Running head: Professional Practice Paper 1

Professional Practice Paper:

Chi Wai Ronald Lam

Dr. Gregory Canillas

Pepperdine University

PSY 642.20
Professional Practice Paper 2

New Directions in Borderline Personality Disorder

Introduction

About 10 years ago, Borderline Personality Disorder (BPD) is a very common

personality disorder in ever culture. It has affected about 2% to 3% of the general population

(Gunderson, 2001). A recent study, the prevalence has raised to 5.9% of the general population

(Sansone & Sansone, 2011). These people, they tend to experience turbulence in relationships,

fear of abandonment, and lack of control (Philips, Yen, & Gunderson, 2003). As a result of

inability to form healthy relationships and to control their own emotions, they frequently engage

in self-destructive behaviors, such as cutting themselves or killing themselves. There was about

6% of the BPD populations committed suicide from 1989 to 1993 (Stone, 1989; Widiger &

Trull, 1993), and we would expect that the percentage is higher now due to the fact that there are

more people to be diagnosed as having BPD. BPD patients often feel intense emotions; they can

go from anger to deep depression or the other way around in a short time. They are also

impulsive in ways to help them reduce their tensions (Bohus et. al., 2000). Feelings of emptiness,

boredom, having difficulties with their own identities are also common (Wilkinson-Ryan &

Western, 2000).

Etiology

In understanding the development of BPD, and so do other psychiatric disorders, it is

important to look at the interactions between the biological, psychological, and social factors.

Biologically speaking, there may be a genetic component to the disorder that it runs in

family (Links, Steiner, & Huxley, 1988). Not surprisingly, many of the BPD patients also have a

comorbid mood disorder, such as major depressive disorder, or bipolar disorder (Radaelli et. al.,

2012). In terms of psychophysiology, BPD, like other psychiatric disorders, does not seem to
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have a specific neurocircuitry model. Meaning that, it does not point to a simple pathophysiology

(New, Perez-Rodriguez, & Ripoll, 2012). However, using the Positron emissions tomography

(PET) scan, the researchers found that part of the brain that normally regulate expressions of

emotions maybe structurally impaired. The implication is that BPD patients have more

difficulties in identifying emotional expressions correctly from others, and they tend to overly

interpret anger in neutral faces. They also have difficulties in cooperating with other people

because they simply do not trust them. All these implications truly undermine their ability to

form healthy relationships with others.

On the other hand, familial factors are also examined in BPD patients’ family. BPD

patients’ families tend to be high emotional expression or complete disengaged (Gunderson et.

al., 2011). This style of relating may contribute to the dichotomous thinking seen in BPD

patients. Furthermore, trauma is also an important factor related to BPD. Patients with BPD

reported more early traumatic experience than patients with other psychological disorders. These

traumas are mostly related to sexual and/or physical abuse (Goldman, D’Angelo, DeMaso, &

Mezzacappa, 1992).

Temperament is also another important factor to consider when looking at the etiology of

BPD. Children who are high in affective temperament are more likely to develop BPD than other

similar psychiatric disorders, such as bipolar disorder (Jørgensen, Licht, Nilsson, Straarup,

2010). Therefore, the severity of affective temperament alone is a strong predictor of developing

BPD.

Using the biopsychosocial model, biologically predisposed individuals who have a

temperament of high in affect are more likely to develop BPD, especially when they were abused
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as children (Joyce et. al., 2003). Fortunately, there are some promising treatments available for

BPD.

Treatment

The combined use of medication and psychotherapy is often seen in treating psychiatric

disorders. Altering the cognitive functioning, behavioral symptoms, and mood is an important

task for both medication and psychotherapy.

In twenty years ago, psychiatrists also used lithium, a mood stabilizer, to treat BPD

(Links, Steiner, Boiago, & Irwin, 1990). However, nowadays, common psychiatric medications

used for treating BPD are antidepressants or antipsychotics, such as Prozac and Risperdal

respectively. BPD patients are also often hospitalized for their suicidal attempts. Intense care is

required.

Dialectical behavior therapy (DBT) was the most comprehensive and promising

psychotherapy in treating BPD, developed by Linehan (1987, 1993). DBT assumes that people

want to do the best they can to improve. They must learn new behaviors to cope with their day-

to-day life. They may not have all the responsibilities for what had happened to them in the past,

but they must take the responsibility to change. DBT teaches BPD patients to identify the

triggers of their emotions and how to cope with them. Problem-solving is also capitalized in

DBT. DBT has been found effective in reducing suicide attempts and lowers the dropouts of

treatment and hospitalizations (Linehan, Armstrong, Heard, Allmon & Suarez, 1991; Linehan,

Heard, & Armstrong, 1992). Recent study is also showing that DBT is a promising intervention

in treating posttraumatic stress disorder (PTSD) and BPD (Harned, Foa, Linehan, & Korslund,

2012).
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In addition to psychotherapy and psychopharmacological intervention, there are many

residential programs available as well. These residential programs provide a platform for BPD

patients to relearn and improve their social skills.

