Borderline personality disorder is a personality disorder that affects many people in today’s society. Dealing with borderline personality disorder is challenging for not only the people who suffer from this disorder, but also the people that are most close to them. Emotion regulation, teaching the patient how to deal with overwhelming or negative emotions, is used to help patients try to maintain better and stable relationships. Pharmacological therapy and DBT, dialectical behavior therapy, are two types of therapy that are used when treating borderline personality disorder. Going along with DBT, mindfulness is used in teaching the patients how to live in the moment and being able to feel their emotions but without dwelling on them.
Keywords: borderline personality disorder, mindfulness, DBT, emotion regulation, emotion dysregulation
Borderline personality disorder falls into cluster B of personality disorders, referred to as the dramatic, emotional, and erratic cluster. Disorders in this cluster typically share problems in impulse control and also emotion regulation. Borderline personality disorder is a severe psychiatric condition marked by a pervasive pattern of emotional dysregulation, impulsive behavior, identity problems, and interpersonal conflicts (Elices, Pascual, Carmona, et al., 2015). Borderline personality disorder has been described as an extreme and maladaptive variant of normal temperamental dimensions; such as neuroticism, impulsiveness, and aggression-hostility (Elices, Pascual, Carmona, et al., 2015). Certain studies have revealed that certain contextual factors, such as adverse childhood experiences, are also related to borderline personality disorder symptoms and how severe it is (Elices, Pascual, Carmona, et al., 2015). Traumatic experiences and neuroticism are also independent predictors of borderline personality disorder severity; neuroticism and adverse childhood experiences having interaction does not only add more severity to borderline personality disorder, but it also adds to the development of borderline personality disorder (Elices, Pascual, Carmona, et al., 2015). According to the current DSM, DSM-IV, in order for someone to be diagnosed with borderline personality disorder they have to fit five out of the nine criteria (Zanarini, 2014). The five-factor model is the trait model that is used for reformulating personality disorders; extraversion, agreeableness, conscientiousness, neuroticism, and openness (Zanarini, 2014). Borderline personality disorder is consistently associated with high neuroticism, low agreeableness, and low conscientiousness (Zanarini, 2014). Low extraversion, such as low warmth and low positive emotions, are also sometimes associated with borderline personality disorder (Zanarini, 2014).
One of the major downfalls of borderline personality disorder is their unstable relationships, meaning that it is extremely hard for someone with borderline personality disorder to deceiver whether or not what they believe about a relation is true, or because of their disorder (Albright, 2016). For example, if someone sends a text message to a friend and they do not answer, the rational thought would be that the person is busy and will get back to them when they can. Someone who suffers from borderline personality disorder, they would automatically go back and forth between that or the fact that this person is trying to tell them that they do not want to be friends anymore, that they are ignoring them, they think they are a burden, etc. In doing such, the person who suffers from borderline personality disorder may actually end up sabotaging the relationship with this person because what they are thinking seems rational to them, but in reality is not. According to the research article by Albright (2016), borderline personality disorder patients are regularly classified as having preoccupied, unresolved, or fearful attachment patterns (Agrawal, Gunderson, Holmes, et al., 2004). Persistent loneliness is one of the key experiences reported by individuals who suffer from borderline personality disorder (Lis, 2016). Adler and Buie identified the experience of painful aloneness as a core disturbance and central aspect of people who suffer from borderline personality disorder (Lis, 2016). Loneliness and aloneness have both been linked to the experience of emptiness, which is one of the diagnostic criteria for borderline personality disorder (Lis, 2016). Peplan and Perlman (1982) emphasizes that feelings of loneliness can arise when patients perceive a discrepancy between desired and actual social relationships (Lis, 2016). Like in the text message example, people who suffer from borderline personality disorder tend to internalize feelings about their relationships that are in fact not true, but to them it feels true, thinking that someone does not really care about you when in fact the person has never done or said anything that could back that thought up.
