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What is BDP

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Post  Guest on Thu 1 Jul - 10:13

Borderline Personality Disorder is one of ten personality disorders recognised by the DSM IV.

A personality disorder is a type of mental illness and to be diagnosed particular criteria must be met. With personality disorders, the symptoms have usually been present for a long time. These symptoms have an overall negative affect on the sufferer’s life.

One of the core signs and symptoms in BPD is the proneness to impulsive behaviour. This impulsiveness can manifest itself in negative ways. For example, self-harm is common among individuals with BPD and in many instances, this is an impulsive act. Sufferers of BPD can also be prone to angry outbursts and possibly criminal offences (mainly in male sufferers) as a result of impulsive urges.

Another common feature of BPD is affective lability. This means that sufferers have trouble stabilising moods and as a result, mood changes can become erratic. Other characteristics of this condition include reality distortion, tendency to see things in ‘black and white’ terms, excessive behaviour such as gambling or sexual promiscuity, and proneness to depression.
(To learn more about symptoms and diagnostic criteria please go to the section on diagnostic criteria.)

These traits can sometimes make it very difficult for a person to maintain a relationship with someone with BPD as their behaviour and actions can be difficult to tolerate and hard to understand. It is important for persons close to a BPD sufferer to educate themselves on the condition so they can empathise with what the sufferer is going through and how they are feeling.

BPD is not usually diagnosed before adolescence. It has been suggested that BPD symptoms can sometimes improve as time goes on or even disappear all together. This is not always the case however as BPD can continue to affect sufferers well into later life.

Traits from other mental illnesses and psychological conditions from the DSM IV can often co-exist in BPD patients. These are usually anxiety disorders, eating disorders, obsessive-compulsive disorder (OCD) and bipolar disorder (also known as manic depression).

Is borderline personality disorder a mental illness?
Yes! A mental illness is an illness that affects a person’s behaviour primarily rather than their physical well-being. BPD is considered by medical practitioners to be a severe psychiatric disorder. It is recognised as such by the DSM IV.

Mental illness is often not taken as seriously as physiological illness even though it is very common and can be very debilitating. It is often viewed as moodiness, craziness or a weakness when it is in fact a genuine illness that can be caused by physiological factors. People have as much control over developing a mental illness as they do over catching a cold. Like physical illness, mental illness needs treatment and is not something that someone can just will to go away.

Why the name borderline?
The name borderline was coined by Adolph Stern in 1938. This name was used to describe patients who were on a ‘borderline’ between neurosis and psychosis. However, the symptoms of BPD are not so simplistic as to be defined in terms of neurotic and psychotic. The diagnosis of BPD is based upon signs of emotional instability, feelings of depression and emptiness, identity and behavioural issues rather than signs of neurosis and psychosis. However, the name Borderline has remained even though the definition has changed. Throughout Europe, the same disorder has been given the more appropriate and less misleading title of ‘Emotionally Unstable Personality Disorder.’
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Post  FSoares on Thu 1 Jul - 11:05

Good finding Antoinette. What is BDP Icon_flower
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Post  Guest on Thu 1 Jul - 11:48

According to the DSM IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), “A person who suffers from borderline personality disorder has labile interpersonal relationships characterised by instability”. This pattern of interacting with others will have persisted for years, and is usually closely related to the individual’s self-image and early social interactions. The pattern is present in a variety of settings (i.e. not just at work or home), and is often accompanied by a similar lability (fluctuation back and forth, often in a quick manner) in a person’s affect (mood) or feelings. Relationships and the person’s affect may often be characterised as shallow. A person with this disorder may also exhibit impulsive behaviours and exhibit a majority of the following symptoms:


1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterised by alternation between extremes of idealization and devaluation.

3. Identity disturbance - markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging, e.g. spending, sex, substance abuse, reckless driving or binge-eating.

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.

6. Affective instability due to a marked reactivity of mood, e.g. intense episodic dysphoria, irritability or anxiety, which usually lasts for between a few hours and several days.

7. Chronic feelings of emptiness

8. Inappropriate, intense anger, or difficulty controlling anger, e.g. frequent displays of temper, constant anger or recurrent physical fights.

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Anyone with six or more of the above traits and symptoms may be diagnosed with Borderline Personality Disorder. However, the traits must be long-standing (pervasive), and there must be no better explanation for them, e.g. physical illness, a different mental illness or substance misuse.


