Friday, March 7, 2014

Girl Interrupted: Examining Borderline Personality Disorder and Treatment

This was the final paper for my final class of my Master's degree. I was happy that it worked out that the assignment was to write about a mental disorder, and of course I chose the one I know the best. Please excuse any grammatical or spelling errors.

Abstract
This paper looks into the mental disorder of Borderline Personality Disorder, and three different types of treatments used to help those with the disorder. Borderline Personality Disorder is a serious mental disorder, and there are many approaches to treating it. This paper explores a cognitive approach, a pharmacological approach, and an alternative approach. This paper will also look into the personal account of its author, and how Borderline Personality Disorder has affected her.
Borderline Personality Disorder
I was trying to explain my situation to myself. My situation was that I was in pain and nobody knew it, even I had trouble knowing it.” (Kaysen, 1994). This is a quote from the book, “Girl Interrupted.” The story follows Susana Kaysen and her year-long stay at a mental hospital for treatment of Borderline Personality Disorder.
I started experiencing mental issues at an early age. However, it was not until early adulthood that the onset of the symptoms became prevalent and detrimental to her life. I experienced severe mood swings, one relationship after another, promiscuous sex, poor spending habits, and perhaps the most frightening; hospitalization for attempted suicide and recurring suicidal thoughts.
After a traumatic and psychotic breakdown in 2008, I went back to therapy and finally got the proper diagnoses. I was told I have Borderline Personality Disorder. The following analysis provides and in-depth look at Borderline Personality Disorder and current ways psychologists are treating it. The first part of this analysis will discuss the onset and symptoms of Borderline Personality Disorder. Next three different methods of treatment will be described: cognitive, pharmacological, and an alternative method. Finally this author will look at the changing attitudes on borderline and how modern day society’s view differs in both definition and treatment.
The Borderline Personality: Onset, Symptoms, and Description
If there is one word to describe the world of a person with Borderline Personality Disorder (BPD) it would be, chaos. The American Psychiatric Association (2000), defines BPD as mainly a pattern of intense emotions, poor self-image, unstable interpersonal relationships, and impulsivity. A person with BPD perceives even the smallest slight as earth shattering and will go to extreme lengths to avoid abandonment that is either real or perceived.
According to the American Psychiatric Association (2000), a person who suffers from BPD interprets even realistic separation as earth shattering and will experience intense fear and anger. For example, a friend who does not return a text message may find him or herself with an abundance of irate replies as well as angry voicemails. People with BPD cannot stand to be alone, and thus will stop at nothing to avoid it. In their mind any sort of separation implies they are bad or have done something wrong.
The American Psychiatric Association (2010) explains that people suffering from BPD also have a pattern of intense and unstable relationships. The core of these relationships stems from a very polarized view of people. The world view of someone with BPD sees people as either on pedestals (idealization) or in the dirt (devaluation). This type of thinking is known as black and white thinking or splitting. A person with BPD has a very difficult time seeing the gray areas of life. According to Gunderson (2011), a person with BPD has both internal and external splitting. Externally they perceive any type of criticism as rejection or proof that they are not worthy of love. A person with BPD needs to have a connection to believe her or she has self-worth. However, the BPD patient frequently defines that connection by unrealistic expectations of availability. The internal struggle comes from when the BPD patient gets any sort of negative reaction. Even something as simple as a friend being annoyed could be interpreted by the BPD patient as them being unworthy of love.
According to Gunderson (2011), the all or nothing thinking of the BPD patient makes it extremely difficult to remain in a relationship. As mentioned previously, their incapability to see the grey greatly affects their outlook on life. BPD patients also have a high frequency of suicidal threats in behaviors. Often they will use such behaviors as a means to avoid abandonment. According to Gunderson (2011), a person with BPD may feel intense anger over the smallest thing. Later the anger turns into guilt. Because of the splitting someone with BPD cannot see the situation as a mind bump in the road and something to learn from. Instead they see it as complete hyperbole.
According to Gunderson (2011), the majority of BPD patients (75%) are female. The onset of symptoms is a combination of nature and nurture. Studies have shown that the major traits of BPD (hypersensitivity, impulsivity, etc) are traceable in families. Environmental factors such as neglect, family issues, trauma, and abuse also play a role in the onset of BPD. Outside heritable and nurture factors, BPD also has biological factors. According to Gunderson (2011), scans have shown that patients with BPD have a hyper responsive amygdala and an impaired prefrontal cortex.
