Two approaches to treat Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a serious mental illness that centres on the inability to manage emotions effectively. The disorder occurs in the context of relationships: sometimes all relationships are affected, sometimes only one. It usually begins during early adulthood. People with borderline personality disorder may experience mood swings and may display uncertainty about how they see themselves and their role in the world. As a result, their interests and values can change quickly. People with borderline personality disorder also tend to view things in extremes, such as all good or all bad. Their opinions of other people can also change quickly. An individual who is seen as a friend one day may be considered an enemy or traitor the next. These shifting feelings can lead to intense and unstable relationships. While some people with BPD are high functioning in certain settings, their private lives may be in turmoil. Most people who have BPD suffer from problems regulating their emotions and thoughts, might engage in impulsive and reckless behaviour. Other disorders, such as depression, anxiety disorders, eating disorders, substance abuse and other personality disorders can often exist along with BPD.

The diagnosis of BPD is frequently missed and a misdiagnosis of BPD has been shown to delay and/or prevent recovery. Bipolar disorder is one example of a misdiagnosis as it also includes mood instability. There are important differences between these conditions but both involve unstable moods. For the person with bipolar disorder, the mood changes exist for weeks or even months. The mood changes in BPD are much shorter and can even occur within the day.

Officially recognized in 1980 by the psychiatric community, BPD is more than two decades behind in research, treatment options, and family psycho-education compared to other major psychiatric disorders. BPD has historically met with widespread misunderstanding and blatant stigma. In the past, many mental health professionals found it difficult to treat borderline personality disorder (BPD), so they came to the conclusion that there was little to be done.
However, evidenced-based treatments have emerged over the past two decades bringing hope to those diagnosed with the disorder and their loved ones. Dialectical behaviour therapy (DBT) (Linehan, 1993a) is the most frequently used treatment for people diagnosed with borderline personality disorder. Concerns have been raised regarding its efficacy as a treatment (Scheel, 2000). Recent studies have also demonstrated the effectiveness of schema therapy for treating borderline personality disorder. This article will review literature to highlight the relative strengths and weaknesses of the dialectical behaviour therapy and schema focused therapy for treating individuals with borderline personality disorder and discuss the implications of the findings for treatment and risk management. This article will begin with brief comparisons of the treatment approaches of both therapeutic modalities and discuss the theoretical underpinnings of the therapies. Secondly, it will briefly review the effectiveness of the treatments. Dialectical behaviour therapy finds its roots in cognitive and behavioural therapies (Dimeff and Linehan, 2001). Linehan combined both acceptance and change to build the base of DBT (Linehan, 1993). One feature of DBT that makes it different from other cognitive behavioural therapies is the use of dialectics. DBT integrates the therapist’s attitude towards the problematic behaviour exhibited by the clients, with warmth and acceptance (Linehan, 1993). The dialectical opposites are combined together through the practice of mindfulness (Montgomery Graham, 2016). The dialectical nature of DBT is coupled with hierarchical therapy objectives. The treatment first focuses on the life threatening behaviour then moves on to deal with therapy motivation, followed by reducing behaviours that interfere with quality of life and lastly, increasing the behavioural skills to appropriately respond to emotional arousal (Montgomery Graham, 2016). Similar to DBT, schema therapy is based on the cognitive and behavioural therapy approaches. However, schema therapy also incorporates gestalt and psychodynamic principles, as the founder of schema therapy understood the importance of longer duration of treatment and more exploration of childhood experiences for the therapy to have a positive effect on the client (Kellogg & Young, 2006).
Dialectical behaviour therapy is based on the principle that emotional dysregulation is the primary cause for the difficulties experienced by individuals with BPD (Feigenbaum, 2007). It is considered that due to adverse childhood experiences or biological underpinnings, people with borderline personality disorder have heightened emotional response systems (Paivio & Laurent, 2001). People with borderline personality disorder respond to external stimuli with more strength and speed, which in turn leaves them more vulnerable to cognitive and behavioural dysfunction (Feigenbaum, 2007). High emotional arousal results in cognitive confusion and individuals with borderline personality disorder find it difficult to cope and make effective decisions and therefore act impulsively. Therefore, one of the strengths of the DBT model is that it conceptualises problematic behaviours: self-harm, suicide attempts, substance abuse, exhibited by individuals with borderline personality disorder, as a consequence of emotional arousal as well as maladaptive coping mechanisms to avoid negative situations (Feigenbaum, 2007). Thus, DBT focuses on determining, accepting and regulating emotional responses (McMain, Korman & Dimeff, 2001).

