Patients with borderline personality disorder (BPD; known in ICD–10 (World Health Organization, 1992)
as emotionally unstable personality disorder) pose some of the most
difficult management problems facing the clinical psychiatrist.
They frequently present
in crisis, but are often difficult to engage in any form of treatment.
Their behaviour causes considerable
anxiety but their ambivalence about treatment often
leaves professionals feeling frustrated and resentful. These feelings
can all too easily be transformed into therapeutic
nihilism. As well as being a significant problem in its own right,
comorbid
personality disturbance complicates the management of
other psychiatric disorders and has a negative effect on their prognosis
(Reich & Vasile, 1993).
Borderline personality disorder has an estimated prevalence of up to 2% in the community (Widiger & Weissman, 1991) and 15 % among psychiatric in-patients (Kroll et al, 1982).
Yet, despite an extensive psychoanalytic literature and growing
attention in the USA, BPD has until recently received relatively
little attention in the British psychiatric
literature. However, this situation is beginning to change as a result
of recent
developments in both research and treatment.
Developmental research is shedding increasing light on the aetiology of
BPD,
new models of treatment have been developed and
long-term research on outcome is helping to dispel some of the pessimism
that
has long surrounded the disorder. This paper will
review some of these developments.
Box 1.
DSM–IV (American Psychiatric Association, 1994) diagnostic criteria for borderline personality disorder
At least five of:
Intense and unstable personal relationships
Frantic efforts to avoid real or imagined abandonment
Identity disturbance or problems with sense of self
Impulsivity that is potentially self-damaging
Recurrent suicidal or parasuicidal behaviour
Affective instability
Chronic feelings of emptiness
Inappropriate intense or uncontrollable anger
Transient stress-related paranoid ideation or severe dissociative symptoms
New perspectives on aetiology
Research over the past decade or so has
emphasised the importance of childhood experiences in the aetiology of
BPD. Ideas
derived from psychoanalysis have received some
empirical support and the central aetiological role of childhood trauma
has
become apparent. Attachment, identity and the
ability to make sense of feelings are increasingly seen as interlinked
and all
are adversely affected by abuse or neglect in
childhood.
Trauma, affect regulation and self-harm
Childhood abuse and neglect are extremely common among borderline patients: up to 87% have suffered childhood trauma of some
sort, 40–71% have been sexually abused and 25–71% have been physically abused (Perry & Herman, 1993). The effect of abuse seems to depend on the stage of psychological development at which it takes place; in general, the
earlier it takes place, the more damaging it is likely to be (van der Kolk et al, 1994).
This is probably due to the young child's cognitive immaturity and
consequent inability to make sense of traumatic experiences.
Sexual abuse, as well as being damaging in its
own right, may also reflect the generally dysfunctional nature of
families
who are unable to protect their children
adequately.
There is considerable evidence that borderline patients have difficulty modulating emotion, and this appears to be linked
with early trauma (van der Kolk et al, 1994). Trauma, in the form of sexual abuse, is also strongly correlated with self-mutilation in borderline patients (Herman et al, 1989).
Self-mutilation such as cutting is often experienced as painless at the
time, suggesting that it takes place in a dissociated
state. Indeed, the combination of severe trauma
and dissociative phenomena in BPD has led some researchers to link it
with
post-traumatic stress disorder.
Attachment and reflective self-function
Research based on attachment theory is
beginning to elucidate the links between childhood trauma and the
capacity to think
about oneself and others. Borderline patients
are typically preoccupied with their disturbed early relationships yet
unable
to give a coherent account of them (Patrick et al, 1994; Fonagy et al, 1996). Severe childhood trauma in these patients appears to result in a specific inability to think about their own thoughts and
feelings, as well as those of others.
This finding is consistent with the
observation that maltreated children have difficulty in expressing both
negative and positive
feelings. As well as contributing to problems in
interpersonal relationships, the inability to think about feelings may
combine
with defective affect regulation to produce the
impulsivity which is so characteristic of borderline patients.
