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Therapy for Clients with Personality Disorders
Description of the Condition Selected
The selected personality disorder is borderline personality disorder (BPD). The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lists 10 personality disorders divided into the 3 clusters (A, B, and C). BPD is 1 of 4 Cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic (American Psychiatric Association, 2013). The condition is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior. Also, BPD causes significant impairment and distress and is associated with multiple medical and psychiatric co-morbidities. Surveys have estimated the prevalence of BPD to be 1.6% in the general population and 20% of the psychiatric inpatient population (Brüne, 2016).
The DSM-5 diagnostic criteria for BPD include a pervasive pattern of instability of interpersonal relations, self-image, and affects as well as marked impulsivity beginning by early adulthood (American Psychiatric Association, 2013). BPD present in a variety of contexts as indicated by five or more of the symptoms such as frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes and idealization and devaluation, and identity disturbances. Also, patients diagnosed with BPD must report impulsivity in at least two potentially self-damaging areas, such as spending, substance abuse, binge eating, sex, and reckless driving. They should also present affective instability due to a marked reactivity of moods, such as intense episodic dysphoria, irritability, or anxiety lasting for a few hours (American Psychiatric Association, 2013).
Therapeutic Approaches for BPD
Since patients with BPD suffer considerable morbidity and mortality, BPD causes a therapeutic challenge for clinicians. First-line treatment for BPD is psychotherapy. However, symptom targeted medications have also been found useful. The psychotherapies that have been adapted to treat patients with BPD are; Dialectical behavior therapy (DBT), Mentalization-based therapy, Transference-focused therapy, Cognitive-behavioral therapy (CBT), and Schema-focused therapy (Kulacaoglu & Kose, 2018). These therapies provide active and focused interventions that emphasize current functioning and relationships. These therapy modalities also offer a structured manual supporting the therapist and providing recommendations for common clinical problems. They are structured so that they encourage increased activity, proactivity, and self-agency for the patients.
According to the literature, the pharmacological treatment for BPD is limited. It is suggested that the patient with BPD who continues to experience severe, impairing symptoms such as affective dysregulation, impulsive-behavioral dyscontrol, and perceptual symptoms despite receiving psychotherapy, should receive symptom-focused, adjunctive medication treatment (Wheeler, 2014). Low-dose antipsychotic drugs are more useful for cognitive and perceptual symptoms such as dissociation, paranoid ideation, and hallucinations compared with antidepressants or mood stabilizers. Mood stabilizers are found to be more effective for impulsivity, aggression, and behavior control in BPD. Mood stabilizers in the meta-analyses were lamotrigine, topiramate, valproate, and lithium (Brüne, 2016). Lithium is also found to be effective in preventing suicide in BPD patients, as reported by a retrospective study. But lithium has limited usage due to significant side effects.
How to Share the BPD Diagnosis to Patients
Training communication strategies is essential when communicating BPD diagnosis to clients due to the stigma associated with it. There are two primary strategies of communicating the BPD diagnosis to clients without damaging a therapeutic relationship. The first strategy is to withhold BPD in favor of axis I diagnosis. Clinicians should use various tactics to communicate their patients’ mental health conditions, generally without directly giving the diagnosis of BPD (Sulzer et al., 2016). For example, clinicians often chose to discuss co-morbid mood disorders like depression and anxiety without disclosing the borderline diagnosis. The second strategy is to withhold BPD in favor of euphemistic diagnosis (Sulzer et al., 2016). Clinicians should employ involved the use of euphemisms such as cluster B symptoms, borderline traits, difficulty regulating emotions. These expressions were used in place of a diagnosis when explaining to the patient that they had a mental health condition
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Brüne, M. (2016). Borderline Personality Disorder: Why ‘fast and furious’?. Evolution, medicine, and public health, 2016(1), 52–66. https://doi.org/10.1093/emph/eow002
Kulacaoglu, F., & Kose, S. (2018). Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe. Brain sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201
Sulzer, S. H., Muenchow, E., Potvin, A., Harris, J., & Gigot, G. (2016). Improving patient-centered communication of the borderline personality disorder diagnosis. Journal of mental health (Abingdon, England), 25(1), 5–9. https://doi.org/10.3109/09638237.2015.1022253
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.