ICD
The ICD (International Classification of Diseases) also provides a description of BPD. The ICD 10 calls the disorder by its European name - ‘emotionally unstable personality disorder’. The ICD describe BPD as a:

“Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.”

(www.who.int/classifications 2005)


Borderline Personality Disorder is one of ten personality disorders recognised by the DSM IV.

A personality disorder is a type of mental illness; in order to be diagnosed, certain criteria must be met. With personality disorders, the symptoms have usually been present for a long time. These symptoms have an overall negative affect on the sufferer’s life.

Many people with BPD are prone to impulsive behaviour. This impulsiveness can manifest itself in negative ways. For example, self-harm is common among individuals with BPD and, in many instances, this is an impulsive act. Sufferers of BPD can also be prone to angry outbursts and even criminal offences as a result of impulsive urges (mainly male sufferers).

Another common feature of BPD is affective liability; sufferers have trouble stabilising moods - as a result, mood changes can become erratic. Other characteristics of this condition include the distortion of reality, a tendency to see things in ‘black and white’ terms, excessive behaviour such as gambling or sexual promiscuity, and proneness to depression. To learn more about symptoms and diagnostic criteria, please go to the section on diagnostic criteria.

These traits can sometimes make it very difficult for a person to maintain a relationship with someone with BPD, as their behaviour and actions can be difficult to tolerate and hard to understand. It is important for those close to a BPD sufferer to educate themselves on the condition so that they can empathise with what the sufferer is going through and how they are feeling.

BPD is not usually diagnosed prior to adolescence. It has been suggested that BPD symptoms can sometimes improve as time goes on, or even that they can disappear altogether. This is not always the case, however, as BPD can continue to affect sufferers well into later life.

Traits from other mental illnesses and psychological conditions from the DSM IV can often co-exist in BPD patients. These are usually anxiety disorders, eating disorders, obsessive-compulsive disorder (OCD) and bipolar disorder (also known as manic depression).

Is borderline personality disorder a mental illness?
Yes. A mental illness is an illness that primarily affects a person’s behaviour, as opposed to their physical well-being. BPD is considered by medical practitioners to be a severe psychiatric disorder and is recognised as such by the DSM IV.

Often, mental illness is not taken as seriously as physiological illness, even though it is very common and can be very debilitating. It is often viewed as moodiness, craziness or a weakness, when it is in fact a genuine illness that can be caused by physiological factors. People have as little control over the development of a mental illness as they do over whether they catch a cold or not. As with physical illness, mental illness requires treatment, and is not something that someone can just will to go away.

Why the name borderline?
The name borderline was coined by Adolph Stern in 1938. The name was used for patients who were on a ‘borderline’ between neurosis and psychosis. However, the symptoms of BPD are not as simple as this description might make them sound: the diagnosis of BPD is based upon signs of emotional instability, feelings of depression and emptiness, and identity and behavioural issues, rather than signs of neurosis and psychosis. However, the ‘borderline’ label has remained, even though the definition has changed. Throughout Europe, the same disorder has been given the more appropriate, and less misleading, title of ‘Emotionally Unstable Personality Disorder.’
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Post  Guest on Thu 1 Jul - 11:49

There are many theories as to what causes and influences the occurrence of Borderline Personality Disorder. No one factor has been recognised as the ‘true’ cause of BPD.

Developmental
In people with BPD there is often a history of childhood sexual abuse, physical abuse, witnessing violence in the home, emotional abuse and neglect. BPD patients often come from a background of dysfunctional family relationships. This suggests that trauma and suffering of this ilk could be a key factor in why people may go on to develop BPD.

This cannot be considered the sole reason as to why BPD occurs. However, this cannot be ignored because such a high percentage of sufferers report the aforementioned types of childhood experience. It has been suggested that BPD may be a form of, or similar to post traumatic stress disorder.

Biological
Another accepted theory is that BPD may be a result of biological and genetic factors.

According to research, there is evidence to suggest a genetic component. Parents with BPD have an increased likelihood of having children who are prone to BPD and other psychiatric disorders. Genetic factors may cause a slight susceptibility to a person developing BPD. This susceptibility may only result in a disorder when nurtured in a triggering environment i.e. that of abuse or neglect.