Another important aspect that DBT considers as a crucial developmental factor is the unstable environment in which children grow up wherein the care-givers react inappropriately to the child, therefore making the child more vulnerable to developing feelings of abandonment and neglect (Feigenbaum, 2007; Gunderson, 1996). One of the fundamental roles played by parents or primary care-givers is to assist the child in cultivating an understanding of their emotional experiences, ways of expressing their emotions and ability to manage these experiences effectively.
Invalidating families fail to provide children with such skills (Feigenbaum, 2007). Individuals with BPD become wary of abandonment and rejection and constantly test relationships. Invalidating environments (such as childhood abuse) tend to cause distrust or avoidance of emotional experiences, which makes individuals less capable of identifying and regulating their emotional experiences. Therefore, DBT focuses on identification and modification of self-invalidating cognitions and its consequences.

DBT is a treatment aimed at increasing the ability of clients to regulate themselves (Feigenbaum, 2007). Linehan, Heard and Armstrong (1993), proposed that DBT treatment programmes have five primary functions; firstly it aims at developing new capabilities in clients through skills training wherein individuals acquire new skills to express their emotional arousal. The skills training group is divided into four stages: mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance. Secondly, DBT focuses on enhancing client capability and motivation through detailed behavioural chain analyses relating to the targets of the individual therapy session and practising new skills. During these sessions client’s motivation to change and commitment to therapy are identified and addressed. Ensuring effective transfer of newly acquired response skills through telephone consultation and case management is another function of DBT. It also takes measures to structure the environment through care programme approach meetings by coaching the caregivers, enabling them to recognise and facilitate the effective use of new skills by the client and, lastly, enhancing therapists skills and motivation to continue to work with the client safely through skills development, monitoring stress and burnout. Therefore, DBT is a comprehensive treatment programme and involves hierarchy of treatment goals.

Similarly, schema therapy considers the maladaptive schemas of patients with BPD present in their childhood, genetics and temperament and the interaction between the child’s temperament and the parenting style as the cause of the development of BPD (Kellogg & Young, 2006). It also focuses on the family environment as one of the most important determining factors for the development of BPD. Emotionally disturbed childhood and unstable environment are important factors but they are not always a contributing factor. An individual could have maladaptive schemas despite having a protective childhood environment. Schema therapy characterises patients with BPD to have five modes of self that determine their behaviour (Young, Klosko & Weishaar 2003). Firstly, the client might feel like an abandoned and abused child; feeling isolated and being highly sensitive about how others perceive them. Secondly, the client could be feeling like an angry and impulsive child, possibly because they might have been victimised in their childhood. Thirdly, they may be overwhelmed and be numb to stress and fear, therefore be like a detached protector. The fourth mode would be the client having very low self-esteem and hence would want to punish themselves, this mode is called the punitive parent. The final mode of the clients would be a healthy adult who would act responsible; the schema therapy aims at achieving this stage (Montgomery Graham, 2016).

A recent effectiveness study randomised 86 patients with BPD to either schema therapy or transference-focused psychotherapy (TFP) (Giesen-Bloo et al. 2006). The patients were treated with 3 years of schema therapy or TFP and the study results showed significant improvement in reduction of BPD symptoms and general psychopathology. However, the schema therapy group showed a larger treatment effect on the therapy outcomes. Another RCT by Farrell, Shaw and Webber (2009) randomised a group of 16 female outpatients into schema therapy plus TAU (weekly individual eclectic psychotherapy) or only TAU. There was a significant difference noticed in both groups post-treatment. The group subjected to both schema therapy and TAU showed massive improvement in all outcome variables: severity and frequency of BPD symptoms, general psychopathology and global functioning. Few schema therapy patients (n=15) were no longer diagnosed with BPD. On the other hand, 92% of the TAU group were still diagnosed with BPD after the treatment was concluded, showing a highly significant difference, x 2 (1, N=28) = 20.43, p < .001, OR = 165 (95%CI = 9.27, 2936). The patients who were subjected to schema therapy showed improvement in various aspects of BPD (affect, cognition, impulses and interpersonal interaction). They continued to show such improvements whereas the control group deteriorated.
The results of the study suggests that schema focused therapy (SFT) could be effectively adapted as group therapy since it would be cost effective and could be made available to larger population across health and private settings. Though the SFT in groups is at its early stage of showing effectiveness but the results of the above study adds to the growing evidence supporting SFT as an effective treatment for BPD. However, the study had a small sample size and only included women which limits the generalizability of the results. Future effectiveness studies with larger and more diverse sample size is warranted.

However, it is not clear as to whether schema therapy affects the BPD symptoms, since the studies typically focus on the self-harm and suicidal behaviour and factors like social, intimate relationships and overall quality of life (Montgomery Graham, 2016). Therefore, further research should be conducted to test the effectiveness of schema therapy in comparison with DBT for treating BPD.

