Diagnosis of borderline personality disorder

Borderline personality disorder (BPD) is a psychiatric disorder with a pervasive pattern of instability in four areas: affect regulation, impulse control, self-image, and interpersonal relationships. In this assignment, I am going to explain the what Borderline Personality Disorder is and its history. Also, I will explain the causes and the symptoms of the BPD. I will then focus on the sex bias of the diagnosis of BPD such as causes and the symptom differences between males and females. The final part will conclude in discussing the BPD therapeutic approaches in women.

The term 'borderline' was first used by analyst Adolf Stern in 1938 (Wirth-Cauchon, 2000) to describe patients who he believed were more disturbed than 'neurotic' patients but who were not 'psychotic'. Initially after 1980, BPD was first introduced as a diagnosable personality disorder in America. Nowadays, BPD is by far the most common Personality Disorder (PD) diagnosis and increasingly common as a diagnosis in psychiatry (Johnstone, 2000). The diagnosis of BPD is one of ten PDs and classified by the psychiatric classification system (DSM-IV). BPD is commonly described as a disorder of emotions and of interpersonal relations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) identifies that BPD as "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts" (p. 706). This quotations shows that, individuals with a BDP often experiences a repetitive pattern of disorganization and instability in self-image, mood, behaviour and close personal relationships. This may can cause significant distress or impairment to individuals interpersonal relationships, friendships and work.

Previous studies revealed general symptoms of the BPD. Levine et al., (1997) exposed that individuals with BPD show less emotional awareness, less capacity to coordinate mixed-valence feelings, less accurate recognition of facial expressions of emotion, and more intense reactions to negative emotions than those not having BPD. Stein (1996) also compared individuals with BPD and without BPD and indicates that individuals with BPD show more short-term fluctuations in negative affective states and higher levels of unpleasant affects than non-BPD individuals. However, researchers commonly recognize impulsivity is also a core feature of BPD (Hurt, Clarkin, Munroe-Blum, & Marziali, 1992). To support this idea, according to the DSM- IV-TR, BPD involves impulsivity in at least two areas that are potentially self-damaging such as; spending, sex, substance abuse, reckless driving, binge eating (p. 710). The revised Diagnostic Interview for Borderlines also includes impulsive behaviour, such as substance abuse, sexual deviation, self-mutilation, suicidal efforts, verbal outbursts, and physical fights as a criterion for the diagnosis of BPD (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989). Furthermore, individuals with BPD have severe instability of self-image, mood, impulse, and relationships. They often feel unappreciated, cheated, or discontent and believe that they are misunderstood. They do not perceive social cues accurately; experience severe mood swings; unable to control their emotions and impulses; and unable to develop stable relationships. However, they often have repeated failures, including educational efforts and marriages. Patients with BPD have the most difficulty with negative emotions, and this accounts for many of the behavioural problems they experience (Bland, Williams, Scharer, & Manning, 2004). As for the negative emotions such as obstructive, pessimistic, and immature are frequently applied to them, and they blame others for the distress or disruption that their behaviour causes. According to the DSM-IV-TR (APA, 2000), a person can receive a diagnosis of BPD provided that they meet any five out of nine diagnostic criteria, as shown in Table 1, which allows for as many as 151 different symptom combinations (Sanislow et al., 2002).

Moreover, there are some evidence which supports both genetic and early environmental origins play role on the BPD (Gunderson & Berkowitz; Lieb et al., 2004; Paris, 2005). Genetic origins of BPD have not been studied extensively. The few studies of twins and BPD (Torgersen et al., 2000) found a substantial level of genetic effect in the development of BPD. BPD patients are born with temperaments of aggression, a genetic trait, and further research is being conducted to isolate specific genes that may account for this temperament (Gunderson & Berkowitz, 2003). Other studies show that disorders of emotional regulation (e.g., depression) and impulsivity (e.g., substance abuse) are more common in relatives of BPD patients than other populations. As for the early environmental origins of BPD could be related to a high incidence of parental loss, prolonged parental separation, and feelings of neglect during childhood, all contributing to the patients' later fears of abandonment (Barone, 2003). These fears may be based on actual physical abandonment or a perception of emotional abandonment, where the patients feel that they are different, disconnected, or misunderstood by their families (Gunderson & Berkowitz, 2003). Families of BPD patients often invalidate the patients' wants and needs and will punish the patients for efforts made to communicate their feelings and desires (Gunderson & Berkowitz 2003). An extreme form of invalidation is sexual or physical child abuse. Childhood abuse is reported by 40-71% of inpatients with BPD, and the severity of sexual abuse suffered in childhood has been linked to the severity of the borderline pathology found in adulthood (Gunderson & Berkowitz; Lieb et al., 2004).

