Borderline Personality Disorder 1

Running head: BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder: DSM

Diagnosing and Empirically-Based Treatment

Kelli Rodriguez

Capella University
 Borderline Personality Disorder 2

Abstract

The DSM-IV is widely used in the mental health field. Some of its many uses include providing

a common language among professionals about psychopathology and delineating criteria for

diagnosing individuals with mental disorders. This paper explores the purpose, history, and

limitations of the DSM diagnostic approach. A case study is provided and the DSM-IV-TR is

used to diagnosis borderline personality disorder. The disorder is described and an empirically-

based treatment plan is offered.

Borderline Personality Disorder: DSM Diagnosing and Empirically-Based Treatment

The APA (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM) is widely

used by mental health professionals. It provides a common language about psychopathology

among clinicians, researchers, students, and other mental health professionals. Since its inception

into the field of mental health, it has made a huge impact on clinical practice, research, and

education. Although it has advanced the field of mental health, there is still criticism of the DSM

classification system. Despite its limitations, it continues to be considered an important

reference for mental health professionals. This paper will explore the DSMs use within the field

of psychopathology. Then it will be applied to a case study of a 15 year-old girl with mental

health concerns including a diagnosis of borderline personality disorder. Her symptoms will be

described, criteria for diagnosis will be applied, and a proposed treatment plan will be provided.

DSM

The DSM-IV organizes mental disorders into multi-axial categories and provides

research-based information on each mental disorder, including diagnostic features, subtypes,

specific demographic features, prevalence, course, familial pattern, and differential diagnosis. It

has made an impact in many realms of the mental health profession. In clinical work, the DSM

diagnostic criterion is used for charting clients cases and communicating with other

professionals. The DSM is used to facilitate research on etiology and treatment of mental

disorders. In education, the DSM is seen as the authoritative source of information about

mental disorders (First, 2002, p. 69)

The DSMs history goes back over a half century. The first and second editions of the

DSM were based on the psychodynamic approach and attributed the causation of mental

disorders to environmental events. In 1980, the DSM-III was published and took on a more
 Borderline Personality Disorder 4

medical approach to psychopathology. This edition introduced a multi-axial classification

system that took into account the clients environment and functioning and also provided widely

accepted atheoretical definitions and diagnostic criteria for each mental disorder (Regier,

Narrow, First, & Marshall, 2002). The current edition, DSM-IV-TR, is the result of two

empirically-based revisions of the DSM-III.

Although the current edition of DSM has far surpasses previous editions (Regier et al,

2002, p. 169) and is internationally used, there is still some controversies, limitations, and ethical

concerns of this classification system. Jablensky (2002) points a number of flaws, including

how criteria is not weighed for diagnostic importance, axis II has an absurdly high level of

comorbidity, and reliability, at best, is modest (p. 114).

Much of the literature on the limitations of the DSM-IV-TR focuses on the lack of

cultural context considerations in diagnosing. Lee (2002) explains the role culture plays in

assessing and treating psychopathology. Paykel (2002) points out that the DSM is all very

Western centered and ignores syndromes which may appear in other cultures (p. 98). Regier et

al (2002) agrees that the DSM-IV is limited in its applicability to diverse populations, but also

states that it is limited in cross-cultural applicability as it does not fully address the different

meanings of illness, treatment, and idioms of distress across the diverse array of ethnic, racial,

and cultural groups in the United States (p. 169).

Kastrup (2002) asserts the DSM-IV-TR classification system should be effectively

applied in all settings and cultures. The DSM-IV is not due to be updated with a newer edition

for a few years yet. In the meantime, literature discusses how clinicians can take action to ensure

culture is considered when diagnosing and treating individuals with mental disorders. Mezzich

(2002) stresses the importance of providing a comprehensive diagnosis that takes into account
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biological, psychological, and social information. Constantine, Hage, Kindaichi, & Bryant

(2007) recommend learning about the historical and present implications of oppression in the

lives of marginalized populations, gaining self-awareness of own cultural background and biases,

acquiring knowledge about other worldviews and culture-specific values of culturally-diverse

individuals, and becoming competent in devising and carrying out multicultural interventions (p.

24).

Case Study

The following case study is to be used to demonstrate how the DSM-IV-TR and other

literature in the filed of psychopathology are used to diagnosis mental disorders.