Since we have so many treatments available for BPD patients nowadays, one might

curious about the prognosis.

Prognosis

When BPD was first introduced in the DSM-III in about 30 years ago, its prognosis was

guarded. Even the prognosis is reviewed in recent years, it is still slow and sometimes symptoms

may set back (Van Luryn et. al., 2007). In addition, the anger and instability seem to be

unresponsive to treatment, and for those who cannot control their self-destructive behaviors are

more likely to kill themselves accidentally, especially in young age (Oldham, 2006). These

findings are depressing because it seems like however clinicians tried their best in helping BPD

patients, not many of them truly recover from BPD. However, as these patients aging, their

impulsivity and identity disturbance decline significantly, and their style of emotional expression

change as well (Hunt, 2007). Nowadays, there is a hope for these patients because psychiatry is

making good progress in helping these patients. It is because the medication is focusing on

treating behavioral problems, such as impulsivity, anxiety, depression, psychosis, anger, and

mood dysregulation. The prognosis might be better than we originally thought (Fawcett, 2012).

In another recent study contradicting to what we knew about the prognosis of BPD in the past, It

was an unfortunate in the history of psychiatry because clinicians stigmatized these patients as

untreatable. However, the literature now suggests that BPD is a brain disease with a good

prognosis. These patients can achieve remission at a relatively high rate with low rates of

relapses. Looking at the nature course of the disorder, it may be remission over years, but the
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remission is accelerated by the combined use of psychotherapy and medication (Schulz &

Nelson, 2012). A thorough literature review done by Dr. Zanarini (2012) suggests that, at least

on the symptomatic level, BPD patients actually have a better prognosis than we originally

thought.

Unique issues Faced by the Family Members of BPD

The involvement of family members is increasingly recognized as important to helping

BPD patients because family is the primary place for most people to seek for help and support

(Nelson & Schulz, 2012). The National Educational Alliance for Borderline Personality Disorder

(NEA-BPD) also developed a program for family support and education. The program teaches

family members about the disorder, and how they can help the BPD patient better. Taking care of

a BPD patient can be stressful. Hence, teaching the family to handle the stress is also important.

In contrast, if the family is one of the contributors to the disorder, family therapy can benefit

both the patient and the family. Dr. Gunderson and Berkowitz (2006) developed a family

guideline for the disorder. In the guideline, they emphasize five key components to the

remission. The first component is to educate the family that change is difficult, so it has to go

slow and start low. Namely, asking the family to lower their expectations and set realistic goals

that are attainable for the patient. The family should be emphasizing on the small changes and

progress slowly. A big change will eventually emerge. The second component is the family

environment. Family environment that fosters calmness, safety, and warmth allow the BPD

patients freely express his or her emotions. Finding time to talk together and maintain family

routines can provide a sense of stableness to the patient. The third component is managing crises.

BPD patients are often in emotional crisis. On one hand, their family members have to learn to

stay calm, and on the other hand, they have to learn to manage these crises. The guideline
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suggests their family members not to get defensive, take actions to prevent self-destructive acts,

and listen to their concerns and needs. The forth component is that family members have to learn

how to address problems in a collaborative and consistent way. The fifth component is to teach

family members setting limits and boundaries. Family members should not protect them from

experiencing natural consequences. However, these limits should not be too restricted. There

should be a clear communication that the family has zero tolerance to abusive treatment. The

purpose of the family guidelines is to empower the family members to be more effectively in

helping the patient to achieve remission.

Conclusion

Borderline personality disorder is one of the severe psychiatric disorders that undermine

the sufferer’s ability to form healthy relationships and to live a stable life. These patients are

characterized by the feeling of emptiness, boredom, and identity disturbance. Although we do

not have a clear answer to why the number of people being diagnosed as having BPD has

increased in recent years, the disorder has received intense attention in the recent years. As the

technology advances, new neurophysiological findings might shed some lights on the etiology of

BPD, suggesting the idea that BPD is actually a brain disease. A body of research has identified

several treatments work especially well with BPD. In addition to individual psychotherapy and

medication, family involvement is also becoming to be recognized as an important factor in

promoting change. However, there is still plenty of room for researchers to find out whether

family therapy would be beneficial to the patient and the family. In terms of prognosis, BPD has

been stigmatized among clinicians that these patients are extremely difficult work. Even so,

clinicians may refer these patients once they find out that these patients are suffering from BPD.

This is a form of malpractice, and it is unethical. The stigmatization leads to clinicians to believe
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that BPD has a poor prognosis. Fortunately, the field did not give up on this population. Recent

studies have actually found that BPD might have a better prognosis than clinicians originally

thought. The findings are encouraging because they have switched the view of BPD around. New

directions in understanding and treating BPD give hope to the field of clinical psychology, the

family, and the BPD individuals.

References

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