Box 2.
Possible effects of childhood trauma in borderline personality disorder
Self-mutilation
Defective affect regulation
Lack of reflective capacity
Dissociation
Impulsivity
Disturbed interpersonal relationships
Identity and the self
The lack of a sense of self is a core
feature of the psychopathology of BPD, and psychoanalysts have
traditionally linked
this phenomenon to pathological splitting of the
ego and object. Splitting is often very marked in borderline patients,
who
may engender powerful yet conflicting feelings
in different members of the psychiatric team. Such splitting has
traditionally
been thought of as a ‘primitive’ defence
mechanism that indicates arrested psychological development. However, it
may be an
appropriate response to abuse from someone who
is also a parent or carer. Recent research confirms the link between
splitting
and sexual abuse and suggests that it may, in
fact, be a relatively sophisticated psychological mechanism for dealing
with
traumatic experience (Calverley et al, 1994).
The concept of self is central to the work of Heinz Kohut and the branch of psychoanalysis known as self-psychology (Kohut, 1984).
Kohut's ideas have been incorporated into the treatment approach
developed by Stevenson & Meares (1992). Ryle (1997), from
the somewhat different perspective of
cognitive–analytic therapy, has developed an aetiological model of BPD
based on the
concept of multiple self-states. These are
partially dissociated states between which the patient switches
abruptly. Each
self-state is linked to specific moods,
behaviours and symptoms and is associated with corresponding
interpersonal roles.
Both these therapies are described later in this
paper.
New developments in treatment
Several new forms of treatment for BPD
have been developed over the past few years and evidence is also
emerging for the effectiveness
of some of the more established approaches.
Dialectical behaviour therapy
Dialectical behaviour therapy (DBT;
Linehan, 1993) is based on the principle that BPD is essentially the
result of deficits
in interpersonal and self-regulatory skills and
that these skills can be taught in therapy. Defective affect regulation
is
seen as particularly important. Treatment
consists of weekly individual and group therapy sessions based on a
skills-training
model, together with out-of-hours telephone
contact with the therapist.⇓
Fig. 1
An aetiological model of borderline personality disorder
Dialectical behaviour therapy has been shown, in a single study, to be superior to ‘treatment as usual’ in reducing self-harm
and time spent in hospital, but not subjective experiences such as depression and hopelessness (Linehan et al, 1991). There were also significant improvements in social and global functioning and anger (Linehan et al, 1994). However, by one year after the end of treatment, rates of self-harm were no different in the DBT and treatment-as-usual
groups, although both had improved (Linehan et al, 1993).
Box 3.
New therapies for borderline personality disorder
Cognitive analytic therapy
Brief psychoanalytic psychotherapy
Interpersonal psychotherapy
Dialectical behaviour therapy
Schema-focused cognitive therapy
Despite this essentially negative
finding, DBT has attracted considerable interest; however, Linehan's
study is open to a
number of methodological criticisms. Only 39
patients were studied, all of them female, and of these only 20 were
fully assessed.
The level of self-harm required for entry into
the study (two episodes in the last five years and one in the last eight
weeks)
may have led to the inclusion of patients who
were less severely disturbed than those commonly seen in clinical
practice.
Furthermore, DBT involves a high level of input
from professionals and it is not yet clear whether it is the skills
training
itself or simply the high level of support which
leads to the reduction in self-harm.
Psychoanalytic psychotherapy
Psychoanalytic psychotherapy has long
been used in the treatment of borderline patients but has never been
subjected to formal
evaluation. The available data suggest that only
a minority of borderline patients benefit from psychoanalytic
psychotherapy
in its traditional form (Waldinger & Gunderson, 1984). However, a modified approach, which emphasises current rather than past experiences and in which the therapist takes a
more active role, may be more suitable for the treatment of BPD.
Stevenson & Meares (1992) have
described encouraging results using a specialised form of brief
psychotherapy which is designed
specifically to meet the needs of borderline
patients. This model draws on both self-psychology and Hobson's
‘conversational
model’ (Hobson, 1985).