The prevalence of Emotionally Unstable BPD is about 1% of the general population (Lenzenweger, Lane, Loranger, & Kessler, 2007; Torgersen, Kringlen, & Cramer, 2001). However, individuals with BPD are well represented in treatment settings and generally this is seen in 15-20% of psychiatric inpatients and 10% of psychiatric outpatients (Skodol et al., 2002). Moreover, gender bias in the diagnosis of BPD has been investigated in several studies (Adler, Drake, & Teague, 1990; Ford & Widiger, 1989; Henry & Cohen, 1983). In these studies, differences between male and female clients were not significant with respect to the diagnosis of BPD. However, only two large representative population-based studies (Lenzenweger et al., 2007; Torgersen et al., 2001) did not find sex differences in the prevalence of BPD. Some previous studies have been reported higher BPD prevalence rates in men (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006). Contrary to this results, other researchers reported higher BPD prevalence rates in women (Maier, Lichtermann, Klingler, Heun, & Hallmayer, 1992). However, a numerous studies generally support that BPD is also more often diagnosed in women than in men which is about 75% (reference). To support this idea, a meta-analysis of 75 studies by Widiger and Trull (1993) showed that 75% of those diagnosed with BPD in clinical samples are women. However, this rate could represent sex bias in diagnosis instead of a true sex difference in prevalence rate (Skodol & Bender, 2003). Grant et al.,( 2008) also found similar results in the most recent, largest, and most nationally representative epidemiological study, BPD is found to affect 5.9% of the population, and although equally prevalent among men and women, is associated with more severe physical and mental disability for women. Additionally, in an extensive review of British mental health services for women, the Department of Health (2002) estimated that, for women in high security mental health care at least 70% may have histories of child sexual abuse and over 90% self-harm. They also note that such women are more likely than men are to be given the diagnosis of BPD, and that this is the most prevalent diagnostic category for high security female psychiatric patients.

Furthermore, it is evident BPD has seen more in women than men. This emphasizes that, BPD does seem to capture something of the generic female condition. Current descriptions of this disorder emphasise affective symptomatology including rage, depression, self-destructiveness (including suicidality), feelings of emptiness, and emotional lability. The BPD symptoms above supports that the main reasons of the gender bias in the diagnosis of BPD depends on the kinds of the descriptors, because emotional lability and self-destructiveness, represent the extreme characteristics of the female role and hence, are more likely to typify women than men (Tavris, 1993). Furthermore, the severity of the reported abuse history correlates with the severity of borderline symptoms. However, from a psychological point of view, childhood neglect, emotional trauma, and abuse (often sexual) are considered potential origins and are more frequently found in the reported history of those with BPD (40% to 86% with a history of alleged sexual abuse) than for the general population (22% to 34%) (Silk et al., 1995).Similarly, women in high security mental health care are frequently diagnosed with BDP and commonly report histories of child abuse, in particular child sexual abuse, and the vast majority also self-harm (reference). According to Johnson et al., (1999), large-scale community-based longitudinal study of 639 individuals found that those with a documented abuse history in their state records were four times more likely to be diagnosed with a personality disorder in early adulthood, and that documented childhood physical abuse, sexual abuse, and neglect were each associated with an increase in personality disorder symptoms in early adulthood. As a result, a number of previous researchers, it is proved that BPD is commonly diagnosed in women. However, childhood abuse has been found to be related to the later emergence of psychiatric symptoms associated with the borderline syndrome. There are some evidence which child sexual abuse is of particular significance (Brownand Anderson, 1991, Western et al, 1990), and that increased severity, duration and number of perpetrators differentiates this disorder from others (Silk et al, 1995; Koerner and Linehan, 1996). For example, if sexual abuse is an important factor in determining the later emergence of the borderline syndrome, it is unsurprising that women predominate in this category as they are more likely to experience this form of abuse than men are (Finkelhor, 1994). This may be especially the case for involuntarily detained female patients. To support this idea, Wilkins and Warner (2001) study examined that, one of the British high security mental hospital found that all women patients (16 women) diagnosed as BPD reported histories of child sexual abuse (the majority corroborated). However, over half the sample reported that their histories of physical abuse and removal into care; and all could be judged to have suffered from emotional abuse and neglect.

