhealthy environment by way of the still-face experiment where a baby is actively ignored to see how a lack of emotional acknowledgement would affect its growth.

    • In the video it can be seen that a baby is actively denied a simple interaction where the mother shows no emotion and only a blank face, which affects the child causing them to cry.

    • Those who have experienced an unhealthy environment develop special coping skills to survive those experiences, which become more detrimental as the patient gets older.

  • Looking at complex and complete psychosocial histories can help understand why a particular patient acts the way that they are, which helps the therapist give compassion.