Patients are seen twice-weekly for a year and therapy can be delivered
by trainee therapists following a treatment manual.
In their study, this form of therapy produced
significant improvements in violent behaviour, use of medication,
self-harm
and hospital admissions. Improvements were also
observed in impulsivity, affective instability and suicidal behaviour
and
by the end of treatment, 30% of patients no
longer met DSM–III–R (American Psychiatric Association, 1987) criteria for BPD.
Therapeutic communities
Recent work has provided evidence for the effectiveness of therapeutic community treatment. Dolan et al
(1997) compared 70 patients treated at the Henderson Hospital with
those referred but refused funding by their health authorities.
Eighty per cent of their patients had a
diagnosis of BPD and many also met the diagnostic criteria for other
personality disorders.
Forty-three per cent of the treated patients
showed a clinically significant change in core borderline
psychopathology at
one year after discharge, compared with 18% of
those who had been refused funding.
Another approach to evaluating the
effectiveness of therapeutic community treatment is to calculate service
consumption and
costs to public services before and after
treatment. Recent studies have found substantial reductions in service
consumption
and costs following treatment in three National
Health Service therapeutic communities: the Cassel and Henderson
Hospitals
in London and Francis Dixon Lodge in Leicester (Chiesa et al, 1996; Dolan et al, 1996; Davies et al, 1999).
Interpersonal therapies
Interpersonal difficulties are one of
the most common presenting features of BPD. Not only do they cause
considerable suffering
to the patient but they are also likely to
manifest themselves in complex and ambivalent relationships with
professionals.
Benjamin (1996) has developed a
technique for analysing patterns of interpersonal behaviour known as the
Structural Analysis
of Social Behavior (SASB). This instrument
allows dysfunctional interpersonal patterns to be identified and coded
and has
led to the development of a therapeutic approach
that is aimed at modifying interpersonal behaviour. In therapy,
maladaptive
interpersonal patterns are identified and their
origins explored. An eclectic mix of techniques is used including role
play,
free association, dream analysis and educational
assignments. When the patient is ready to do so, the therapist helps
him
or her to ‘block’ maladaptive patterns and learn
new ways of functioning.
The brief interpersonal therapy (IPT) developed by Klerman and his colleagues (Klerman et al, 1984)
has also been adapted for use with borderline patients. Originally
designed to treat depression, IPT is a structured and
time-limited therapy which focuses on the
relationship between symptoms and interpersonal difficulties. A small
pilot study
has been carried out using an 18-session
programme for borderline patients (Angus & Gillies, 1994), but the results have yet to be published.
Cognitive–analytic therapy
Cognitive–analytic therapy (CAT) for borderline patients employs a collaborative approach between patient and therapist in
order to identify self-states (Ryle et al, 1997).
Inadequate parenting is thought to result in an inability to integrate
these self-states, leading to rapid shifts between
them. These shifts between self-states and their
associated interpersonal roles are seen as a cause of the instability
that
borderline patients display.
In therapy, the patient is helped to
make links between early experience and current behaviour. The
collaborative nature of
the therapeutic relationship also gives the
patient experience of a new and more healthy way of relating and thus
contributes
to the process of change. Although promising,
CAT has yet to be evaluated adequately in clinical practice.
Schema-focused cognitive therapy
Another novel but untested approach is schema-focused cognitive therapy (Young, 1994). This therapy concentrates on identifying and modifying the ‘early maladaptive schemas’ thought to underlie BPD. Schemas
are:
“broad pervasive themes regarding oneself and one's relationship with others, developed during childhood and elaborated throughout one's lifetime, and dysfunctional to a significant degree” (Young, 1994).
Early maladaptive schemas have their
origins in adverse childhood experiences and are particularly resistant
to change. They
cover themes familiar to psychoanalytic
psychotherapists and are organised into five principal domains:
disconnection and
rejection; impaired autonomy and performance;
impaired limits; other-directedness; and overvigilance and inhibition.
