Visions Journal, 2011, 7 (1), p. 5
I am pleased to have this opportunity to work with Visions to raise awareness of borderline personality disorder (BPD) in BC. People with BPD are among the most misunderstood and stigmatized groups in the mental health community. Although there are effective treatments for BPD, these treatments can be difficult to access, leaving people with BPD uncertain as to where to turn for help.
Within this guest editorial, I hope to begin separating the facts on BPD from the fiction by describing what BPD is and how it is diagnosed. I want to dispel some misconceptions about BPD and discuss some of the problems we need to solve in order to better help people with BPD.
What is BPD? The symptoms and diagnosis
A serious mental health concern, BPD is a “personality disorder,” which is a pattern of thoughts, feelings and actions that tends to persist over time and leads to distress and problems in functioning (e.g., in relationships, jobs). BPD involves instability in several areas of life, including relationships, emotions, identity, thinking patterns and mental state (i.e., suspicious thoughts about others, dissociation), and behaviour.
People with BPD often engage in self-destructive behaviours such as suicide attempts (up to 75% have attempted at least once), self-injury (up to 80% have self-injured) and death by suicide (approximately 9%).1 Many people with BPD struggle with intense self-hate, shame and feelings of inadequacy/failure. They have difficulty navigating relationships both at work and with loved ones, and difficulty understanding and managing their emotions.
In order to get a diagnosis of BPD, a person has to have five out of nine total criteria, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). These criteria include the following:
problems with relationships (fears of abandonment; unstable relationships)
unstable emotions (frequent emotional ups and downs; high emotional sensitivity)
unstable identity (unclear sense of self; chronic feelings of emptiness)
impulsive and self-damaging behaviours (impulsive behaviour; self-injury or suicidal behaviour)
unstable thinking/cognition (suspiciousness; tendency to dissociate when under stress)2
Although it may seem easy to “self-diagnose,” it is important to know that a valid diagnosis of BPD involves a fairly extensive assessment. This should be done by a professional trained to make valid psychiatric diagnoses, such as a psychologist or a psychiatrist. All too often, I have seen people receive a diagnosis of BPD (sometimes in error) based on a clinician’s impressions after a very brief meeting.
Diagnosing BPD takes time and effort and must be done using methods with scientific support, such as structured diagnostic interviews, during which the clinician asks the patient a set of standardized questions about symptoms and experiences in order to arrive at an accurate diagnosis. Examples of these include the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II), or the Diagnostic Interview for Personality Disorders (DIPD). It is important for patients to know that the gold standard way to diagnose BPD includes these structured interviews and that they are much more reliable than the clinician simply asking questions that occur to him/her or using informal impressions to make a diagnosis.
BPD is not a life sentence
One of the most harmful misconceptions about BPD is that it is a life sentence—that people with BPD will struggle with the disorder for their entire lives, and that little can be done about it. The term “personality disorder” does not help the situation, as it implies that there is something fundamentally flawed with an individual’s personality, or who they are as a person.
In fact, there are many reasons for hope. First and foremost, studies have found that rates of recovery from BPD are much higher than previously thought. In one of the longest studies on BPD, Dr. Mary Zanarini and colleagues found that, over 10 years following hospitalization:
86% of people with BPD stopped meeting criteria for BPD for at least four years
50% of people recovered completely (as shown by no longer meeting BPD criteria and having good social and work functioning)3
Many of these people were receiving some kind of treatment, but some were not. Although many people with BPD clearly struggle for a long time, BPD is not a hopeless diagnosis, and many people recover.
A second reason for hope is that treatment works. The most extensively researched treatment for BPD is dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan at the University of Washington in Seattle. DBT involves the following:
Weekly individual therapy sessions aimed at helping clients reach their goals, reduce self-destructive behaviours and move forward on a path toward a more fulfilling life
A weekly training group that teaches skills in the areas of mindfulness (paying attention to the present), emotion regulation (understanding and managing emotions), interpersonal effectiveness (dealing with relationships and acting assertively), and distress tolerance (surviving crises, and accepting yourself for who you are)
Availability of the therapist by phone, e-mail, or other means in between sessions when help is needed4
Several rigorous clinical trials have shown that DBT works.5 In my own experience, I’ve seen clients improve their lives and relationships, achieve goals they never thought they could achieve, reduce their suffering, and even use what they’ve learned to help others in their lives and in the mental health community.
