PHOTO: Jakayla Toney
Text: Alejandra Misiolek
There is a common conviction that a personality disorder, especially the borderline personality disorder (BPD), is not treatable.
In this post I am going to address this issue based on current scientific studies.
Before we start, let´s define what a BPD is.
BPD is a severe condition with a lifetime prevalence estimated at up to 6% (Grant et al, 2008, in: Bateman and Fonagy, 2016) in general population and up to 20% in psychiatric population. Therefore, as for a mental disorder, it is not rare at all. Moreover, it appears quite frequently alongside mood disorders like depression and bipolar disorder, anxiety disorders, narcissistic personality disorder (Bateman and Fonagy, 2016) and eating disorders (Robinson et al, 2019). This makes it even more difficult to diagnose well and to treat.
What does it mean that borderline is a personality disorder?
A personality disorder is defined according to functional impairment and pathological personality traits.
Therefore, for a personality disorder to be diagnosed, features of character like specific patterns of thinking, expressing and experiencing emotion and relating to others, must appear. Moreover, these affect significantly the personal and social functioning of the person who suffers from it.
The personality disorders are arranged into three clusters based on their primary difficulties. Cluster A represents the eccentric disorders (including schizoid and paranoid), Cluster B represents the erratic disorders (such as antisocial, narcissistic and borderline) whilst Cluster C describes the fearful and anxious personality disorders (including obsessive-compulsive and avoidant).
What is the borderline personality disorder?
Borderline personality disorder (BPD) belongs to Cluster B and is the commonest form of personality disorder. According to the Diagnostic Manual (DSM-5), in order to diagnose a borderline personality disorder, 5 out of 9 criteria must be present persistently and since early adulthood:
- Emotional instability including intense anguish or irritability.
- Inappropriate and intense outbursts of anger.
- Chronic feelings of emptiness.
- Engaging in damaging acts such as reckless driving, substance misuse or risky sexual behavior.
- Recurrent suicidal ideation or threats, or self-harming behavior such as cutting, hitting or burning oneself.
- A markedly and persistently unstable sense of self or self-image.
- Paranoid thoughts or periods of dissociation.
- Engaging in frantic behavior to avoid real or imagined abandonment.
- Intense and unstable relationships, alternating between over and undervaluing loved ones.
Moreover, we can define the borderline personality disorder as an impairment in functioning related to the identity (with difficulties in experiencing the self as a unique entity with boundaries and coherent sense of personal history), self-direction (which involves impairment in the pursuit of short and long-term life goals), empathy and problems with intimacy. There is consensus among many authors that the base of BPD are: difficulties in emotion regulation, impulsivity and social dysfunction. According to the mentalizing approach, the problems with social cognition, and particularly a compromised capacity to understand oneself and others in terms of mental states, are the core of BPD.
Where does BPD come from?
Research and clinical practice have shown that a history of early neglect, especially emotional, is very common among people with BPD. Early neglect is a traumatic experience that can disrupt the capacity to mentalize. Both emotional neglect and further difficulties in understanding social relationships (or disrupted mentalizing) lead to creating an insecure attachment, with our caregivers and then with later relationships. A vicious cycle is created where having experienced abandonment or neglect conditions the person to fear being abandoned in relationships and triggers behaviors that are supposed to protect them (like seeking attention) but can become difficult and annoying for their partners or friends in the long run and provoke even more abandonment. Such mechanism is called self-fulfilling prophecy and explains why such disorders persist.
How can we treat it?
The first line of treatment for borderline personality disorder is psychotherapy. Two types of psychotherapies have proved to be effective for BPD:
Dialectical Behavioral Therapy (DBT): Stemming from the assumption that emotional dysregulation is the core difficulty in BPD, DBT focuses on learning skills to manage dysregulation and reduce dysfunctional methods of managing strong emotions. It focuses on four skills: mindfulness, interpersonal effectiveness (successfully asserting needs and navigating conflict in relationships), distress tolerance; and emotion regulation.
Mentalization-Based Therapy (MBT): MBT focuses on improving the ability to make sense of the thoughts, feelings and beliefs of oneself and others, particularly in situations which evoke strong emotions and dysfunctional behaviors. The effects of MBT have been documented with multiple randomized controlled trials showing benefits in adult and adolescents.
On the other hand, there is also pharmacological support. Although there are no medications that have been specifically licensed and approved for the treatment of BPD, several classes of psychiatric medication are useful in the management of specific symptoms of the disorder. According to scientific studies, we can confirm that the following classes of drugs have been approved to help people with BPD:
- Mood stabilizers
Finally, is it really treatable?
Yes. Studies show that although the treatment is difficult and lengthy, with high rates of dropout, it can be effective in the long run.
A longitudinal study of 362 individuals with BPD (Zanarini, 2007) showed that over 85% of the sample were in remission 10 years later.
It is crucial to conclude that the likelihood of recovery is greatly enhanced by access to appropriate treatment. Psychotherapy specialized in treatment of personality disorders together with a good diagnosis and awareness of possible comorbidities (other disorders that go alongside) is key to recovery. Therefore, the question is not whether BPD is treatable but rather how to treat it so that it is effective.
- Bateman, A., & Fonagy, P. (2016). Mentalization based treatment for personality disorders: A practical guide. Oxford University Press.
- Bateman A. Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. American Journal of Psychiatry. 2001;158:36–42. https://www.ncbi.nlm.nih.gov/pubmed/11136631
- Bateman A, Fonagy P. Psychotherapy for Borderline Personality Disorder: Mentalisation Based Treatment. Oxford (UK): Oxford University Press, 2004. https://www.ncbi.nlm.nih.gov/pubmed/17365158
- Bateman A. Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry. 2009;166:1355–1364 https://www.ncbi.nlm.nih.gov/pubmed/19833787
- Kvarstein EH, Pedersen G, Urnes O, Hummelen B, Wilberg T, Karterud S. Changing from a traditional psychodynamic treatment programme to mentalization-based treatment for patients with borderline personality disorder–does it make a difference? Psychol Psychother. 2015;88(1):71–86. https://www.ncbi.nlm.nih.gov/pubmed/25045028
- Robinson, P., Skårderud, F., & Sommerfeldt, B. (2018). Hunger: Mentalization-based treatments for eating disorders. Springer.
- Rossouw TI. Fonagy P. Mentalization-based treatment for self-harm in adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;51:1304–1313. https://www.ncbi.nlm.nih.gov/pubmed/23200287
- Zanarini MC, Frankenburg FR, Reich DB, Silk KR, Hudson JI, McSweeney LB. The subsyndromal phenomenology of borderline personality disorder: a 10‐year follow‐up study. American Journal of Psychiatry 2007;164(6):929‐35. https://www.ncbi.nlm.nih.gov/pubmed/17541053