Borderline Personality Disorder Treatment
Borderline syndrome, also known as Borderline Personality Disorder, is a complex personality disorder. People with Borderline Syndrome are emotionally unstable and live in a constant pool of emotions – between exalted and deathly sad. At the same time, they report a feeling of inner emptiness.
“Borderline Personality Disorder” have problems with regulating their emotions and often react impulsively. Even a little thing can be enough, that the emotional situation tilts. As a result, those affected are quickly labeled as whimsical or unpredictable.
What is “Borderline Personality Disorder”?
This emotional chaos is also evident in the interpersonal relationships: sometimes the Borderline Personality Disorder patients idealize their partner, and a short time later they devalue him because he can not live up to expectations. A borderline relationship is therefore characterized by intense emotions – both positive and negative.
People with “Borderline Personality Disorder” are also very afraid to be left or disappointed by their partner: even a temporary separation can lead to mistrust or cause fears.
Borderline syndrome is an emotionally unstable personality disorder. The disease is characterized by a continuous pattern of instability in
- social relationships,
- in self-image and
- the mood.
The term borderline originated from the assumption that the patients move in the borderline (English borderline) between neurosis and psychosis .
In the life history of people with borderline syndrome, there are often massive experiences of abuse or other traumatic experiences such as physical violence. Genetic factors probably also play a role.
Often, the intensity of borderline personality disorder decreases as those affected become older. With advancing adulthood, many people are psychologically more stable, both in their private and professional lives.
Borderline Personality Disorder: symptoms
People with borderline syndrome have a hard time regulating their emotions. This can lead to different symptoms:
- The borderline sufferers are often desperate to avoid actual or suspected abandonment . For example, time-limited separations or even minimal delays of the other are perceived as very threatening and trigger strong fears .
- “Borderliner” idealize their partner at the beginning of a relationship usually very strong. However, the strong idealization quickly turns into devaluation of the same person, for example, if this is the expectation “always to be there for the other” is not enough. During the relationship, therefore, there are frequent separations and reconciliations.
- In addition, borderline personality disorder affects the self-image and self-awareness of those affected. They see themselves as “evil” or “sinful” and often show self-harming behavior . For example , some people consume drugs , drive cars too fast, gamble away their money, or cut themselves or burn. The background is often to avoid being abandoned – but also to punish or feel oneself.
- In general, the emotional state of people with borderline personality disorder is very changeable. So it comes in rather depressed mood to phases of strong excitability, fear or despair. These are often an expression of the tendency to react very quickly and extremely to interpersonal stress. In particular, if the person experiences neglect or rejection, it often leads to outbursts of anger, which are hardly controllable for those affected.
- People with “borderline” often complain about a persistent feeling of inner emptiness ; They suffer from a tormenting sense of boredom and are often looking for employment.
- Under extreme conditions, such as drug addiction or actual or expected abandonment, persecution ideas or so-called dissociative symptoms such as self-alienation temporarily accompany borderline syndrome. The affected then perceive their own person or body differently or are insensitive to pain.
Borderline Personality Disorder: causes
In the emergence of a borderline personality disorder probably play
- both traumatic childhood experiences
- as well as genetic factors
According to psychoanalytic explanatory models, borderline personality disorder is a so-called early disorder . This means that those affected have remained structures and thought patterns that are typical of early childhood. In this time hate and envy conflicts are in the foreground, there is still no differentiated perception of the own or foreign persons, but a rigid assessment of humans as “good” or “evil”.
In recent years, Borderline syndrome has been increasingly used to investigate abuse as possible causes. It showed that most of those with borderline syndrome report serious traumatic experiences such as sexual or physical abuse , extreme domestic violence, or marked neglect in childhood.
In many cases, the abusive offender is an important caregiver, exposing those involved to the contradiction that a loved one they should protect is identical to the person they are protecting themselves from. In this contradiction , it is difficult for those affected to perceive and express their reactions to anger and disgust towards the caregiver.
Possibly, these negative feelings may then turn against one’s own person in borderline personality disorder, so that the abuse can be justified by one’s own “bad personality”.
Experiences of abuse can also have a decisive influence on the subsequent relationship design , as at the same time incompatible emotions are experienced: for example, the tenderness of the offender combined with the simultaneous fear of him. In addition the feeling, to be preferred, in addition, intensive shame. This extreme contradictoriness of feelings makes those affected fluctuate between extreme Poles later in their dealings with other people.