Emotional switching defined as the occurrence of sudden emotional changes from a positive to a negative emotional state or vice versa, is a specific type of emotional instability of someone who has borderline personality disorder (Houben, Claes, Sienaert, et al., 2015). People who suffer from borderline personality disorder experience a) high emotional sensitivity to emotional stimuli b) intense reactivity to emotional stimuli and c) a slow return to an emotional baseline (Houben, Claes, Sienaert, et al., 2015). In a study by Coifma, Berenson, Rafelia, et al., (2012) it showed that borderline personality disorder patients tend to evaluate their affective experiences in a more polarized manner, either good or bad, which was shown by a stronger negative association between momentary positive and negative affect over time (Houben, Claes, Sienaert, et al., 2015). In another study by Second, Linehan, Bohus, et al., (2008) they looked at the occurrence of emotional switching in borderline patients, concluding that these patients switch from anxiety to sadness more frequently, then anxiety to anger, and lastly sadness to anxiety (Houben, Claes, Sienaert, et al., 2015). In effective treatments of borderline personality disorder, dialectical behavioral therapy, DBT, emotion regulation skills training is often an important component focusing on teaching patients how to handle emotions and emotional responses (Houben, Claes, Sienaert, et al., 2015).
Dialectical behavioral therapy, DBT, is an approach that was first introduced by Dr. Marsha Linehan in the United States (O’Connell, Dowling, 2014). Linehan was hospitalized at age 14 due to consistently cutting her arms, legs, stomach, and burning of her wrists with cigarettes (O’Connell, Dowling, 2014). After she was released, she vowed that she was going to do something to help not only herself but others, which is how she went on to study clinical psychology and developed DBT for the treatment of women with chronic self-harming and suicidal tendencies (O’Connell, Dowling, 2014). DBT is a complex therapy that is normally delivered over a year, aiming to change behavior and manage emotions and behaviors through a balance and synthesis of both acceptance and change (O’Connell, Dowling, 2014). It involves acceptance of oneself as one is, derived from Zen Buddhist theory, and taught practically as mindfulness and self-acceptance techniques (Bendit, 2014). DBT states that there is no one truth, and therefore there is a need to integrate multiple perspectives in any complex human problem (Bendit, 2014). DBT uses principles of CBT, cognitive behavior therapy, combined with mindfulness, acceptance, and dialectics (O’Connell, Dowling, 2014). Linehan suggested that borderline personality disorder is primarily a dysfunctional emotional regulation system (O’Connell, Dowling, 2014). DBT includes weekly one on one session and skills group training, as well as access to individual therapists in case of a crisis (O’Connell, Dowling, 2014).
The four modes of intervention for DBT are 1) group therapy 2) individual psychotherapy 3) phone calls and 4) consultation team meetings, which run usually over a year period (O’Connell, Dowling, 2014). The root of DBT is in behavioral therapy; where the intention is to target problem behaviors, monitor them, and then systematically analyze the emotional/cognitive/behavioral drivers of the behavior (Bendit, 2014). This involves targeting deliberate self harm or suicidal urges or behaviors and working with the patient to figure out what factors make the behavior more likely to occur (Bendit, 2014). An important component is learning new life skills that are typically taught in a group program that runs alongside individual therapy (Bendit, 2014). Stage 1 of DBT has the goal of behavioral control of maladaptive behaviors of borderline personality disorder, stage 2 involves exposure techniques for PTSD and although some of the techniques of stage 1 will be reinforced in this stage, the treatment now becomes any evidence based approach that can deal with PTSD (Bendit, 2014). Stage 3 involves reclaiming ordinary happiness, and stage 4 is finding a higher purpose in order to make a complete recovery (Bendit, 2014).
Going along with DBT, one of the concepts that go hand in hand is mindfulness. Mindfulness can be described as a particular way to pay attention to the present moment, in an inquiring and accepting manner without judging or reacting to the experience (Elices, Pascual, Carmona, et al., 2015). Mindfulness has five constructs; 1) the capacity to observe and notice the current experience 2) the ability to describe the experience 3) a non-judgmental and non-evaluative stance 4) non-reactivity to an inner experience and 5) acting with awareness (Elices, Pascual, Carmona, et al., 2015). Mindfulness is taught to people who have borderline personality disorder based on the idea that patients have a deficit in certain important mindfulness capabilities, and that this deficit is associated with symptoms of the disorder (Elices, Pascual, Carmona, et al., 2015).
The four noble truths of mindfulness address the concept of suffering and the ability to be still 1) life means suffering 2) the origin of suffering is attachment 3) the cessation of suffering is attainable and 4) there is a path to end suffering (Aguirre, Galen, 2013).
