Cognitive-Behavioral Treatment of Borderline Personality Disorder available in Hardcover, eBook
Cognitive-Behavioral Treatment of Borderline Personality Disorder
- ISBN-10:
- 0898621836
- ISBN-13:
- 9780898621839
- Pub. Date:
- 05/14/1993
- Publisher:
- Guilford Publications, Inc.
- ISBN-10:
- 0898621836
- ISBN-13:
- 9780898621839
- Pub. Date:
- 05/14/1993
- Publisher:
- Guilford Publications, Inc.
Cognitive-Behavioral Treatment of Borderline Personality Disorder
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Product Details
| ISBN-13: | 9780898621839 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 05/14/1993 |
| Series: | Diagnosis and Treatment of Mental Disorders |
| Pages: | 558 |
| Sales rank: | 378,855 |
| Product dimensions: | 6.12(w) x 9.25(h) x (d) |
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CHAPTER 1
Borderline Personality Disorder: Concepts, Controversies, and Definitions
In recent years, interest in borderline personality disorder (BPD) has exploded. This interest is related to at least two factors. First, individuals meeting criteria for BPD are flooding mental health centers and practitioners' offices. Eleven percent of all psychiatric outpatients and 19% of psychiatric inpatients are estimated to meet criteria for BPD; of patients 1 with some form of a personality disorder, 33% of outpatients and 63% of inpatients appear to meet BPD criteria (see Widiger & Frances, 1989, for a review). Second, available treatment modalities appear to be woefully inadequate. Follow-up studies suggest that the initial dysfunction of these patients may be extreme; that significant clinical improvement is slow, taking many years; and that improvement is marginal for many years after initial assessment (Carpenter, Gunderson, & Strauss, 1977; Pope, Jonas, Hudson, Cohen, & Gunderson, 1983; McGlashan, 1986a, 1986b, 1987). Borderline patients are so numerous that most practitioners must treat at least one. They present with severe problems and intense misery. They are difficult to treat successfully. It is no wonder that many mental health clinicians are feeling overwhelmed and inadequate, and are in search of a treatment that promises some relief.
Interestingly, the behavior pattern most frequently associated with the BPD diagnosis — a pattern of intentional self-damaging acts and suicide attempts — has been comparatively ignored as a target of treatment efforts. Gunderson (1984) has suggested that this behavior may come closest to representing the "behavioral specialty" of the borderline patient. The empirical data bear him out: From 70% to 75% of borderline patients have a history of a least one self-injurious act (Clarkin, Widiger, Frances, Hurt, & Gilmore, 1983; Cowdry, Pickar, & Davis; 1985). These acts can vary in intensity from ones requiring no medical treatment (e.g., slight scratches, head banging, and cigarette burns) to ones requiring care on an intensive care unit (e.g., overdoses, self-stabbings, and asphyxiations). Nor is the suicidal behavior of borderline patients always nonfatal. Estimates of suicide rates among BPD patients vary, but tend to be about 9% (Stone, 1989; Paris, Brown, & Nowlis, 1987; Kroll, Carey, & Sines, 1985). In a series of BPD inpatients followed from 10 to 23 years after discharge (Stone, 1989), patients exhibiting all eight DSM-III criteria for BPD at the index admission had a suicide rate of 36%, compared to a rate of 7% for individuals who met five to seven criteria. In the same study, individuals with BPD and a history of previous parasuicide had suicide rates that were double the rates of individuals without previous parasuicide. Although there are substantial literatures both on suicidal and self-injurious behavior and on BPD, there is virtually no communication between the two areas of study.