According to the American Psychiatric Association (2000), BPD usually starts in early adulthood.
Cognitive Treatment: Dialectical Behavior Therapy
According to O’Connor (2003), “Generally speaking, dialectic is a mode of thought, or a philosophic medium, through which contradiction becomes a starting point (rather than a dead end) for contemplation.” (para 1). Bohus, Haff, et. al. (2002) explains that Dialectical Behavioral Therapy (DBT) is a form of therapy created for those who meet the criteria of BPD. Marsha Linehan invented DBT in the early 90’s. Over the course of a year Linehan conducted a controlled treatment study of patients meeting the criteria for BPD. The outpatient DBT that was assigned to them had more effective and positive outcomes than other forms of psychotherapy of mental health treatment (Bohus, Haff, et. al.).
The name Dialectical Behavioral Therapy derives from the use of dialectics applied to behavior therapy. The term “dialectics” applies to the basis of DBT as well as the dialogue and relationship used by therapist to have an effective treatment approach (Linehan, 1993). DBT is similar to Cognitive Behavioral Therapy in that it targets specific problem areas, engages in ongoing assessment, and is a collaborative work between patient and therapist. When Linehan developed DBT she took CBT and put more emphasis on specific areas such as the therapeutic relationship, the dialectic process, and the process of accepting and validating behaviors (Linehan, 1993).
According to Linehan (1993), DBT is best used through both group and individual therapies. The group portion of DBT is conducted over the course of a year and is split into four modules: Mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. In the following sections each of the modules will be discussed in length.
Mindfulness
According to Linehan (1993), the core of DBT is mindfulness. The mindfulness skills derive from central Buddhist and Zen practices. The basis of mindfulness teaches of the three states of mind; reasonable mind, emotion mind, and wise mind. According to Linehan (1993), reasonable and emotion mind work as polar opposites in that the reasonable mind takes a cool, intellectual approach to problems whereas the emotion mind takes a knee jerk reaction approached based on the current emotional state. The goal of mindfulness according to Linehan (1993) is to combine the two states of mind to make wise mind. The wise mind aspects brings together the emotional experience and the logical analysis to take better approaches to problems.
According to Linehan (1993), mindfulness is split into “what” and “how” skills. The “what” skills aim to help the BPD patient become more aware through observing and describing. An example of observing is noticing what is coming through the senses or riding the experience like a wave. Letting the emotions wash over, not clinging on. Putting words on the experience or putting the experience into words are examples of describe. According to Linehan (1993), another aspect of the “what” skills is to participate. Participating teaches BPD patients to become one with their experience, to practice skills until they are second nature. Most important it teaches not to be too eager and willful but also not too hesitant when dealing with problematic experiences.
According to Linehan (1993), the “how” skills consist of non-judgmentally, one-mindfully, and effectively. Part of what is so difficult for BPD patience is their inability not to judge their judging. They tend to evaluate and analyze every choice, opinion, and argument made. According to Linehan (1993), mindfulness teaches BPD patients to separate opinions from facts and not to evaluate situations. The emphasis on just sticking to the facts helps BPD not to judge their judging. A way that mindfulness teaches BPD patients to focus better is by doing things one-mindfully. According to Linehan (1993), Mindfulness expresses the importance of doing one thing at a time and focusing on the moment.
According to the American Psychiatric Association (2000), BPD patients have a marked reactivity of mood. Because of this they experience intense emotion such as anger, panic, anxiety, and even dysphoric episodes. Mindfulness seeks to lessen the intense feelings as well as the inappropriate ways BPD patients express that anger.
Interpersonal Effectiveness
According to the American Psychiatric Association (2000), BPD patients have a difficult time maintaining interpersonal relationships. They experience difficulty in properly and appropriately approach relationships and relationship problems. According to Linehan (1993), focuses on helping the BPD patient acquire changes needed, but still keeping their self-respect and the relationship. Perhaps, more important, it teaches acceptance of other people’s feelings and dealing with being told no. According to Linehan (1993), interpersonal effectiveness breaks down into the following segments and subcategories: Situations for interpersonal effectiveness (attending to relationships, balancing priorities and demands, balancing the wants to should, and building mastery and self-respect), goals of interpersonal effectiveness (getting objectives or goals in a situation met, getting or keeping a good relationship, and keeping or improving self-respect), and factors reducing interpersonal skills (lack of skill, worry thoughts, emotions, indecision, and environment).