Not all people who suffer from borderline syndrome experience abuse. However, all those affected seem to have in common that they have grown up in an environment where behavior and people are always judged to be either “completely good” or “completely evil”.
For example, a typical pattern of behavior learned might never be angry as a “good” child. As a result, those affected do not learn to deal adequately with difficult situations or negative emotions. Also, in the prehistory of a borderline disorder, extreme emotional neglect or excessive severity often characterizes the upbringing.
Memory becomes a burden
The therapy of people who have had traumatic experiences has shown that most people’s emotional responses become weaker when they talk about the trauma . In borderline patients, on the other hand, it can be seen that a repeated reminder of the abuse leads to an increase in the distressing feelings. They seem to have an increased neurobiological excitability . In addition, the repeated and often arbitrary traumatization of people with borderline disorder seems to lead them to develop a strong sense of possible threats.
As a result, seemingly harmless stimuli can be followed by extreme reactions , such as so-called dissociative symptoms . In the process, patients with a borderline personality disorder lose any realism and feel alien to themselves. Their own actions or feelings can not connect them with their person (so-called depersonalization ).
Dissociative symptoms can occur in borderline syndrome at times of subjectively perceived threat. They are similar to the deadbeat reflex in animals: if the person has no options to respond to the threat, the dissociative symptoms help to escape the situation. However, borderline sufferers have the opportunity to learn that they can manage a perceived danger by acting on their own.
The dissociative symptoms, such as changes in the perception of space and time, the feeling of being beside oneself and being unable to feel anything, are very frightening for people with a borderline personality disorder. Often they end this uncomfortable state by self-injurious behavior , such as cutting and scribing with sharp objects to feel again.
Borderline Personality Disorder: diagnosis
In order to diagnose Borderline Syndrome, at least five of the following nine criteriamust be present in the affected person according to the Diagnostic and Statistical Manual of Mental Disorders (DSM):
- desperate efforts to avoid fearful or actual abandonment (not: self-injurious behavior or suicide attempts / threats)
- unstable but intense interpersonal relationships with frequent changes between extreme idealization and devaluation of the partner
- Identity disorder in the form of a pronounced and persistent unstable self-image or unstable self-perception
- strong impulsivity in at least two potentially self-harming areas, such as substance abuse, eating disorders (not: self-injurious behavior or suicide attempts / threats)
- Self-injury, attempted suicide or threatening suicide
- Unstable emotional world (affective instability) with an extreme feeling experience and sudden, often violent mood swings, which can be triggered even by the smallest events
- continuous feeling of inner emptiness
- inappropriate, very violent anger or difficulty controlling anger (eg frequent tantrums)
- temporarily paranoid ideas or dissociative feelings such as self-alienation as a result of stressful situations
The conspicuous behaviors are persistent in borderline syndrome and are not limited to a specific period of time. The disorders occur in childhood or adolescence and persist in adulthood. Using structured interviews, the doctor will ask if there are symptoms typical of Borderline Personality Disorder.
Borderline Personality Disorder test
Frequently, a special borderline test is used for the diagnosis – the so-called diagnostic interview for borderline syndrome (DIB). In an approximately two-hour conversation, the examiner tries to gather information about different subareas through questions and observation. Depending on what the patient says or how he responds, the examiner can evaluate the individual areas and the entire borderline test using a scoring system.
Borderline Personality Disorder Syndrome: Therapy
With Borderline Syndrome, therapy is often difficult for both sides – both sufferers and therapists. This is mainly due to the fact that the patients also in therapy (as in other interpersonal relationships) often fluctuate between idealization and reduction of the therapist. Among other things, many sufferers with a borderline personality disorder often change their therapist.
The psychoanalytic approach of borderline therapy understands the difficulties of those affected in their interpersonal relationships as an expression of intrapsychic conflicts. The focus of borderline therapy is therefore to interpret these problems.
In the 1980s, a highly structured program was developed specifically for the treatment of persons with borderline syndrome. This so-called dialectical behavioral therapy (DBT) is the best documented scientific treatment for borderline personality disorder and is divided into the following sections:
- In a preparatory phase , the therapist informs the affected person about the borderline syndrome and the course of the therapy. He also discusses possible earlier treatment discontinuations or changes. This is to enable those affected to detect possible early warning signs that may indicate that they could terminate therapy early. He can then react to these.
