Borderline Personality Disorder: Diagnosis and Treatment

Table of Contents

One of the most prevalent PDs is borderline personality disorder (BPD), which involves a range of psychosocial symptoms. Its predisposing factors include both physiological and psychological aspects. BPD causes life instability, sensitiveness, and fear. It was considered an untreatable condition for decades but now can be effectively treated by various evidence-based methods (Choi-Kain, Finch, Masland, Jenkins, & Unruh, 2017). A number of therapies have been developed for the treatment of BDP. Understanding the associated clinical features of BDP, risk factors, and precursors by nurse practitioners is critical in providing optimal care for patients with this disorder, which is prevalent in clinical settings. Therefore, the aim of this paper is to review and summarize the predisposing factors, symptoms, and available treatments for BDP.

Predisposing Factors

Several studies suggest that the onset of BDP results from the gene-environment interaction. Specifically, changes in brain functioning that are triggered by childhood exposures to traumatic situations can predispose one to this disorder. The hypothalamic-pituitary-adrenal (HPA) axis is among the neurobiological mechanisms implicated in BDP development. Cattane, Rossi, Lanfredi, and Cattaneo (2017) explain that in stressful situations, the hypothalamic paraventricular nucleus produces “corticotrophin-releasing factor and arginine vasopressin”, which stimulate the secretion of the adrenocorticotropic hormone that induces cortisol synthesis by the adrenal glands (p. 5). This hormone affects a number of physiological functions, including cognition and behavior by interacting with receptors in the hypothalamus and pituitary gland. Therefore, HPA axis (stress response center) dysfunction can cause BPD.

Traumatic experiences in childhood constitute another predisposing factor. Children exposed to maltreatment, emotional abuse, or neglect are more likely to exhibit symptoms consistent with BPD diagnosis in adulthood than controls (Martin-Blanco et al., 2014). Their BPD vulnerability relates to the deleterious effects of childhood stress on neurobiological systems. Co-occurring disorders, including bipolar disorder, depression, and eating and anxiety disorders, also increase the risk of BPD. These trauma-related conditions show similar symptoms as BPD, which include “pathological dissociation, somatizations, and altered central self-schemas” (Cattane et al., 2017, p. 2). They affect the development of behavioral and emotional regulation, mediating the association between trauma in childhood and BPD.

Symptoms

BDP primarily involves clinical presentations of depressed moods and risk-taking behavior. Based on the DSM-5 diagnostic criteria, the core symptoms of this disorder are the fear of abandonment, unstable relationships, identity (self-image) disorder, impulsivity or self-harming behaviors, suicidal ideation, emotional swings, uncontrolled anger, feelings of emptiness, and suspiciousness (Brüne, 2016). The confirmation of any five of these signs is required for BDP diagnosis. Emotional dysregulation may explain symptoms related to idealization, such as impulsive acts and risk-taking behaviors (Brüne, 2016). These signs can be viewed as a behavioral response to high-level stress, which is consistent with the model that links changes in HPA axis to BDP development.

Treatment

A number of specialized, evidence-based treatments with varying levels of efficacy have been developed for BDP. Among the available interventions, the dialectical-behavioral therapy (DBT) is considered the most effective option. This adaptable outpatient treatment method uses the cognitive-behavioral approach to address BDP symptoms by teaching healthier coping tactics, including mindfulness and emotional regulation (May, Richardi, & Barth, 2016). It entails four basic elements: skills training, personalized psychotherapy, remote consultation, and psychotherapist visits. In contrast, the schema-focused therapy targets negative or dysfunctional thoughts or schema beliefs mostly developed in childhood. This cognitive-behavioral intervention involves three phases: assessment to identify cognitive distortions, an experiential stage (teaching coping skills), and behavioral change – replacing unhealthy thoughts with healthy ones (May et al., 2016). This integrative approach can be used to help BDP patients learn new, more adaptive schemas.

Another therapeutic option is the mentalization-based treatment (MBT) seeks to strengthen a patient’s ability to “mentalize under the stress of attachment activation” (Choi-Kain et al., 2017, p. 23). It entails stimulating curiosity to motivate individuals to reevaluate their emotional and interpersonal problems. Another treatment for BDP is the systems training for emotional predictability and problem solving (STEPPS). It entails a 20-week group therapy that includes cognitive-behavioral therapy, skills training, and systems component to improve social functioning (Choi-Kain et al., 2017). In contrast, transference-focused therapy (TFT) seeks to modify problematic interpersonal aspects that cause emotional distortions. TFT depends on the transference mechanism of patient-therapist engagement to resolve disordered negative perceptions in patients and replace them with more balanced thought patterns (Choi-Kain et al., 2017). Thus, the therapist plays a supervisory role in this treatment.

Conclusion

Borderline personality disorder has various psychological symptoms, including emotional swings and instability. Several types of evidence-based psychotherapies exist for this condition, with dialectical-behavioral therapy being the most effective treatment. Most of these interventions focus on replacing maladaptive cognition and behavior in BDP patients with healthier and adaptive ones through skills training.

References

Brüne, M. (2016). Borderline personality disorder: Why ‘fast and furious’? Evolution, Medicine, and Public Health, 2016(1), 52-66. Web.

Cattane, N., Rossi, R., Lanfredi, M., & Cattaneo, A. (2017). Borderline personality disorder and childhood trauma: Exploring the affected biological systems and mechanisms. BMC Psychiatry, 17(221), 1-14. Web.

Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports, 4(1), 21-30. Web.

Martin-Blanco, A., Soler, J., Villalta, L., Feliu-Soler, A., Elices, M., Perez, V., … Pascual, J. C. (2014). Exploring the interaction between childhood maltreatment and temperamental traits on the severity of borderline personality disorder. Comprehensive Psychiatry, 55(2), 311–318. Web.

May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. Mental Health Clinician, 6(2), 62-67. Web.

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