According to the American Psychiatric Association (2000), the DSM-IV-TR sites for following two traits as diagnostic criteria for BPD; “Frantic efforts to avoid real or imagines abandonment,” and, “a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation” (p. 710). According to Linehan (1993), the BPD patient’s world is split in black and white. Either they engage is avoidance of confrontational situation or the confrontation is extremely intense. The skills taught during the interpersonal effectiveness module help to find a balance between the two extremes. Interpersonal effectiveness will help someone with BPD work on building and keeping relationships.
Emotion Regulation
BPD patients are extremely emotional people. Their intensity paired with their penchant for extremes (such as either being in emotion or reasonable mind) makes it difficult for them to regulate any sort of intense or negative emotion (Linehan, 1993). According to the American Psychiatric Association (2000), BPD patients suffer from constant feelings of emptiness as well as low self-worth or self-esteem. Part of the reason for this is their battle with extreme emotions. According to Linehan (1993), emotion regulation incorporates mindfulness skills (as do the other modules because mindfulness is the center of DBT) to help the BPD patient effectively recognize and label emotions.
Emotion regulation trains the BPD patient to be more in tune with his or her emotion, while reducing how vulnerable he or she is to those emotions (Linehan, 1993). Emotion regulation helps BPD patients accept their emotions while not letting them get to an extreme. Often a BPD patient sees any sort of negative emotion (such as anger) as bad and will have a difficult time and become increasingly more intense. According to Linehan (1993), emotions can be self-validating, motivate action, and influence others. With BPD the issue is not developing emotions; it is having no way to organize them.
According to Linehan (1993), a core concept of emotion regulation is the acronym (Marsha Linehan loves her acronyms, which can easily be seen if someone reads more indepth about DBT) PLEASE MASTER. “Treat PhysicaL illness, balance Eating, avoid mood-Altering drugs, balance Sleep, get Exercise, build MASTERy” (Linehan, 1993, p. 125).
Distress Tolerance
The final module of DBT is distress tolerance. Part of what BPD patients have a difficult time with is not so much avoiding stress, but rather being accepting of it. According to Linehan (1993), distress tolerance aims to help BPD patients accept the stressful parts of life and manage them skillfully. To do this DBT teaches a variety of coping skills that either help distract from or understand situations that may cause stress.
According to Linehan (1993), DBT teaches that, “Wise Mind Accepts.” These are skills and tools used to tolerate difficult emotions. “Wise Mind Accepts” skills include activities, contributing, comparisons, emotions, pushing away, thoughts, and sensations (Linehan, 1993, p. 165). Other ways that DBT teaches distress tolerance skills is by using the five senses to self-sooth (for example squeezing a stress ball, smelling lotion, looking at colorful photos), improving the moment (through things such as imagery, encouragement, and prayer), and weighing the pros and cons of the situation (Linehan, 1993).
According to Bohus, Haaf, et. al. (2002), DBT is widely accepted as perhaps the most effective treatment for people living with Borderline Personality Disorder. Originally developed as an outpatient treatment, studies on inpatient treatments have been done and are becoming easier (albeit more expensive) to access.
Pharmacological Treatment: Haloperidol and Valproic Acid
According to Lieb, Zanarini, et. al (2004), one drawbacks to treating BPD is that there is yet to be a medication made specifically for the disorder. Many patients who take medication take it to reduce specific symptoms. According to Lieb, Zanarini, et. al (2004), two of the drugs given to patients with BPD is Haloperidol and Valproic acid. The use of Haloperidol treats symptoms of anxiety, anger, paranoia, and depression. Valproic acid tackles interpersonal sensitivity, aggression, and hostility.
According to Lieb, Zanarini, et. al (2004), placebo controlled studies are done to test the effects on various medications over the course of a series of weeks. While there is a great benefit to treating BPD with medication (such as reducing the high risk of suicide in BPD patients), the drawback once again is that there is no specific medication for the disorder. Patients are better off engaging to the more cognitive and environmental approach of the dialectical behavioral therapy. A mood stabilizer or anti-psychotic will help the BPD patient focus and cope better, but medication cannot stand along concerning this disorder.