Some medical professionals also believe that physical problems in the brain may be a contributing factor or cause of BPD. It has been suggested that BPD can be attributed to brain damage caused to a baby in the womb or during or after birth. There is also some evidence of organic lesions in the brains of people with BPD. Brain imaging has reportedly seen abnormalities in the brains of BPD sufferers.

Other than physical damage to the brain, it has been theorised that there may be a chemical dysfunction in the brains of BPD patients. Hormonal and chemical imbalances found in some BPD subjects may explain some of the BPD symptoms. Investigations have shown BPD patients to have imbalances of several chemicals including serotonin, dopamine, norepinephrine (noradrenaline) and acetylcholine monoamine oxidase.

Both theories are largely indefinite as there is a lack of evidence to conclusively prove either theory. However both genetic and environmental theories are held to be credible, particularly the developmental theories (i.e. childhood experiences) and it is likely that a combination of these increases the chances of developing BPD.
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Post  Guest on Thu 1 Jul - 11:49

Often, newly diagnosed patients are told that they have a personality disorder, that it is very complex and that there is no cure. A lot of psychiatrists believe that medication does not work on people with personality disorders and therefore should not be prescribed, so patients are often also told there is no medicine available that will help. Due to the behaviour of someone who has a personality disorder they are commonly called manipulative, attention-seeking, demanding and obstructive. I would like to go through these individually.

Manipulative
Dictionary definition: “To manage or influence skilfully, esp. in an unfair manner: to manipulate people's feelings”

This is a very harsh comment to make about someone that is using the best skills they have available. Try to imagine what someone with a personality disorder has gone through, and then think about what extremes you would go to protect yourself. Isn’t it true that life is a fight for survival or would it be seen that way through the eyes of someone with a personality disorder?

Attention Seeking
Dictionary definition: “seizing the attention”

There are many people with personality disorders; they may be considered attention seekers but let me ask you, if you had a cold, what is it you look for from your partner or friends? Isn’t it comfort, reassurance and attention? So why would it be any different for someone suffering from severe emotional distress? The other point to note on this is that people with personality disorders have often had their behaviours reinforced. As an example should someone with a personality disorder threaten to cut themselves with a knife because their partner was going out for a drink with a mate and in turn the partner agreed not to go, the behaviour is reinforced and makes it more likely to occur again.

Demanding
Dictionary definition: “requiring more than usually expected or thought due; especially great patience and effort and skill”

Imagine having a broken leg, you know there is treatment and with a little patience you will be better before you know it. With a personality disorder you are likely to experience the problem for many years with no real hope of a cure but your symptoms are likely to lessen as you grow older. Unlike a broken leg, you can not exactly see what is wrong but you can definitely feel it. I am sure everyone will agree this would make anyone quite demanding and impatient.

Obstructive
Dictionary definition: “To impede, retard, or interfere with; hinder”

People with mental health issues have been often through mental health services for years. People with a personality disorder are likely to be involved with services for much longer than the standard mental health patient. They are offered so many services and therapies that have different names but often mean the same; they often end up feeling like a bit of a guinea pig, and reluctant to continue with another service or therapy.
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Post  Guest on Thu 1 Jul - 11:50

Borderline personality disorder is regarded as difficult to treat, with therapy usually lasting for at least a year. During treatment it is important, as with the treatment of other personality disorders, that a structured and therapeutic setting is established from the onset. Client’s with borderline personality disorder are often discriminated against by mental health care professionals and regarded as “trouble-makers”. It is important that therapists takes into consideration the fact that the client’s behaviour, whilst sometimes regarded as inappropriate, is a result of their disorder. The main aim of therapy should be to provide a highly structured environment in which the client’s ability to live more independently is improved.

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Post  Guest on Thu 1 Jul - 11:50

Why choose a therapeutic community?
The services provided to those with Borderline Personality Disorder can often not provide the support these clients need. In some cases weekly therapy may be provided, but the gap between these sessions can often cause clients to feel alone. As those with BPD can struggle with both closeness and being alone, the time between therapy sessions can result in crisis; with clients engaging in both self-harm and suicidal behaviours. In this case in-patient treatment may be provided. However, this can result in a both a loss of control over their everyday lives and privacy, which can therefore lead to further distress. Although in-patient treatment in a psychiatric ward may provide some short-term benefits, in the long run staff do not have the opportunity to work with the client therapeutically and gain a full understanding of them. However, out-patient treatment is also not enough. When this is the case, therapeutic communities, which provide residential and day-care treatment, specifically for those with personality disorders may be considered.