On the other hand, researchers have accumulated considerable evidence on the effectiveness of DBT treating BPD. The earliest randomised control trials (RCT) done to test the effectiveness of DBT, randomly categorised women with severe BPD and recent history of suicidal gesture, into one year of DBT or treatment as usual (TAU) in community. This RCT by Linehan, Armstrong, Allmon, Heard and Suarez (1991) displayed a decrease in the frequency and medical severity of self-harm behaviours in the initial stage of the treatment as well as one year after. It also showed a decrease in the number of in-patients and increased retention in treatment. There was a significant improvement on the Global Assessment Scale and improvements were consistent even after 12 months follow ups (Linehan et al., 1993). However, the study had few limitations. The study was conducted by the developers of the therapy and therefore could possibly be biased. Moreover, the sample size was small and only consisted of females with no comorbid substance abuse, hence limiting the generalizability of the results to wider settings. The TAU group did not control for certain aspects of DBT, such as the amount of treatment time and therapist skills. There were no significant differences between the TAU group and DBT group on factors like depression, hopelessness and suicidal ideation improvements.

Koons et al., (2001) replicated the above study and compared 20 women with BPD randomised into TAU (pharmacotherapy and individual psychotherapy) or DBT. The study found a reduction in factors like suicide ideation, depression and hopelessness. However, the results showed no significant improvements in para-suicidal behaviour and in-patient bed days, but those who displayed a reduction in these factors were in the DBT group. But the therapy in the study had a different focus than the one by Linehan et al., 1991, since they did not have a prerequisite of recent para-suicidal behaviour and therefore the population engaged in fewer life threatening behaviour. Thereby, the therapy focused on emotional and interpersonal change. The study’s results showed considerable change in the measures of affect and cognition related to suicidal ideation and quality of life occurring in the DBT group. There are few weaknesses of this study; the small sample size and the exclusion factors of the study (excluded males, comorbid substance dependence and antisocial personality disorder) made it difficult to be generalizable in different clinical settings. The study is also limited in terms of non-specific comparison to the TAU, similar to the Linehan study in 1991. In addition, there is no follow up data for this study to show any consistent effects of the treatment for this population.

Third important RCT of DBT randomly assigned 58 women with BPD to either DBT or TAU (Verheul et al., 2003). The DBT group displayed fewer dropout rates from therapy and reduction in self harm and impulsive behaviours compared with usual treatment. Similar to Koons study (2001) the participants did not require to have a recent history of para-suicidal behaviour thereby limiting the changes in this variable, however a major advancement in the study was the inclusion of participants with comorbidity of substance abuse. According to the study’s findings DBT is more effective for those with a recent history of self-harming behaviours. Though the attrition rates (37% DBT vs. 77% TAU) were considerably different for the two treatment groups, it was higher than the above mentioned two RCTs. This could possibly be due to the inclusion of clients with co-morbid substance dependence who are a difficult group to retain in treatment. The study is limited by comparison to TAU wherein the effects of number of hours of treatment, therapist’s commitment are not considered.
Similarly, to check whether DBT is more effective than other expert treatment, Linehan and colleagues (2006) compared DBT to community treatment by experts (CTBE). The study revealed that suicide attempts were less in clients in the DBT group. They also showed that clients in the CTBE group were more likely to use crisis services and have more instances of psychiatric hospitalisations. The treatment retention rate was more in the DBT group compared to CTBE groups. Though, the study was limited by the sample characteristics as it only included women thus limiting generalizability, but it included clients with a range of comorbid disorders indicating the effectiveness of DBT even in different client groups with comorbid disorders.

A number of concerns have been raised on the applicability of DBT based on the available RCTs (Feigenbaum, 2007). BPD is a complex disorder and individuals with BPD have multiple problematic behaviours which take time to change. Additionally, BPD is usually comorbid with other disorders. Moreover, people with BPD have attachment and trust issues; and they find it difficult to form relationships. It is a time consuming treatment to manage these complex problems and therefore DBT is a staged treatment with hierarchical goals (Feigenbaum, 2007). Therefore, DBT should be continued for more than a year. Hence, the RCTs which required the clients to stop therapy after a year without any further clinical treatment are not a reliable source of the efficiency of DBT. Evaluations of a year of treatment is important considering the cost effectiveness and practicality in clinical settings where long term treatment might not be possible. But there is a need for studies to be conducted for more than a year to actually determine the effectiveness of DBT for treating BPD.

Although there might be many treatments that have shown efficacy in treating borderline personality disorder in comparison to TAU or to a more rigorous comparison group of “experts in the community”, there is little difference between well-established treatments. Thus, there exists no empirical evidence for a “treatment of choice” for BPD. It is improbable that one treatment could be identified as “one fits all” treatment for BPD. Further research should focus on improving the mechanisms of the existing treatments that are most effective to guide the patents to a specific treatment at that point of his illness. But DBT has emerged as one of the most recommended treatments for BPD by the UK Department of Health (2003) with empirical evidence supporting it. However, schema therapy has shown evidence of effectiveness for treating BPD. Studies found evidence for the efficacy of schema therapy, but the strength of the results varied. The number of studies on effectiveness is small but reviewed findings suggest that schema therapy is a promising treatment. Borderline personality disorder (BPD) is one of the most complex and often attenuating mental disorder which needs to be investigated and examined further to develop effective treatments.

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