- In the first phase of therapy, the focus is on problematic behaviors that occur in the context of borderline disorder, especially:
- Self-Injuring Behavior and Suicide Attempts : Patients with borderline personality disorder and therapists work together to identify conditions and situations that lead to this behavior and develop other ways in which the person with Borderline Personality Disorder can deal with difficult situations and feelings.
- Treatment-endangering behavior : In borderline therapy, the therapist and the person concerned with borderline personality disorder also discuss factors that endanger the continuation and success of the treatment. Here are both causes on the part of the person concerned, for example, repeated missed appointments, as well as on the therapist side, for example, an excessive demand of the person concerned.
- Behavior that affects the quality of life : behaviors such as substance abuseor financial problems with borderline syndrome are at the heart of this phase of therapy. Also, a first approach to the traumatic experiences takes place, but at first strongly related to the current everyday life. This includes a change in living conditions, which may eventually lead to traumatic experiences. Further therapeutic steps in this stage of the treatment are to better control the trauma-related feelings and to treat the dissociative symptoms.
- Improve Behavioral Skills : Together, the therapist and the sufferer develop behavioral techniques to handle specific situations through exercises on various problem areas. This includes, for example, stress management training. For example, the perception and control of one’s own feelings or the handling of stress is practiced – usually in the context of a group with other people who are suffering from a borderline personality disorder.
- Only in the second therapy phaseis about treating the consequences of traumatic experiences. The therapist deliberately places these burdensome life events in the borderline syndrome at the center of therapy only when the person concerned has previously developed the handling of the intense emotions that occur in this context and stabilized his or her life circumstances. This stabilization may consist in the borderline patient not injuring himself to relieve emotional tensions and suicidal ideation. At this stage, it’s not about experiencing the trauma once again. Rather, people with borderline personality disorder should learn that the negative experiences are a thing of the past and how they can protect themselves from situations that evoke memories of traumatic experiences.
- In the third phase , the person with borderline syndrome should incorporate the learned behavior in the therapy into the daily life. It thereby increases their self-esteem and develops and implements individual goals.
The dialectical behavioral therapy of borderline disorder was developed as an outpatient treatment method. However, in some circumstances, such as life-threatening behavior, in-patient treatment may be advisable at least temporarily. Previous studies on dialectical-behavioral therapy show that patients with borderline syndrome showed significant improvements, especially in the areas of self-injury, hospitalization, depression and social integration.
Further therapy procedures
In addition to the dialectic-behavioral Borderline Personality Disorder therapy (DBT), there are other behavioral approaches, but their effectiveness is less well documented than in the DBT:
- Schema-focused therapy (SFT)
- Mentalization-based therapy (MBT)
- Transfer-focused Psychotherapy (TFP)
The schema focused Borderline Personality Disorder therapy is based on the assumption that negative thought patterns (schemes) are the cause of personality disorder. They may arise, for example, as a result of negative childhood experiences. In the SFT therapist and sufferer together try to recognize and change these schemes. This happens in three phases:
- The person affected by Borderline Personality Disorder and the therapist initially build a positive and trusting relationship with each other as a basis . People with Borderline Syndrome also learn to handle their feelings appropriately at this stage of therapy.
- The second phase is the actual therapy phase , in which the goal is to break up and change the learned negative thought patterns.
- The third phase is for mental stabilization . Concerned people implement the developed strategies in their everyday life and detach themselves from the therapist.
The mentalization-based Borderline Personality Disorder therapy combines psychoanalytic approaches with the so-called attachment theory. The basis is the assumption that persons with borderline personality disorder lack the ability to understand and understand their own experiences and feelings as well as those of others – ie to mentalize. At MBT, therefore, the focus is on the experience of those affected and the ability to empathize with others. The mentalization-based borderline therapy takes place in groups.
The transmission-focused psychotherapy is another form of borderline therapy. It consists of a preparatory and several therapy phases. In the preparatory phase , the person concerned and the therapist conclude a treatment agreement orally in which the therapeutic goals are defined. The individual therapy goals are then processed in different therapy phases. For example, in a therapy phase at the beginning of treatment, the goal may be to better control one’s own behavior and process one’s own feelings.