Individuals who intentionally injure or try to kill themselves and the BPD population have a number of overlapping characteristics, which I describe later in this chapter. One overlap, however, is particularly noteworthy: Most individuals who engage in nonfatal self-injurious behavior and most individuals who meet criteria for BPD are women. Widiger and Frances (1989) reviewed 38 studies reporting the gender of patients meeting criteria for BPD; women comprised 74% of this population. Similarly, intentional self-injuries, including suicide attempts, are more frequent among women than among men (Bancroft & Marsack, 1977; Bogard, 1970; Greer, Gunn, & Kolller, 1966; Hankoff, 1979; Paerregaard, 1975; Shneidman, Faberow, & Litman, 1970). A further demographic parallel of note is the relationship of age both to BPD and to nonfatal self-injurious behaviors. Approximately 75% of instances of self-injurious behavior involve persons between the ages of 18 and 45 years (Greer & Lee, 1967; Paerregaard, 1975; Tuckrnan & Youngman, 1968). Borderline patients also tend to be younger (Akhtar, Byrne, & Doghramji, 1986), and BPD characteristics decrease in severity and prevalence into middle age (Paris et al, 1987). These demographic similarities, together with others discussed later, raise the interesting possibility that the research studies conducted on these two populations, although carried out separately, have in fact been studies of essentially overlapping populations . Unfortunately, most studies of suicidal behaviors do not report Axis II diagnoses.
The treatment described in this book is an integrative cognitive-behavioral treatment, dialectical behavior therapy (DBT), developed and evaluated with women who not only met criteria for BPD but also had histories of multiple nonfatal suicidal behaviors. The theory I have constructed may be valid, and the treatment program described in this book and the companion manual may be effective, for men as well as for nonsuicidal borderline patients. However, from the outset, it is important for the reader to realize that the empirical base demonstrating the effectiveness of the treatment program described here is limited to BPD women with a history of chronic parasuicidal behavior (intentional self-injury, including suicide attempts ). (In keeping with this, I use the pronouns "she" and "her" throughout this book to refer to a typical patient.) This group is perhaps the most disturbed portion of the borderline population; certainly it constitutes the majority. The treatment is designed flexibly, such that as a patient progresses, changes are made in the treatment application . Thus, it is not unlikely that the treatment program would also be effective with less severely disturbed individuals. But at the moment such an extension would be based on speculation, not well-controlled empirical treatment studies.
The Concept of Borderline Personality Disorder
Definitions: Four Approaches
The formal concept of BPD is relatively new in the field of psychopathology. It did not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association until the publication of DSM-III in 1980. Although the particular constellation of traits comprising the diagnostic entity was recognized much earlier, much of the current interest in this population has resulted from its recently gained official status. That status was not achieved without much controversy and dispute. The "official" nomenclature and diagnostic criteria have been arrived at both through political compromise and through attention to empirical data.
Perhaps most controversial was the decision to use the word "borderline" in the official designation of the disorder. The term itself has been popular for many years in the psychoanalytic community. It was first used by Adolf Stern in 1938 to describe a group of outpatients who did not profit from classical psychoanalysis and who did not seem to fit into the then-standard "neurotic" or "psychotic" psychiatric categories. Psychopathology at that time was conceptualized as occurring on a continuum from "normal" to "neurotic" to "psychotic." Stern labeled his group of outpatients as suffering from a "borderline group of neuroses." For many years thereafter, the term was used colloquially among psychoanalysts to describe patients who, although they had severe problems in functioning, did not fit into other diagnostic categories and were difficult to treat with conventional analytic methods. Different theorists have viewed borderline patients as being on the borderline between neurosis and psychosis (Stem, 1938; Schmideberg, 1947; Knight, 1954; Kernberg, 1975), schizophrenia and nonschizophrenia (Noble, 1951; Ekstein, 1955), and the normal and the abnormal (Rado, 1956). Table 1.1 provides a sampling of early definitions of the term. Over the years, the term "borderline" generally evolved in the psychoanalytic community to refer both to a particular structure of personality organization and to an intermediate level of severity of personality functioning. The term dearly conveys this latter notion .