Client Demographic and Descriptive data

Katie is 15 years old. She is a Caucasian female. She appears unkempt (hair oily and not

brushed out, acne, body odor). She is moderately overweight. She has an above average IQ.

Family and social history

Katie was neglected and emotionally, physically, and sexually abused by her mother and

her mothers boyfriend throughout much of her childhood. She was put into foster care at age 7.

Past foster parents, school administrators, and human service professionals that have worked

with Katie report that she is difficult to handle. Her behavioral and emotional disturbances

have caused her to move around many times, from foster home to foster home.

At age 10 Katie moved in with foster parents that were new to fostering children. At

first, Katie seemed to be happy to be part of a stable family and almost immediately displayed

intense love for her new mother and father. Her parents report, though, that Katie was a

challenge from the start of their relationship with her. She displayed inappropriate behaviors for

her age (masturbating openly, lying, tantrums, swearing and destroying property when upset).
 Borderline Personality Disorder 6

For awhile this behavior was met with patience and understanding on the parents part. Other

foster children have moved into the home and two were adopted into the family. As time went

on, Katie presented more signs and symptoms of emotional disturbance. The emotional

outbreaks gradually got worse and often involved yelling profanity and threats and destroying

property. She often manipulates and lies to others to get her way. Katie has been admitted to the

psychiatric ward of the hospital two times in the last year for emotional breakdowns and suicide

ideation and attempts (took pills). Her parents report that they cannot handle her and just

dont know what to do with her. Katie has a difficult time making and keeping friends. Her

relationships with friends are often intense, but short-lived and full of conflict.

Presenting problem

Katies behavior has gotten to a point that warrants serious attention and demands an

action-oriented treatment plan that addresses many aspects of Katies life. She has been expelled

from school because of her emotional outbursts and complete disregard for authority. She has

been waking up in the middle of the night to get on the internet to communicate with older guys.

She recently thought she was pregnant after having sex with an 11 year old foster child that was

also living in the home. When confronted by her parents about the inappropriateness of her

actions, a physical altercation occurred in which her mother slapped her face and caused her nose

to bleed. Police were called and her mother was arrested. The interactions between Katie and

her mother after the arrest have not been positive. A triangle was created between Katie, her

mother, and her father. The conflict between Katie and her mother pushed the mother into an

emotional breakdown. The mother was admitted into a psychiatric ward after an attempt of

suicide. Her parents feel helpless and as if Katie is breaking up the family. The mother reports
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that Katie is out of control. The mother is fearful that Katie will cause her to have another

break-down or that Katie will do something harmful to the other children in the home.

Signs and Symptoms

Katie reportedly is skilled at manipulating others according to her wants at the time. She

is deceitful and lies often. She can appear upbeat and in a pleasant mood (especially when first

meeting someone). She can be loving, caring, helpful, and seeking hugs at times but then her

mood can change in moments when she is met with resistance or authority. When told she

cannot do something she wants to, Katie yells out whatever she can to hurt the individual

standing in her way of doing as she desires. She has little regard for rules at school or home.

She has been expelled from public school and is now being tutored at home. She threatens harm

against other when upset. She is promiscuous. She is impulsive and fails to think about the

consequences of her actions beforehand. She cannot be left alone in the home as she is

irresponsible (disregard for home rules, past suicide attempts/threats, lack of consistency with

self-care). She has run away from home on numerous occasions when her parents try to enforce

rules and limitations.

DSM-IV Diagnosis

Katie displays signs and symptoms characteristic of borderline personality disorder

(BPD). According to the DSM-IV-TR, individuals with BPD display a pervasive pattern of

instability of interpersonal relationships, self-image, and affects, and marked impulsivity

beginning by early adulthood and present in a variety of contexts (2000, p. 710). The following

DSM-IV-TR criteria for BPD are present in Katies case: frantic efforts to avoid real or imagined

abandonment; a pattern of unstable and intense interpersonal relationships characterized by

alternating between extremes of ideation and devaluation; impulsivity in potentially self-

damaging areas (e.g., promiscuity, communicating with strangers and possible predators online,

and binge eating); recurrent suicidal threats and attempts; affective instability due to marked

reactivity of mood (e.g. episodic dysphoria, irritability, or anxiety); chronic feelings of

emptiness; inappropriate, intense anger or difficulty controlling her anger (DSM, 2000, p. 710).

