Factors associated with the development of borderline personality disorder and their influence on clinical interventions
-Namitha Babu, Psychologist
Borderline personality disorder (BPD) is a psychiatric disorder characterized by a long-term display of impulsivity, distorted self-image, instability in interpersonal relationships and regular mood changes along with significant fear of real or imagined abandonment and rejection and prolonged bouts of depression often accompanied by suicidal attempts and self-harm (DSM-V, as cited by Davey, 2014, p.417). The term borderline was first coined by Adolph Stern in 1938 – he found that a group of his patients would not fall in to the existing classification system that was used to distinguish psychoses from neuroses (Gunderson, 2009). Comorbidity with at least one other psychological disorder is a common feature of borderline personality disorder. Generally, it is seen to co-occur with Axis-I and Axis-II disorders, mood-disorders, anxiety disorders, substance use disorders and other personality disorders (such as narcissistic, dependent and schizotypal) (Tomko, Trull, Wood and Sher 2014). Lifetime mood disorders like major depression and mania, also lifetime anxiety disorders like agoraphobia, posttraumatic stress disorder and panic disorders are the disorders that are strongly comorbid with borderline personality disorder (ibid). Borderline personality disorder is seen to be the most researched as well as the most diagnosed personality disorder among the general population. Freeman and his colleagues (2005), found that almost 11% of the psychiatric outpatients and 19% of the psychiatric inpatients have been diagnosed with borderline personality disorder. Almost 40-70% of the patients with borderline personality disorder reported to have had childhood sexual abuse and 25-73% of patients report childhood physical abuse. This Report suggests that borderline personality disorder could be a result of a significant early loss or could have stemmed from a family where there are histories of substance abuse, mood disorders or parents with severe depression or character problems. The origin of borderline personality disorder is not yet clearly defined. Many years ago, uninformed parenting was believed to be the root cause of
the development of the disorder (Friedel, 2012). Although the proliferating studies on borderline personality disorder throws light on the developmental pathology of the disorder, most of these findings are not universally accepted. For example, there have been huge contentions on the gender bias in the diagnosis of the disorder where it is considered as the
‘bad girl’ among the psychiatric disorders as Becker (2000) presumes the disorder to be diagnosed more among women (Freeman, Stone, Martin and Reinecke 2005). The origin of borderline personality disorder is not yet clearly defined. Many years ago, uninformed parenting was believed to be the root cause of the development of the disorder (Friedel, 2012). Although the causes of the development of the disorder are unknown, various genetic, biological, psychosocial and environmental factors contribute to the onset of the disorder. It can be called a biopsychosocial diathesis-stress model as the cognitive developmental model tries to incorporate findings from each of these domains (Freeman, 2007). The factors that predispose people to borderline personality disorders can be chaotic home environment, childhood sexual or physical abuse, behavioural impulsivity, familial history of substance abuse or depression, disorganized attachment, separation or early loss (ibid).
Even though a specific causative gene has not been found for borderline personality disorder, evidences show that genetic and biological factors play a major role in the development of the disorder. In the twin studies conducted, the heritability rate was found to be 0.65 to 0.75; whereas it was found to be 40-60% in the general personality disorders (Leichsenring, Leibing…Leweke, 2011). Studies have found that the impulsivity trait associated with the disorder is a result of lower serotonergic levels as assessed by the neuroendocrine challenge (Paris, 2007). Leichsenring and colleagues (2011) also said that some of the genes associated with the psychopathological development of the disorder are linked to the serotonergic system. These authors suggests that polymorphisms in 5HTTLPR (the serotonin transporter-linked promoter region) regulates the relationship between serious life events and the impulsive behaviour in borderline patients. Although the data from candidate-gene study and gene-gene interactions reveals a role for polymorphisms in 5HTTLPR; the complex gene-gene as well as the gene-environment interactions makes the studies difficult to conclude. Even though the exact molecular nature of the disorder is not evident, research suggests that there is an abnormality in the serotonergic function that underlies the impulsive behaviour in the patients. And this leads to the assumption that these defects might be linked to specific genetic risk factors (ibid).
Studies conducted by Zanarini and colleagues (1997) suggests that the initial focus of the researches on the childhood experiences of the people diagnosed with borderline personality disorder was on the early loss or separation as well as uninformed parenting; but recent studies places its focus on childhood physical and sexual abuse as reported by most of the patients with the disorder. Out of the reported cases, 10-73% of the patients had gone through physical abuse either by a parent or an adult caretaker and 0-33% reported to have had depraved relationships or sexual abuse by adult caretakers or non-caretakers. Four major results were drawn from the study conducted by Zanarini and colleagues (1997). Firstly, it was found that childhood experiences of sexual abuse and neglect were omnipresent. Second major finding was that experiences of emotional abuse, overall sexual abuse, emotional withdrawal by a caretaker, inconsistent treatment and denial of the patients thoughts and feelings are found to be higher in borderline patients than in the comparative subjects. The third major finding was, borderline patients who were sexually abused were reported to come from more chaotic environments than the patients who were not sexually abused. The fourth finding states that in the pathology of the development of borderline personality disorder, sexual abuse is one of the most important factors even though the other factors play an important role.