Therapy consists initially of
identifying and activating core schemas (for example, with the use of
imagery), which therapist
and patient then discuss. Schemas are then
modified using cognitive reconstruction, behavioural and experiential
techniques
and discussion of issues arising in the
therapist–patient relationship.
Long-term outcome
Several studies have now established that the long-term prognosis in BPD is significantly better than is often assumed and
that the majority of patients improve over time (for review see Stone, 1993) . For example, Links et al
(1998) found that 53% of patients followed-up for seven years no longer
met diagnostic criteria for BPD. In one of the largest
studies, long-term follow-up of a cohort of
patients treated at the New York Psychiatric Institute found that
two-thirds were
clinically well (Stone et al, 1987).
Future developments
Our understanding of the aetiology of BPD
has grown considerably over the past decade and it is increasingly
being seen as
a disorder of psychological development. However,
major questions remain. Are some individuals more vulnerable to the
development
of the disorder than others? Are there potentially
protective factors? Perhaps most crucially of all, can early
intervention
with at-risk families help to prevent the
development of BPD?
At the clinical level, there is an urgent
need for more research into the outcome of different forms of
treatment. Studies
of treatments such as DBT and brief psychoanalytic
psychotherapy need to be replicated, and the effectiveness of therapies
such as CAT and IPT needs to be evaluated. The
relative merits of different therapies have yet to be assessed and it is
unclear
how best to match patients to therapies. Many of
the new therapies for BPD share a theoretically coherent, manual-based
structure
and it may be that the coherence and consistency
this provides is particularly important for borderline patients. We do
not
yet know whether these structured, short-term
therapies will prove sufficient on their own or will in future be used
as a
prelude to more exploratory therapy for suitable
patients. Moreover, it is probable that most borderline patients will
continue
to be managed by general psychiatrists and the
place of such specialised therapies within generic mental health
services will
need to be determined.
The apparent success of these brief
therapies is somewhat at odds with the view held by many clinicians that
borderline patients
benefit from a relatively prolonged relationship
with a therapist or therapeutic team. This view is consistent with the
evidence
for disordered attachment in BPD, which suggests
that a stable therapeutic attachment may be helpful in allowing patients
to develop psychologically in a more functional
way. Long-term follow-up studies will be needed to clarify whether the
effects
of brief therapies persist beyond the end of the
treatment period.
Despite many unanswered questions, recent
developments give grounds for optimism. It is now difficult to sustain
the view
that all borderline patients are untreatable.
Psychoanalysis, cognitive therapy and empirical research are converging,
and
a coherent aetiological model of the disorder is
beginning to emerge. The outlook for this challenging group of patients
may
be starting to improve.
Multiple choice questions
-
The prevalence of borderline personality disorder among in-patients is estimated to be:
-
10%
-
15%
-
20%
-
12%
-
5%.
-
-
Multiple self-states are associated with:
-
schema-focused cognitive therapy
-
self-psychology
-
cognitive–analytic therapy
-
dialectical behaviour therapy
-
interpersonal therapy.
-
-
In borderline personality disorder:
-
a disturbed sense of self is common
-
patients are preoccupied with disturbed early relationships
-
pathological splitting is uncommon
-
the New York Psychiatric Institute follow-up study found that one-third were clinically well
-
therapeutic community treatment produces a reduction in service consumption.
-
-
With respect to childhood trauma:
-
physical abuse is more common than sexual abuse
-
defective affect regulation is related to early trauma
-
trauma has been linked to difficulty thinking about oneself and others
-
sexual abuse is strongly correlated with self-mutilation
-
up to 87% of patients have suffered childhood trauma.
-
-
In the treatment of borderline personality disorder:
-
dialectical behaviour therapy is clearly superior to treatment as usual
-
dialectical behaviour therapy reduces depression
-
cognitive–analytic therapy is more effective than interpersonal therapy
-
theoretical coherence may be important
-
interpersonal therapy was originally developed to treat depression.
-
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