Gunderson (1984) has summarized four relatively distinct clinical phenomena responsible for the continued psychoanalytic interest over the years in the borderline population. First, certain patients who apparently functioned well, especially on structured psychological tests, nonetheless were scored as demonstrating dysfunctional thinking styles ("primitive thinking" in psychoanalytic terms) on unstructured tests. Second, a sizeable group of individuals who initially appeared suitable for psychoanalysis tended to do very poorly in treatment and often required termination of the analysis and hospitalization. J Third, a group of patients were identified who, in contrast to most other patients, tended to deteriorate behaviorally within supportive, inpatient treatment programs. Finally, these individuals characteristically engendered intense anger and helplessness on the part of the treatment personnel dealing with them. Taken together, these four observations suggested the existence of a group of individuals who did not do well in traditional forms of treatment, despite positive prognostic indicators. The emotional state of both the patients and the therapists seemed to deteriorate when these individuals entered psychotherapy.
The heterogeneity of the population referred to as "borderline" has led to a number of other conceptual systems for organizing behavioral syndromes and etiological theories associated with the term. In contrast to the single continuum proposed in psychoanalytic thought, biologically oriented theorists have conceptualized BPD along several continua. From their viewpoint, the disorder represents a set of clinical syndromes, each with its own etiology, course, and outcome. Stone (1980, 1981) has reviewed this literature extensively and concludes that the disorder is related to several of the major Axis I disorders in terms of clinical characteristics, family history, treatment response, and biological markers. For example, he suggests three borderline subtypes: one related to schizophrenia, one related to affective disorder, and a third related to organic brain disorders. Each subtype occurs on a spectrum ranging from "unequivocal" or "core" cases of the subtype to milder, less easily identifiable forms. These latter cases are the ones to which the term "borderline" is applied (Stone, 1980). In recent years, the tendency in the theoretical and research literature has been toward conceiving of the borderline syndrome as located primarily on the affective disorders continuum (Gunderson & Elliott, 1985), although accumulating empirical data cast doubt on this position .
A third approach to understanding borderline phenomena has been labeled the "eclectic-descriptive" approach by Chatham (1985). This approach, embodied primarily at present in the forthcoming DSM-IV (American Psychiatric Association, 1991) and Gunderson's (1984) work, rests on a definitional use of borderline criteria sets. The defining characteristics have been derived largely by consensus, although empirical data are now being used to some extent to refine the definitions. For example, Gunderson's criteria (Gunderson & Kolb, 1978; Gunderson, Kolb, & Austin, 1981) were originally developed through a review of the literature and distillation of six features that most theorists described as characteristic of borderline patients. Zanarini, Gunderson, Frankenburg, and Chauncey (1989) have recently revised their BPD criteria to achieve better empirical discrimination between BPD and other Axis II diagnoses. However, even in this latest version, the methods of selecting new criteria are not made clear; they appear to be based on clinical criteria rather than empirical derivation. Similarly, the criteria for BPD listed in DSM-III, DSM-III-R, and the new DSM-IV were defined by consensus of committees formed by the American Psychiatric Association, and were based on the combined theoretical orientations of the committee members, data on how psychiatrists in practice use the term, and empirical data collected to date. The most recent criteria used to define BPD, the DSM-IV and Diagnostic Interview for Borderlines — Revised (DIB-R) criteria, are listed in Table 1.2.
A fourth approach to understanding borderline phenomena, based on a biosocial learning theory, has been proposed by Millon (1981, 1987a). Millon is one of the most articulate dissenters from the use of the term "borderline" to describe this personality disorder. Instead, Millon has suggested the term "cycloid personality" to highlight the behavioral and mood instability that he views as central to the disorder. From Millon's perspective, the borderline personality pattern results from a deterioration of previous, less severe personality patterns. Millon stresses the divergent background histories found among borderline individuals, and suggests that BPD can be reached via a number of pathways.
The theory I present in this book is based on a biosocial theory, and in many ways is similar to that of Millon. Both of us stress the reciprocal interaction of biological and social learning influences in the etiology of the disorder. In contrast to Millon, I have not developed an independent definition of BPD. I have, however, organized a number of behavioral patterns associated with a subset of borderline individuals-those with histories of multiple attempts to injure, mutilate, or kill themselves. These patterns are discussed in detail in Chapter 3; for illustrative purposes, they are outlined in Table 1.3.