Moreover, BPD is complicated and difficult to treat, there is significant interest in the approaches psychotherapists tend to use for this disorder. Several newer treatment protocols have been developed and shown to be effective in reducing a number of symptoms in persons with BPD. For example, Dialectical Behavior Therapy (DBT) has been shown to be effective in reducing self-injury (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) and substance abuse (Linehan et al., 1999) in BPD patients. One randomized controlled trial of Mentalization-Based Therapy, a psychoanalytically oriented treatment done in the context of a partial hospital program, found significant improvement in depressive symptoms, decrease in suicidal and self-mutilatory acts, reduction in-patient days and better social and interpersonal functioning compared to treatment-as-usual (Bateman & Fonagy, 1999). Results from an uncontrolled trial suggest that Beck's Cognitive Therapy (CT) is effective in producing significant reduction in a number of symptoms including suicide ideation, hopelessness, and depression, as well as specific borderline behaviors (Brown, Newman, Charlesworth, Crits-Christoph, & Beck, 2004)

Cognitive Behavioural Therapy (CBT) is a type of psychotherapy used with people who have BDP. This therapy emphasizes how important the role that thinking has in how people feel and in what they do. There are several approaches to CBT including: Rational Behaviour Therapy, Rational Living Therapy, and especially Dialectic Behaviour Therapy (DBT), which is used exclusively for patients diagnosed with BPD. The therapist who uses the Cognitive-Behavioural approach teaches their patient that it is not their thinking makes them feel and behave the way they do; instead, the approach is that if people have undesirable feelings and behaviour, they must first find the cause of the feelings and behaviour. Then, they can replace undesirable thoughts with desirable thoughts that lead to desirable behaviours. CBT as used in the treatment for BPD is based on the Cognitive Model of Emotional Response, the term used to describe the belief that individuals thoughts control of their feelings and behaviours. This is in contrast to traditional forms of therapy, which hold to the belief that outside influences, such as people, events, and situations, cause us to feel or behave in a certain way. Believing this way, by changing the way people think, they can still change their behaviour, even if their outside circumstances stay the same.CBT is effective for BPD because it is one of the quickest forms of therapy, compared to traditional therapies such as "talk therapy." Clients of CBT usually only need to attend sixteen sessions, whereas traditional therapies can take years to obtain the same results.

Moreover, DBT was developed by Linehan (1993). DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD (Linehan et al, 1991; Linehan et al., 1993). DBT developed out of the recognition that traditional CBT techniques, while of some assistance for symptoms of BPD, seemed to have limited impact on the core problems in BPD. In this theory, patients were offered individual therapy and group sessions addressing mindfulness skills, interpersonal effectiveness skills, emotion modulation skills and distress tolerance skills. The four skills modules were scheduled in order of the need that most prevailed among the client group, and patients joined the next scheduled module after recruitment. Skills groups were offered by any two of the four trained therapists. Weekly case consultation meetings were attended by all therapists. This therapy focuses on helping the patient develop skills which can help them to remain grounded and in control of their body and mind, cope with interpersonal conflict, tolerate stressful situations and help them regulate their emotions. However, research indicates that DBT is also effective in treating patients who represent varied symptoms and behaviours associated with spectrum mood disorders, including self-injury (Brody, 2008).

Furthermore, a number of drugs have been tried in pharmacotherapy of BPD. The drugs currently being assessed include certain antidepressants and antipsychotics; one group of antidepressant drugs, the MAO inhibitors; and Lithium. However, there is little to recommend antidepressants, but antipsychotic show more modest effects on Borderline patients' anxiety, suicidality, and psychotic symptoms (Gitlin, 1993). Because such patients often abuse drugs and are suicide risks, extreme caution must be used in any drug therapy regimen (Waldenger & Frank, 1989). Previous researches indicate that problematic behaviours, such as deliberate self-harm and attempted suicide, are exhibited by 75% of borderline clients (APA, 2000; Comtois et al.; Linehan, 1993; Morris, 2003; Paris, 2005), and approximately 10% of those who present to treatment and 36% of people with a severe form of the disorder eventually commit suicide (Krawitz & Watson, 2000; Paris, 2002). So far the results of drug therapy are not entirely clear because most of these disorders have not been found to be very responsive to drugs in the past (Sarason & Sarason, 1996 book).

Consequently, the person diagnosed as a BPD has instability in relationships, mood, and self image. Patients with BPD are argumentative, irritable, sarcastic, quick to take offense and altogether very hard to live. However, from past to nowadays, researchers supports that BPD has prevalence of 1 to 2 percent and a number of previous studies results indicate that probability of BPD have seen more commonly in women than men. The increased frequency of borderline disorders among women may also be a consequence of the greater incidence of incestuous experiences during their childhood. For example, people diagnosed with the disorder have experienced major trauma as children including sexual, physical or emotional abuses. Finally, treatment includes psychotherapy which allows the patient to talk about both present difficulties and past experiences in the presence of an empathetic, accepting and non-judgemental therapist. The therapy needs to be structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways. Sometimes medications such as antidepressants, lithium carbonate, or antipsychotic medication are useful for certain patients or during certain times in the treatment of individual patients.

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