Sometimes, nature or environment can play an important role in triggering the behaviours in borderline patients. Instances like moving away from home, beginning a close relationship or sometimes a traumatic event like a car crash, could trigger in an individual who is genetically or psychosocially predisposed to experience intense depression or frustration that has been preceded by a traumatic childhood experience (Zanarini & Frankenburg, 1997). The object relations theory, which is a form of psychodynamic theory, argues that if the important people (e.g. parents) in the developmental past have given inadequate love and care, the child would develop fear of rejection and separation and lack of self-esteem which stems from an insecure ego-the key features of borderline personality disorder. This would also lead to the development of a defence mechanism called splitting which is present in people with weak ego. Splitting is a condition where individuals perceive people, things or events in a black and white way by classifying things as good or bad with no in between (Davey, 2014).
Creating a healthy, safe and comfortable therapeutic relationship with the patient is very important for a successful intervention outcome as most of the patients have long histories of neglect and abuse. This is where the Schema focused cognitive therapy for the borderline personality disorder is of utmost importance as this is an integrative therapy which includes cognitive behavioural therapy and experiential therapy. Schema therapy is the kind of therapy that helps the patient to fulfil the unfulfilled childhood emotional needs by providing techniques such as limited reparenting which helps to diminish the early emotional memories such as neglect or abandonment. The therapist must be able to unusually be close to the patient but clearly knowing where to draw the boundaries. This therapy mainly focuses on the childhood traumas which lead to the development of the disorder and takes an approach which is different from all the other interventions that helps to breakthrough all the dysfunctional and maladaptive pattern the patient has created (Arntz & Genderen, 2011).
Several methods of psychotherapy like cognitive behaviour therapy, dialectic behaviour therapy, interpersonal or psychodynamic treatments can be used to treat patients with borderline personality disorder. In several studies that compared dialectical behaviour therapy and usual treatment methods, DBT was found to be more effective in reducing suicidal behaviours and self-mutilating behaviours as well as for depression and anxiety (Leichsenring et.al. 2011). The first and foremost focus of dialectical behaviour therapy is to accept the behaviour and the reality. Emotion regulation, interpersonal and self-management skills, distress tolerance and mindfulness are the main components of DBT as it focuses on the behaviour analysis of the patient as well as addressing all the problematic behaviour. DBT requires the therapist to think dialectically and help the patient change the non-dialectical and rigid thinking pattern. Both in and out of sessions, fear-eliciting situations are created and are taught to avoid threatening situations. DBT helps in changing the distorted self-image or self-perception of the individual by helping to accept reality and behaviour also helps in coping with the environmental as well as the psychosocial risk factors (Linehan, 1993).
Another effective treatment for borderline personality disorder is the Mentalization-based treatment based on attachment theory which integrates both psychodynamic and cognitive theories. This treatment helps in mentalization of the individuals wherein the individual will be able to focus on the mental states such as beliefs, thoughts and wishes. MBT argues that the suicidal or the self-mutilating behaviour as well as the fear of rejection, separation or abandonment and emotional dysregulation all result from the lack of self-perception or an instable self-structure. The theory, from the attachment contexts, focuses on the mentalization process and by stabilizing internal representations and helping to create more secure relationships (Groot, Verheul & Trijsburg, 2008).
Though the therapeutic techniques vary according to the psychopathological factors of the disorder, most the therapies have more similarities that outnumber the differences. The similarities also throw light on the fact that this is due to the successful outcomes of the various therapies offered to the patients of borderline personality disorder. Although there are various techniques used in the clinical intervention, what we do not know by far is what technique is accurately be used for a specific developmental pathology (Groot, Verheul & Trijsburg, 2008). Even though the factors for the development of the disorder are mentioned, the root causes are not clearly evident. Further researches have to be carried out in order to know the familial relationships of the patients with borderline personality disorders. Also, more research has to be focused on the neurological aspect of the disorder, as the neurological as well as the genetic factors that contribute to the development of the disorder is not yet evident. More studies have to be carried out on children who are predisposed or at high risk of developing borderline personality disorder as it will help develop the clinical pathology as well as help intervene from a very young age which could help delineate the childhood developmental problems such as attachment problems, fear of separation and abandonment and help in the process of mentalization.
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