Two mindfulness practices that Aguirre and Galen talk about in their book “mindfulness for borderline personality disorder” are RIDE THE WAVE and BEHAVE and THINK. RIDE THE WAVE teaches the patient to mindful of their current situation; Register your body sensations, Identify your action urges, Determine the emotion, Express to yourself nonjudgmentally, Take deep breaths, Hands and body are open, Establish a grounded position, and WAVE watch and notice your emotion as if it were a wave (Aguirre, Galen, 2013). BEHAVE is used when patients feel as though they are going to act in a relationship-destroying fashion; Breathe and stay in this moment, Experience and label emotions as they arise, Hear what the other person is saying and notice your judgments, Apologize to the other person if you have not upheld your values, Validate that each of you may have a different point of view, and Expand your awareness by taking in as many different aspects of the relationship as you can (Aguirre, Galen, 2013). THINK is also used for this as well; Take a breath to slow yourself down, Hold your hands open, palms facing upward, Identify any cognitive distortions, you are not your thoughts, and be kind to yourself (Aguirre, Galen, 2013).
Other than DBT, pharmacological therapy is also used when treating borderline personality disorder. Although medication cannot “cure” borderline personality disorder, it makes it easier for the person to live with. Medication helps the patient feel more in control of their emotions, perceptions, thinking, and behavior (Friedel, 2012). Medication mainly helps in reducing symptoms and enhancing the therapeutic results of psychotherapy (Friedel, 2012). The two types of medications that work the best in helping to treat borderline personality disorder are mood stabilizers and antipsychotic agents (Friedel, 2012). Mood stabilizers do not reduce suspiciousness, spilt thinking, dissociative episodes, or paranoia in borderline personality disorder, but they reduce symptoms such as impulsivity, anger, anxiety, depressed mood, and general level of functioning for the patient (Friedel, 2012). Antipsychotic agents help in coping with what mood stabilizers lack; suspiciousness, spilt thinking, dissociative episodes, and paranoia (Friedel, 2012). The effectiveness of medications in treatment depends on both the specific symptoms of the patient, the medication that is selected, and the biological makeup of the patient (Friedel, 2012).
Borderline personality disorder is a personality disorder that effects many people of today’s society, and although there is exact “cure” for it, there are multiple ways for a person who suffers from this mental illness to cope and live a full functioning life with it. DBT, dialectical behavior therapy, and pharmacological therapy are two types of therapy that help patients in doing so, and including in DBT patients will learn mindfulness skills, helping them be able to live in the moment rather than living in the past or the present, without judgement and teaching them that not every action needs a reaction.
- Aguirre, B. A., & Galen, G. (2013). Mindfulness for borderline personality disorder: Relieve your suffering using the core skill of dialectical behavior therapy. Oakland, CA: New Harbinger Publications.
- Albright, J. (2016). Object relations predicts borderline personality disorder symptoms beyond emotional dysregulation, negative affect and impulsivity. Personality Disorders: Theory, Research, and Treatment, online first publication, 1949-2715. http://dx.doi.org/10.1037/per0000188
- Bendit, N. (2013). Reputation and science: Examining the effectiveness of DBT in the treatment of borderline personality disorder. Australasian Psychiatry, 22 (2), 144-148. Doi:10.1177/1039856213510959
- Elices, M., Pascual, J. C., Carmona, C., et al., (2015). Exploring the relation between childhood trauma, temperamental traits and mindfulness in borderline personality disorder. BMC Psychiatry, 15 (1). Doi:10.1186/s12888-015-0573-z
- Friedel, R. O. (2004). Borderline personality disorder demystified: An essential guide for understanding and living with BPD. New York: Marlowe & Co.
- Houben, M., Claes. L., & Sienaert, P., (2015). Emotional switching in borderline personality disorder: a daily life study. Personality Disorders: Theory, Research, and Treatment, 7 (1), 50-60. http://dx.doi.org/10.1037/per0000126
- Lis, S. (2016), Loneliness, social networks, and social functioning in borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, online first publication, 1949-2715. http://dx.doi.org/10.1037/per0000208
- O’Connell, B., & Dowling, M. (2013). Dialectical behavior therapy (DBT) in the treatment of borderline personality disorder. Journal of Psychiatric and Mental Health Nursing ,21 (6), 518-525. Doi:10.1111/jpm.12116
- Rizvi, S. L., Hughes, C. D., & Thomas, M. C. (2016). The DBT coach mobile application as an adjunct to treatment for suicidal and self-injuring individuals with borderline personality disorder: a preliminary evaluation and challenges to client utilization. Psychological Services, online first publication, 1541-1559.