How are therapeutic communities structured?
Therapeutic communities offer an intensive programme and vary in length from a daily residential programme to a weekly one-day session. This programme can further vary between lasting a number of weeks, months, years or indefinite period of time. In order for a therapeutic community programme to be effective clients are encouraged to attend on a regular basis, with lateness or non-attendance being challenged as part of the therapy. Within a therapeutic community, sessions are usually group-based although some may also be held on an individual basis as part of the programme. Group sessions usually consist of a small number of people and have an interpersonal and psychodynamic focus. Group sessions may also include friends and family members, depending on the needs of the client.

Therapeutic community availability
Despite the growing push for day treatment as opposed to day-care, for some people a residential therapeutic community may be the best option as it provides them with the support they need to manage their feelings in a safe environment and to learn from others who are experiencing similar emotions. The availability of therapeutic communities however, is rather limited. In the UK there are 28 such communities, 2 of these are found within prisons, 17 are voluntary agencies, with only the remaining 9 being run by the NHS.
Within a therapeutic community, the clients themselves take on many staff functions in regards to the day to day running of the community. This includes cooking, cleaning, administration, finances and new admissions into the community. This provides them with a valued and necessary role within the community.
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Post  Guest on Thu 1 Jul - 11:51

Therapies for BPD
There are relevant therapies to treat Borderline Personality Disorder (BPD), these are:

Cognitive Behaviour Therapy

This can help you to change how think and what you do in everyday situations. Unlike some talking therapies this focuses on the ‘here and now’ problems and things you find hard. It looks at ways of improving your state of mind now, instead of causes of your distress from the past. It breaks down problems into smaller pieces (Thoughts, emotions, physical feelings and actions) and this makes it easier to see how they affect you and how that can be changed overtime. CBT can be done individually (therapist) and sessions will last between 5 and 20 depending the severity of the disorder or with a group of people.

Cognitive Analytical Therapy

This is a time limited therapy which aims and focuses on repeating patterns that were learnt in childhood as a way of coping with emotional difficulties and deprivations. This helps to recognise and change unhelpful patterns in relationships and behaviour. This therapy will last anywhere between 16-20 sessions and lasting around hour each time.

Psychotherapy

This is a long-term talking therapy that aims to find the roots of present feelings and behaviour. It helps the patient understand what helps them feel positive or anxious, as well as accepting their strong and weak points. If people can identify their feelings and ways of thinking they become better at coping with difficult situations.This strongly relies on a strong and trusting relationship between client and therapist. This therapy can last months or even years.


Dialectical behaviour therapy (DBT)

DBT was designed by Marsha Linehan is regarded as the most effective treatment for client’s with borderline personality disorder as it was created specifically to treat those with the disorder. The aim of DBT is to teach the client to take control of their emotions and their lives. It is frequently used through a group therapy setting, although it may not be an ideal treatment for those clients who struggle to learn new concepts.

Dialectical Behaviour Therapy (DBT) has been defined as:

“A novel method of therapy specifically designed to meet the needs of patients with Borderline Personality Disorder and their therapists. It directly addresses the problem of keeping these patients in therapy and the difficulty of maintaining therapist motivation and professional well-being. It is based on a clear and potentially testable theory of BPD and encourages a positive and validating attitude to these patients in the light of this theory.

The approach incorporates what is valuable from other forms of therapy, and is based on a clear acknowledgement of the value of a strong relationship between therapist and patient. Therapy is clearly structured in stages and at each stage a clear hierarchy of targets is defined. The method offers a particularly helpful approach to the management of parasuicide with a clearly defined response to such behaviours.

The techniques used in DBT are extensive and varied, addressing essentially every aspect of therapy and they are underpinned by a dialectical philosophy that recommends a balanced, flexible and systemic approach to the work of therapy. Techniques for achieving change are balanced by techniques of acceptance, problem solving is surrounded by validation, confrontation is balanced by understanding.

The patient is helped to understand her problem behaviours and then deal with situations more effectively. She is taught the necessary skills to enable her to do so and helped to deal with any problems that she may have in applying them in her natural environment. Generalisation outside therapy is not assumed but encouraged directly. Advice and support available between sessions and the patient is encouraged and helped to take responsibility for dealing with life's challenges herself. The method is supported by empirical evidence which suggests that it is successful in reducing self-injury and time spent in psychiatric in-patient treatment”.