Medications (so-called psychotropic drugs ) can complement the therapy in borderline syndrome: for exampleNeuroleptics that are also used in schizophrenia therapy , or selective serotonin reuptake inhibitors.
Borderline Personality Disorder syndrome: often takes a chronic course
The course can be very different in borderline syndrome . With increasing age, the intensity of the disorder usually decreases, so that many adults are psychologically more stable in adulthood both in the private and in the professional field.
Borderline Personality Disorder syndrome often takes a chronic course . In addition to persistent instability in various areas, sufferers with borderline personality disorder often lose in stages completely in control of their feelings. In the case of borderline syndrome, the course depends heavily on adequate therapy. Since Borderline Personality Disorder is characterized by multiple difficulties in interpersonal relationships and self-harming behavior, treatment is often difficult. For example, sufferers with borderline syndrome often change the therapist.
Typical behavior in a borderline disorder is often observed in those affected in childhood and adolescence. However, the diagnosis “borderline syndrome” should not be made before the age of 14, because until then the personality of a person is still subject to strong developments.
How to treat Borderline Personality Disorder (BPS)
One of the very few treatment approaches that have been proven (proven) in BPS therapy is Marsha M. Linehan’s “Dialectic Behavioral Therapy in Borderline Personality Disorder”, MM Linehan is a psychologist at a psychiatric ward in Seattle, USA, specializing in the treatment of self-harm.
Time and again, the treating psychologists and doctors have to realize that many BPS patients stop the treatment. They often move from one therapy or medical treatment to another, only to end them there after a short time. Conversely, for therapists working with BPS patients is sometimes a significant burden that can lead to tensions in the therapeutic working relationship. The drop-out rate in the treatment of BPS is very high compared to other mental health problems.
In the course of 20 years of work, M. Linehan and her colleagues have tried to find out why so many BPS patients are often unable to perform regular psychotherapy. And they were able to gain many important insights into how therapists and patients need to work together so that therapy can actually bring relief to the often unbearable suffering of sufferers.
The result is “Dialectical Behavioral Therapy,” a sometimes very rigorous treatment model in which there are some clear rules right from the start (see below). Many elements of the treatment are derived directly from the explanatory model that appears on the page “How to explain a borderline personality disorder?” is shown. Since the treatment concept is very extensive,
Balancing between changing and accepting
Because BPS patients have been suffering from strong emotions for a long time and have found so much misunderstanding in their environment (“invalidating environment”), they vacillate between the two extremes, believing either their own feelings or the opinions of other people.
Sometimes they have the impression that their strong negative feelings have their good reason and are desperate about their stressful situation, sometimes they agree with the negative opinion of their environment (for example, if they say that one is “hysterical” or “one should to pull themselves together “) and then evaluate themselves as” weak “or” bad “.
In the DVT, therapists try to work against this development by repeatedly searching for and finding the true core of their feelings together with the patients. They try to counteract the invalidating environment and help patients to clearly recognize their feelings and to trust them more again, So, when those affected feel strong anger or severe sadness and depression, therapists help them to accept these feelings as appropriate and appropriate.
On the one hand, this is always a confirmation and reassurance for the patients who have experienced the opposite many, many times. On the other hand, of course, they have to recognize and accept a very negative reality. You may have to accept that important people often make mistakes out of congestion, but they are only human, that they are being treated unfairly, that injustice belongs to life and that sometimes it has to endure, and so on. This experience is very painful for BPS patients, sometimes unbearable.
Simply accepting that one’s own life is extremely stressful, without at the same time seeing a way out of the burden, would be extremely depressing for anyone. Of course, the second important part of treatment in DVT is the development of skills (see below) that will allow patients to change and manage stress over time.
Thus, balance and quality of life can gradually be built up. This is a normal part of any behavioral therapy. Much more than other problems, BPS’s Dialectical Behavioral Therapy emphasizes not just working on change.
It seeks to strike a balance between accepting one’s own feelings (and thus accepting a negative reality) and building skills (and thus change). A single focus on change would indirectly communicate to BPS patients that they would only have to change themselves, then everything will be fine again. Those concerned know this message only too well: their feelings are wrong, they react wrongly, they are asked to pull themselves together.