The etiology of BPD is not exactly known but research has found a number of risk factors

including childhood neglect and/or abuse (Gunderson, Daversa, Grilo, McGlashan, et al, 2006;

Linning & Kearney, 2004), trauma (Donnelly & Amaya-Jackson, 2002), and disrupted

attachment (Bradley, Conkin, & Western, 2005). These developmental experiences are common

among individuals diagnosed with BPD and can provoke a fear of abandonment, interpersonal

instability, and other dysfunctional behaviors associated with BPD (i.e. detachment, emotional

instability, uncontrolled anger, emptiness, depression, inability to self-soothe, impulsivity,

identity disturbances, self-mutilative behavior, and suicidal ideation) (Becker, Grillo, Edell, &

McGlashan, 2002; Bradley et al, 2005; Donnelly & Amaya-Jackson, 2002; Gunderson et al,

2006; and Linning & Kearney, 2004, and Sanislow et al, 2002) .

The disturbances in Katies behavior and affect causes clinically significant impairment

in social and academic functioning, including school expulsion, family turmoil, and lack of

friends (APA DSM-IV, 2000, p. 99). Katies psychological, social, and academic functioning is

20 on the Global Assessment of Functioning (GAF) Scale (DSM-IV, 2000, p. 34) as indicated by

the presence of some danger of hurting herself or others (e.g. suicide attempts, frequently violent,

threats of harm to others) and lacks desire to maintain personal hygiene (e.g. bathes infrequently

and frequently refuses to change clothes, brush hair and care for teeth).

Treatment Plan
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BPD is a complex disorder made up of collection of symptoms, dysfunctional cognitions

and behaviors, and maladaptive personality traits, thus treatment should address each of these

concerns in a systematic way using a variety of interventions (Sanislow et al, 2002; Livesley,

2004). The following treatment plan incorporates a combination of empirically-based

interventions that target the complex problems of Katies case:

Diagnosis

Axis I V71.09 No diagnosis

Axis II 301.83 Borderline personality disorder

Axis III No diagnosis

Axis IV Victim of childhood abuse and neglect. Problems with education, primary

support group, and social environment.

Axis V GAF = 20; some danger of hurting self or others

Objective of Treatment

Livesley (2004) recommend the ranking of symptoms according to urgency and stability

and taking a sequential approach to interventions in which the more urgent and readily changed

symptomatic components are addressed first. Ben-Porath (2004) also stresses the importance of

establishing an early therapeutic alliance to prevent the common problem of drop-outs or

premature termination in treatment of individuals with borderline personality disorder. Thus the

initial objective of Katies treatment is developing a strong therapeutic alliance, fostering client

commitment (Ben-Porath, 2004), and managing and containing self-harm behaviors and related

problems with emotion and impulse regulation (Livesley, 2004, p. 187). The focus of treatment

then can move to improving social and interpersonal functioning and changing maladaptive
 Borderline Personality Disorder 10

cognitions and behaviors. Towards the end of treatment, the objective is to create a healthy sense

of self and stable identity (Livesley, 2004).

Assessments

Assessment for Katies case should include a referral for a physical examination and

assessment instruments that measure borderline personality symptoms, like the Harkavy-Asnis

Suicide Survey, Beck Depression Inventory, Life Problems Inventory, Scale for Suicidal

Ideation, Symptom Checklist 90-Revised, and the Structured Clinical Interview for DSM-IIIR

Personality Disorders, Borderline Personality Module (Rathus & Miller, 2002).

Clinician Characteristics

The ideal characteristics of the clinician treating Katie include being able to be

understanding, nonjudgmental, and encouraging when faced with resistance or hostility from

Katie. The clinician should be patient and comfortable with slow progress. The clinician should

also be knowledgeable about the complexities of the diagnosis and be skilled in a variety of

theoretical approaches and interventions (Seligman, 2005, p. 398).

Location of Treatment

Katies case should be treated at an inpatient hospital setting at first with daily sessions to

reduce symptoms of suicidal ideation and potentially harmful impulsivity. Once risk of harm to

self and others is decreased, twice weekly outpatient sessions in the clinicians office should be

scheduled.

