Mental health articles

Treatment of borderline personality disorder as follows:

Psychological approaches

Treatment of people with borderline personality is not easy, and there are relatively few controlled trials examining the effects of therapy. Roth and Fonagy tried to establish some overall goals of therapy and guidelines for who may benefi t from it most. They suggested the following:

Psychotherapy is more likely to be effective for less severe personality disorders. In individuals under the age of 30 years, the greatest risk comes from suicide. Prevention of this, rather than ‘cure’, may form a legitimate therapeutic target. Individuals with good social support, chronic depression, who are psychologically minded and with low impulsivity, are most likely to benefi People who have high levels of impulsivity are most likely to benefi t from a ‘limit-setting’ group or a therapist who is supportive of their attempts to struggle with uncontrollable impulses. Commitment and enthusiasm of the therapist may be of special signifi cance, and fi nding the ‘right’ therapist for the ‘right’ patient is particularly important.

Because of the complex facets of the disorder, including the threat of self-harm, therapy with people with personality disorder is necessarily complex and the approaches used should be governed by the individual’s ability to cope with particular therapeutic issues. It may be useful for some people to stay in hospital during the early stages of therapy, as they may fi nd therapy sessions so stressful they either drop out or harm themselves in some way. The hospital can provide a safe environment, where their behaviour can be observed and controlled, and both therapist and client have the security of knowing that any impulsive self-harming behaviour will be seen and dealt with should it occur. t from ‘talking therapies’.

Cognitive therapy The core of cognitive therapy is the identifi cation and modifi cation of cognitive schema that drive inappropriate behaviours, using an approach known as schema therapyor cognitive analytic therapy . These approaches may combine with a number of other strategies, including developing problem-focused plans to cope with urges to self-harm, mood disturbances and suicidal feelings, improving relationships, and so on. The issues addressed in therapy and the strategies used are dependent on the most pressing and problematic behaviour at the time . One of the most important therapeutic aims is to minimize risk of self-harm. This involves identifying the antecedents to episodes of self-harm, the thoughts and feelings that accompany them, and their consequences . Each of these forms a potential point of intervention. Alternatives to self-harm often involve a high intensity action, such as listening to loud music, or painful, but not damaging, behaviours such as squeezing a ball until the muscles ache. Where there is risk that an episode of self-harm will escalate into a serious attempt at suicide, specifi c strategies may be used to minimize this risk, including problem solving and identifying reasons for living . Evidence of the effectiveness of these approaches is still gradually accumulating. Blum et al. compared outcomes of a cognitive behavioural programme similar to schema therapy with ‘treatment as usual’. In addition to working with individuals, they included what they termed a systems approach, involving a two-hour session to which family members or other signifi cant individuals were invited. During this session, these people were taught about the nature of the problems their relative was experiencing and patients were encouraged to share their experiences of the treatment programme. In the year following the intervention, participants in the cognitive behavioural intervention experienced greater improvements on measures of impulsivity, negative affect and global functioning. They were no better on measures of the frequency of self-harm or suicide attempts, which are generally considered key outcomes of any intervention. However, they did make fewer visits to hospital emergency departments. GiesenBloo et al.  compared two interventions, each of which was conducted over a three-year period: schema therapy and psychodynamically based transference-focused psychotherapy. They found that more people remained in the schema therapy over this time (presumably indicating the degree to which they felt they were gaining some benefi t from attending).

In addition, participants in the schema therapy intervention were most likely to recover, to have better improvement scores, and to report better overall quality of life.

Dialectical behaviour therapy A second key therapeutic approach to the treatment of borderline personality disorder involves a form of therapy called dialectical behaviour therapy. This can be considered a third-wave approach as it has a strong behavioural component (and many similarities to ACT) and does not focus on cognitive change as a key contributor to change. The therapy involves the client in working individually with a therapist and in therapy groups. As with schema therapy, self-injurious and suicidal behaviours are key targets. Therapy involves teaching four sets of skills: interpersonal effectiveness, core mindfulness, emotion regulation and distress tolerance, which draw strongly on mindfulness, distraction and acceptance skills. A few studies have shown DBT to be an effective intervention. In one of the early randomized controlled trials of its effectiveness, Van den Bosch et al. evaluated treatment outcomes, comparing one year of DBT versus usual care, and found lower levels of parasuicidal and impulsive behaviours, sustained for six months after the completion of treatment. In a comparison between a similar programme and non-behavioural psychotherapy, Linehan et al.  found one-year follow-up outcomes were again supportive of DBT: participants receiving DBT were half as likely to make a suicide attempt and required less hospitalization for suicide ideation than those in the psychotherapy intervention. In addition, they were less likely to drop out of treatment and to be admitted to hospital. More recently, Clarkin et al.  compared the effectiveness of DBT with transference-focused psychotherapy and found the transferencefocused therapy to be the more effective of two. Both interventions achieved good results, with signifi cant gains on measures of suicidality, depression, anxiety, global functioning and social adjustment. However, the psychotherapy achieved reductions in anger not found with DBT.

Tags: borderline personality disorder, disorder, personality, treatment