Transcript Borderline Personality Disorder: Moving Beyond Diagnosis

Borderline Personality Disorder:
Moving Beyond Diagnosis
Dr Helen Barlow, Clinical
Psychologist
CPFT
Symptoms and Features of BPD
• Instability in thought processes, emotions, relationships,
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identity and behaviour
‘Frantic’ efforts to avoid real or imagined abandonment
Intense, unstable relationships (idealising/devaluing)
Unstable sense of self
Impulsivity
Recurrent suicidal behaviour
Chronic feelings of emptiness
Difficulties with anger
Stress-related paranoia or severe dissociation
And summarised by Marsha
Linehan….
• Emotion dysregulation
• Interpersonal dysregulation
• Behavioural dysregulation
• Identity dysregulation
• Cognitive dysregulation
Biosocial theory of BPD
Biological dysfunction in the emotion regulation
system
Invalidating environment
Pervasive emotional dysregulation
(see handout)
This means….
• Rising from 0-100 quickly and stay there for longer, with
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unpleasant emotions
Physical and mental pain
No strategies for self-soothing- only unhealthy solutions
Disturbed restless sleep- high arousal – stressfulcontinuous triggers – exhaustion
Give up asking OR overdemanding re: getting needs met
Aim: reduce unhealthy behaviours & simultaneously teach
new ones
Principles of management
• Have a crisis plan
• Actively managing strong feelings i.e.
validate but encourage calmness
• Persist with goals/objectives
• Boundaries and supervision
Early stages
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Talk through story
- feed back relation to symptoms
Identify life patterns and relate to BPD
Give info about BPD
Also..
• Identify risky behaviours (self-harm,
neglect, suicide, driving, sex, alcohol,
drugs)
• Pros/cons of changing those behaviours
• Short-& long-term benefits/consequences
• Identify client’s goals for change
Targets for therapy
Decrease:
- Life threatening behaviours
- Therapy/Intervention interfering behaviours
- Quality-of-life interfering behaviours
Increase:
- Core mindfulness
- Distress Tolerance
- Interpersonal effectiveness
- Emotion Regulation
- Self-management
Decrease:
Life threatening behaviours
->develop a crisis plan including survival
strategies– initial focus is keeping them
alive
- identify why self-harm
- teach skills to manage pain
- don’t encourage work on e.g. PTSD
Crisis planning
• Acknowledge that ‘disasters’/crises do happen
• Identifying risk factors and warning signs–
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review previous crises
Identify alternative strategies
Create a personal crisis plan
Exploration of the aftermath of crises: helpful
and unhelpful things the patient or others did
An example crisis plan
These are the three main Crises that happen
to me.
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When these happen the ways it often ends
are:
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What we agreed I could do about a
Crisis
1. A way I could try and stop a crisis if one
seemed likely….
2. A way I could make a crisis less bad if one got
started…
3. Some people I could contact and ask for help
and their phone numbers…
How NOT to deal with a Crisis
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Drinking too much or taking street drugs
Taking an overdose or self harming
Trying to end your life
Uncontrollably anger; hurting/driving others away
Refusing to leave the house and taking to bed.
Eating too much or not letting yourself eat at all
Care for self, not damaging, & not self-criticism. The heart
of all self help is looking after and caring for yourself.
Decrease:
Quality of life-interfering behaviours
i.e. Increase stability
• Sleep
• Eating
• Exercise
• Occupation
• Routine
Goals for change
Increase:
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Core mindfulness
Distress Tolerance
Interpersonal effectiveness
Emotion Regulation
Self-management
Mindfulness
• Acceptance
• Focussing attention to task in hand
• Observe sensations
• Being present in the moment
• Describe experience; just facts
• Non-judgemental
Distress Tolerance 1
Not distress elimination e.g.
• Activities
• Contributing
• Comparisons
• Emotions
• Pushing Away
• Thoughts
• Sensations
Distress Tolerance 2
• Imagery
• Meaning
• Prayer
• Relaxation
• One thin at a time
• Vacation
• Encouragement
Interpersonal effectiveness
• Achieving your objectives/ goals
• Maintaining a good relationship
• Self-respect
• Assertiveness
• Offering solutions
• Validating others and being truthful
Emotion Regulation
• Understanding emotions
• Reducing vulnerability to negative
emotions (physical health; eating; drugs;
sleep; exercise; mastery)
• Build positive experiences
• Warranted emotions – problem solving
• Unwarranted emotions – act opposite
Final Message
• Acceptance
• Change
• Hope
Reading:
The BPD Survival Guide, Chapman & Gratz
The DBT Skills Workbook, Mackay, Wood, & Gantley
Skills Training Manual for BPD: Marsha Linehan
Complex Cases Service – 6 session PD intervention