According to Medline Plus (2013), haloperidol treats psychotic disorders as well as disorders that have severe behavioral problems (such as Borderline Personality Disorder). Haloperidol is a conventional antipsychotic that works to decrease abnormal excitement in the brain. Some of the side effects of Haloperidol include: dry mouth, constipation, heartburn, drowsiness, and loss of appetite (Medline Plus, 2013).
According to Medline Plus (2013), Valproic acid is a medication used to treat the manic side of bipolar disorder (common misdiagnoses). The drug is also used to treat the aggressiveness in ADHD patients. The drug works by increasing the natural substances in the brain. According to Medline Plus (2013), common side effects of Valproic acid are mood swings, abnormal thinking, blurred vision, agitation, and ringing in the ears.
The side effects mentioned are just some of the side effects that come with the two aforementioned medications. A person has to wonder if it is even worth it to try to target BPD with a pharmacological approach.
Alternative Treatment: Omega-3 Fatty Acids
According to the University of Maryland (2011), Omega-3 fatty acids are essential fatty acids that can be found in various types of fish such as salmon, tuna, and halibut. The role of Omega-3 Fatty acids is essential to both the function of the brain and heart.
According to Zanarini and Frankenberg (n.d.), studies are conducted on the use of omega-3 fatty acids to reduce aggression and mood symptoms in BPD patients. One particular study included 30 women who met the criteria in the DSM-IV for Borderline Personality Disorder. According to Zanarini and Frankenberg (n.d.), 1000mg of an omega-3 fatty acid or a mineral oil placebo was given to subjects daily over the course of eight weeks. Results reflected that 90% of the patients favored the omega-3 over the placebo.
According to Zanarini and Frankenberg (n.d.), data collected in the study shows a vast effect on the aggressive and depressive traits of Borderline Personality Disorder. The plus side of this particular method of treatment is that they are both readily available and provide no serious toxins. The downside is that the study only included female patients who were moderately ill. According to Zanarini and Frankenberg (n.d.), further progress needs to be made linking the use of omega-3 fatty acids to those with more severe forms of BPD.
Contemporary Attitudes
Attitudes toward treatment for BPD greatly favor the use of dialectical behavioral therapy. According to the National Youth Mental Health Foundation (2009), explains that DBT has been a proven effective treatment for both adults and adolescents with Borderline Personality Disorder. Studies are conducted to collect evidence on the effectiveness of various treatments. According to the National Youth Mental Health Foundation (2009), the treatment with the most reasonable amount of evidence is dialectical behavior therapy.
The role of medication in treating BPD is small and should not be a primary method of treatment. The risk of side effects paired with there not being a specific medication for BPD, but rather specific symptoms, makes it the least effective method (National Youth Mental Health Foundation, 2009).
The world view of Borderline Personality Disorder has changed since its inclusion in the DSM-III. Originally thought to be on the border of psychotic and neurotic during a time when people were put into either those two categories or a “normal” category. The borderline was seen not as severe as psychotic patients but also did not respond as well to the therapies given to neurotic patients Hoadley (2001). During the time the term “border line” was first used (1938), it was meant for patients who did not fit a certain criteria. As time went on specific criteria to describe the borderline personality was developed, thus leading to the study of more effective and focused treatments Hoadley (2001). BPD patients have come a long way from simply being thrown in ineffective psychoanalysis to a therapy designed specifically for them (DBT).
Conclusion
In conclusion, the world of the BPD patient is an intense and chaotic one. The disorder is possibly one of the most difficult to treat because therapists often find themselves in the whirlwind of emotional outbursts, splitting, and fear of rejection that comes with having Borderline Personality Disorder (National Youth Mental Health Foundation, 2009).
This paper has been a discussion on the patient with Borderline Personality Disorder. The first part of this analysis on BPD was a description of the disorder, including symptoms and onset during the first part of this paper. Next there was an examination of the various treatments for BPD. These treatments included a cognitive and pharmacological one as well as an alternative treatment. Finally, in the last part of this paper contemporary views on BPD and treatment were described.

References
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