Aside from DBT, other promising psychological treatments have emerged in recent years, further showing that there is hope for recovery from BPD: mentalization-based therapy (MBT),6 schema-focused therapy (SFT)7 and transference-focused psychotherapy (TFP).8 (For more on these therapies, see page 21.)
Medication also can be helpful for people with BPD (especially mood stabilizers, atypical antipsychotic medications, and selective serotonin reuptake inhibitors, or SSRIs).9 Experts caution, however, that treatment by medication alone, without any psychological treatment or therapy, is not advisable.
The bottom line is that BPD is not a life sentence: Many people recover and sustain their recovery, and effective treatments exist.
One major challenge: finding effective treatment
Despite these reasons for hope, one major challenge facing BPD sufferers and their loved ones is that effective treatments are often hard to find and access. DBT has been around since the early 1990s, and yet, there are few DBT programs in B.C.
That said, there have been some promising developments around the province. These include the Dialectical Behaviour Therapy Centre of Vancouver and the establishment of DBT-oriented services at Vancouver General Hospital, through Tri-Cities Mental Health and at Surrey Memorial Hospital. Child and Youth mental health clinicians across the province, under the Ministry of Children and Family Development, have received training in DBT. And DBT strategies are incorporated into treatment provided through Correctional Services of Canada.
Progress is happening, but many people with BPD still suffer and cannot find adequate help. I am hoping that this issue of Visions will highlight some of the existing resources for people with BPD and get the word out that people with BPD need more available, accessible services. This is a major problem that we need to solve.
Another major challenge: the problem of stigma
Another major problem to solve is that of stigma. People with BPD often suffer from stigma from the community at large, people in their social networks or professional settings, and even from the treatment providers who are supposed to be helping them.
People jump to many conclusions about people with BPD, assuming that they are difficult to deal with, angry, clingy, out of control, likely to be violent, untreatable, down-and-out and/or unable to hold a job. Most of these assumptions are simply incorrect. Some of the people with BPD that I’ve known are among the most courageous, passionate, interesting and compassionate people I have met. If we are blinded by our stereotypes and assumptions about people with BPD (or any other mental illness), we might not even notice the many strengths and positive assets they have to build upon.
People with BPD are among the most intensely suffering groups in the mental health community. They need compassion, understanding and help. Therefore, I urge readers to put aside biases and assumptions about those with BPD, figure out how you can help, listen and react to people with BPD with an open mind, and reach out to do what you can.
About the author
Alex is an Assistant Professor and the Associate Chair (Graduate) with the Department of Psychology at Simon Fraser University. He is also President of the Dialectical Behaviour Therapy (DBT) Centre of Vancouver. For more on the DBT Centre, visit www.dbtvancouver.com
Skodol, A.E., Gunderson, J.G., Pfohl, B. et al. (2002). The borderline diagnosis I: Psychopathology, comorbidity, and personality structure. Biological Psychiatry, 51(12), 936-950.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Zanarini, M., Frankenburg, F.R., Reich, D.B. et al. (2010). Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. American Journal of Psychiatry, 167(6), 663-667.
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
Robins, C.J. & Chapman, A.L. (2004). Dialectical behavior therapy: Current status, recent developments, and future directions. Journal of Personality Disorders, 18(1), 73-89.
Bateman, A. & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165(5), 631-638.
Giesen-Bloo, J., van Dyck, R., Spinhoven, P. et al. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs. transference-focused psychotherapy. Archives of General Psychiatry, 63(6), 649-658.
Clarkin, J.F., Levy, K.N., Lenzenweger, M.F. et al. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6), 922-928.
Lieb, K., Völlm, B., Rücker, G. et al. (2010). Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials, British Journal of Psychiatry, 196(1), 4-12.