Stages of DBT

Patients with BPD present multiple problems and this can pose problems for the therapist in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organised into a number of stages and structured in terms of hierarchies of targets at each stage:

Pre-treatment stage

This focuses on assessment, commitment and orientation to therapy.

Stage 1

Focuses on suicidal behaviours, therapy interfering behaviours and behaviours that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

Stage 2

Deals with post-traumatic stress related problems (PTSD)

Stage 3

Focuses on self-esteem and individual treatment goals.

The targeted behaviours of each stage are brought under control before moving on to the next phase.

DBT Targets

DBT consists of a hierarchy of targets in which the main goal of each is to increase “dialectical thinking”. An example of such a hierarchy would be:

1.Decreasing suicidal behaviours.
2.Decreasing therapy interfering behaviours.
3.Decreasing behaviours that interfere with the quality of life.
4.Increasing behavioural skills.
5.Decreasing behaviours related to post-traumatic stress.
6.Improving self esteem.
7.Individual targets negotiated with the patient.
In an individual DBT session, the targets outlined above should be dealt with in that order. If in between therapy sessions, self harm or any other incidents have occurred these must be dealt with first before the therapist moves on to anything else.

How are DBT sessions structured?

Dialectical Behaviour Therapy is separated into four parts, three of which the client will experience.

1) Individual Therapy
In one to one therapy with a DBT therapist you will work on your self-damaging behaviours and work to continually ensure you are following the skills taught by the DBT course.

2) Group Work
Group work will help you to work on your social skills but also teach you new skills from the DBT modules and ways of implementing these.

3) Telephone support
Should you be feeling suicidal or as if you may be at risk of self-harm then you may contact your therapist or a member of the DBT team to discuss these and work through your thoughts. You will be urged to apply your DBT skills and techniques. You may only call between times agreed between your therapist and yourself.

4) This is for the therapist only
This is the consult group. You could also call it group supervision. This group would meet frequently and is made up by all those who have trained to become DBT Therapists. It’s a place to let off some steam and to make sure you are working effectively and efficiently but also keeping to the model of DBT. The group will encourage you to remain non judgemental and validating of the persons thoughts and feelings.

So now you have a feel for the way the therapy works let’s go into the four separate modules, working on increasing the quality of life of the sufferer.

DBT Skills

Mindfulness

Mindfulness is considered the most important part of Linehan’s DBT skill module. The mindfulness skills focus on "what" and "how" skills; "what" the individual needs to do in order to be mindful and "how" to do this. For example, a typical approach to developing the "what" skill would include an intent and attempt to observe, describe and participate in open dialogue. The "how" skill may require non-judgement, one-mindfulness, and collaboratively determining what is effective.

Interpersonal Effectiveness

Interpersonal effectiveness skills that are used in DBT sessions focus on assertiveness in saying no, making a request, and coping with problems. The purpose of the Interpersonal effectiveness skills are to allow the individual to increase the likelihood of goals being met, while maintaining self respect and keeping the relationship.

Distress Tolerance

Distress Tolerance is the skill set for accepting, finding meaning for, and tolerating distress. This area of DBT focuses on learning to bear the emotional pain resulting from distressing circumstances and events in the individual's life. An important focus in Distress Tolerance is the idea of radical acceptance. Linehan describes radical acceptance as a means by which to free oneself from suffering, and requires a choice to let go of fighting with reality. These skills in "letting go" promote acceptance without judgment or evaluation of the self, others or the situation in general. In theory, focusing on the acceptance of reality rather than the approval of reality will foster a clearer understanding of controllable vs. uncontrollable factors and help facilitate manageability of emotional pain.

Emotional Regulation

Emotional regulation assists individuals with reducing their vulnerability to an emotional state of mind. This is accomplished by providing methods to identify and label emotions, finding barriers in changing emotions and applying distress tolerance skills. The other key component of this skill set is to find ways to increase positive emotional events through healthy living and participation in activities that increase self-confidence.

Downfalls of DBT

DBT is an effective treatment for borderline patients but does have its downsides. These include:

the course being very difficult and requires a lot of commitment,

It excludes those with alcohol, substance misuse and those with eating disorders, even though these groups account for a high number of those with a diagnosis of personality disorder.
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