Ingeneral, neither behavioral nor cognitive theorists have proposed definitional or diagnostic categories of dysfunctional behaviors comparable to the others described here. This is primarily a result of behaviorists' concerns about inferential theories of personality and personality organization as well as their preference for understanding and treating behavioral, cognitive, and affective phenomena associated with various disorders rather than "disorders" per se. Cognitive theorists, however, have developed etiological formulations of borderline behavioral patterns. These theorisits view BPD as a result of dysfunctional cognitive schemas developed early in life. Purely cognitive theories are, in many respects, similar to more cognitively oriented psychoanalytic theories. The various orientations to borderline phenomenology described here are outlined in Table 1.4.
Diagnostic Criteria: A Reorganization
The criteria for BPD, as currently defined, reflect a pattern of behavioral, emotional, and cognitive instability and dysregulation. These difficulties can be summarized in the five categories listed in Table 1.5. I have reorganized the usual criteria somewhat, but a comparison of the five categories I discuss below with the DSM-IV and DIB-R criteria in Table 1.2 shows that I have reorganized but not redefined the criteria.
First, borderline individuals generally experience emotional dysregulation. Emotional responses are highly reactive, and the individual generally has difficulties with episodic depression, anxiety, and irritability, as well as problems with anger and anger expression. Second, borderline individuals often experience interpersonal dysregulation. Their relationships may be chaotic, intense, and marked with difficulties. Despite these problems, borderline individuals often find it extremely hard to let go of relationships; instead, they may engage in intense and frantic efforts to keep significant individuals from leaving them. In my experience, borderline individuals, more so than most, seem to do well when in stable, positive relationships and to do poorly when not in such relationships.
Third, borderline individuals have patterns of behavioral dysregulation, as evidenced by extreme and problematic impulsive behaviors as well as suicidal behaviors. Attempts to injure, mutilate, or kill themselves are common in this population. Fourth, borderline individuals are at times cognitively dysregulated. Brief, nonpsychotic forms of thought dysregulation, including depersonalization, dissociation, and delusions, are at times brought on by stressful situations and usually clear up when the stress is ameliorated. Finally, dysregulation of the sense of self is common. It is not unusual for a borderline individual to report that she has no sense of a self at all, feels empty, and does not know who she is. In fact, one can consider BPD a pervasive disorder of both the regulation and experience of the self — a notion also proposed by Grotstein (1987).
(Continues…)
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Copyright © 1993 The Guilford Press.
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Table of Contents
I. THEORY AND CONCEPTS.1. Borderline Personality Disorder: Concepts, Controversies, and Definitions.
2. Dialectical and Biosocial Underpinnings of Treatment.
3. Behavioral Patterns: Dialectical Dilemmas in the Treatment of Borderline Patients.
II. TREATMENT OVERVIEW AND GOALS.
4. Overview of Treatment: Targets, Strategies, and Assumptions in a Nutshell.
5. Behavioral Targets in Treatment: Behaviors to Increase and Decrease.
6. Structuring Treatment Around Target Behaviors: Who Treats What and When.
III. BASIC TREATMENT STRATEGIES.
7. Dialectical Treatment Strategies.
8. Core Strategies: Part I. Validation.
9. Core Strategies: Part II. Problem Solving.
10. Change Procedures: Part I. Contingency Procedures (Managing Contingencies and Observing Limits.
11. Change Procedures: Part II. Skill Training, Exposure, Cognitive Modification.
12. Stylistic Strategies: Balancing Communication.
13. Case Management Strategies: Interacting with the Community.
IV. STRATEGIES FOR SPECIFIC TASKS.
14. Structural Strategies.
15. Special Treatment Strategies.
Interviews
Clinical psychologists, psychiatrists, clinical social workers, mental health counselors, and psychiatric nurses. May serve as a text in graduate-level courses.
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