Interventions to be Used

Dialectical behavioral therapy (DBT) is the most empirically supported treatment for

borderline personality disorder (Sharma, Dunlop, Ninan, & Bradley, 2007). It has been shown to

reduce suicidal ideation, emotional distress, impulsive behaviors, interpersonal difficulties,

emotional dysregulation, identity confusion, hospital admittance, and early termination of

treatment (Rathus & Miller, 2002). DBT uses a combination of interventions to address specific

problems in order of importance, including client-centered interventions to strengthen the

therapeutic alliance and commitment fostering interventions (refer to Ben-Porath, 2004 for

specific strategies); behavioral interventions to teach self-regulating and interpersonal skills;

cognitive interventions to change maladaptive cognitions and defense processes; and

psychodynamic interventions to address attachment patterns, fear of abandonment, and feelings

of rejection and emptiness (Bradley et al, 2005, p. 1016).

Emphasis of Treatment

Rathus and Miller (2002) explain how DBT is characterized by its balance of acceptance

and change, and by its well-specified communication strategies, dialectical strategies, validation

strategies, problem-solving strategies, case management strategies, and hierarchy of treatment

targets (p. 149). An emphasis on establishing a strong therapeutic relationship should also be

stressed throughout the entire treatment process (Ben-Porath, 2004).

Numbers

For Katies case, individual therapy is the primary mode of treatment, with family

therapy (Sharma et al, 2007), group therapy (Seligman, 2005), and multifamily skills training

groups (Rathus & Miller, 2002) being combined.

Timing

Literature suggests that Katie will likely need long-term therapy with short-term goals

being established and worked on through the process (Ben-Porath, 2004; Seligman, 2005).

Weekly sessions are often not enough, especially in times of crisis or regression (Seligman, 2005,

p. 398).
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Medications Needed

The treating physician will likely prescribe some medication to lessen Katies symptoms.

Pharmacological interventions (e.g. Zoloft, clonazepam, sertraline, quetiapine) are often used to

lessen the severity of the symptoms of borderline personality disorder (Sharma et al, 2007).

Donnelly and Amaya-Jackson (2002) discuss research studies on the effectiveness of a variety of

psychotropic drugs medication.

Adjunct Services

Seligman (2005) suggests a support group may be beneficial for Katie and family

involvement in therapy and skills-building exercises.

Prognosis

Gunderson et al (2006) examine the predictors of treatment outcomes and provide

prognosis information for patients with BPD. Due to Katies early history of abuse and neglect

prognosis may be poor (p. 824). Seligman (2005) suggests only a fair prognosis for changing

underlying personality characteristics (p. 399), but other literature (Livesley, 2004; Sharma et al,

2007) suggests a good prognosis for a reduction in Katies BPD symptoms and for positive

behavioral changes, especially if a variety of interventions are used in treatment (i.e. DBT).

Conclusion

The DSM-IV is used often in the mental health field. It provides a common language

about mental disorders for professionals and assists in the diagnosing of disorders. It has made

an impact in clinical, research, and educational settings. The DSM was first introduced over a

half century ago and has undergone many research-based revisions. Although it has advanced

the field of psychopathology, there are notable limitations and weaknesses of the DSM

classification and diagnosing approach. Limited cultural consideration in diagnosis is one of the
 Borderline Personality Disorder 13

most significant limitations of the DSM-IV-TR. There is much literature on multicultural

practices that professionals in the mental health field can resource. Katie is not of a racially

marginalized population, but has had a unique upbringing and life experiences (i.e. childhood

abuse and neglect and growing up in the foster care system) that must be taken into consideration

when diagnosing and treating her. The criteria and information within the DSM-IV-TR was used

to diagnosis Katie with borderline personality disorder (BPD). She displays a number of

symptoms, negative behaviors, maladaptive cognitions, and other psychosocial problems

characteristic of BPD, including instability of interpersonal relationships, fear of abandonment,

impulsivity, emotional instability, and suicidal ideation. The complex nature of BPD warrants a

comprehensive treatment plan that combines interventions from various approaches to address

the symptoms and problems in Katies case. Dialectical behavioral therapy has been shown to be

effective in reducing problematic symptoms in individuals with BPD. Other research-based

interventions that should be part of Katies treatment plan include those that foster a strong

therapeutic alliance and foster commitment (client-centered interventions), reduce self-harm

behaviors and impulsivity (cognitive-behavioral interventions), and address the interpersonal

difficulties and fear of abandonment (psychodynamic interventions).

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