Understanding Borderline Personality Disorder: Theoretical Grounding, Testing

Recommendations & Treatment

Introduction

An individual’s identity or as we know, personality, is affected by encounters, environmental

situations, and acquired characteristics that in turn impact their way of thinking, feeling, and
behaving that creates an individual diverse from other individuals of one's society. A
person’s identity regularly remains the same over time. In the case of personality disorders,
it is an effected way of thinking, feeling and behaving that deviates from the norms of one’s
culture, causes distress or problems in everyday functioning, and can lasts over time.

In this paper we will be specifically tackling the case or issue of Borderline Personality
Disorder, discussing what this personality disorder is by nature, how it may effect one in
their very own functioning, the theoretical groundings in understanding the disorder, testing
recommendations in identifying the disorder and finally discussing a possible treatment plan
in tackling such a condition.

Borderline Personality Disorder

To better understand Borderline Personality Disorder (BPD) we must first understand what
is a personality disorder a bit further? A personality disorder is an ingrained way of relating
to other people, situations, and events, characterized by a rigid and maladaptive pattern of
inner experience and behavior, a personality disorder deviates markedly from the
individual’s culture and leads to distress or impairment. To fit the current diagnostic criteria,
these behaviors must manifest themselves in at least two of four areas: (1) cognition, (2)
affectivity, (3) interpersonal functioning, and (4) impulse control. As a result of these
behaviors, the individual experiences distress or impairment (Whitbourne, 2020).
BPD is characterized by features such as a deep sense of emptiness, an unstable self-image,
a history of turbulent and unstable relationships, dramatic mood changes, impulsivity,
difficulty regulating negative emotions, self-injurious behavior, and recurrent suicidal
behaviors (e.g., Krause-Utz et al., 2013; Lazarus et al., 2014; Santangelo et al., 2014; Schulze,
Schmahl, & Niedtfeld, 2015). People with BPD tend to be uncertain about their personal
identities—their values, goals, careers, perhaps even their sexual orientations (Nevid,
Rathus & Greene, 2018).

People with borderline personalities often act on impulse, such as eloping with someone
they have just met. Impulsive and unpredictable behavior is often self-destructive, involving
self-mutilation (e.g., cutting) and suicidal gestures or actual attempts, especially when
underlying fears of abandonment are kindled (Gunderson, 2011, 2015; Leichsenring et al.,
2011). Maladaptive behaviors such as cutting, substance use, and lashing out in anger may
be attempts at controlling intense negative feelings (Baer et al., 2012).

To better grasp BPD the table below presents the Dimensional Rating of BPD as expressed in
the DSM-5 Dimensional Rating section 3.

Dimensional Rating Table of BPD (DSM-5 Personality Disorders Dimensional Rating from
Section 3)

Personality Identity Self- Empathy Intimacy Personality

Disorder Direction Trait(s)
Borderline Poorly Unstable Unable to Intense, Negative
Personality developed goals, understand conflicted, Affectivity
and aspirations, how others and unstable Disinhibition
unstable and plans may be relationships Antagonism
self-image; feeling
chronic
feelings of
emptiness

Before giving the final diagnosis for BPD, it is crucial that clients undergo psychological
assessment and evaluation to conclude their prognosis. The table below is a utilization tool
to help helpers in concluding their diagnosis of suspected clients of this disorder, the
following table uses diagnosis criteria found from the DSM-V under BPD:
 Borderline Personality Disorder 301.83 (F60.3)
Description:
A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked impulsivity,
beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
Criterion Criterion Factor descriptions
#
1. Frantic efforts to avoid real or imagined
abandonment.

(Note: Do not include suicidal or self-mutilating

behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal
relationships characterized by alternating
between extremes of idealization and
devaluation.
3. Identity disturbance: markedly and persistently
unstable self-image or sense of self.
4. Impulsivity in at least two areas that are
potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating).

(Note: Do not include suicidal or self-mutilating

behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats,
or self-mutilating behavior.
6. Affective instability due to a marked reactivity of
mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours
and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty
controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical
fights).
9. Transient, stress-related paranoid ideation or
severe dissociative symptoms.

Theoretical Grounding Behind BPD

In the field of Cognitive-behavioral theory it is suggested that an assortment of factors may

give to the development of personality disorders. Cognitive schemas (e.g., beliefs,
assumptions, and attitudes) are said to develop early in life, and in those with personality
disorders (like Borderline Personality Disorder) these schemas can shape themselves as rigid
and fixed into one’s personality (Young, 1999). Young further added and defined these
schemas or negative schemas in this case, as broad and pervasively maladaptive themes
that people hold about themselves and their relationships with others. Because they form
early in life as a result of damaging experiences (e.g., abandonment), Young believed that
negative schemas are familiar. In relation to the topic of Cognitive-behavioral theory and
BPD. Linehan, Cochran & Kehrer (2001), proposed in their own cognitive-behavioral lens,
that people who develop borderline personality disorder come from families who
consistently invalidate their childhood emotional experiences and over simplify the ease
with which life’s problems can be solved. Accordingly, they learn that the way to
communicate and get the attention of their parents (and, as a consequence, to
communicate with others) is through a display of major emotional outbursts.

In a Neurobiological perspective, Biological factors seem to be quite important to the

development of BPD. Genes account for more than 60 percent of the variance in the
development of this disorder. People with BPD also demonstrate lower serotonin function
than do controls (Soloff, Meltzer, Greer, el al., 2000). More direct evidence comes from
neurological theories and studies of the amygdala in BPD. The amygdala is a brain region
that is strongly implicated in emotion reactivity, and activity of the amygdala has been
found to be heightened in several disorders that involve intense emotionality (Kring,
Johnson, Davison & Neale, 2013).

In the lens of Psychodynamic/Psychoanalytic theory, personality disorders like BPD are seen
as resulting from disturbances in the parent–child relationship, particularly in problems
related to separation-individuation (Mahler, Pine, & Bergman, 1975). This refers to the
process by which the child learns that he or she is an individual separate from the mother
and other people and, as a result, acquires a sense of him- or herself as an independent
person. Thus, according to psychodynamic theorists, difficulties in this process result in
either an inadequate sense of self or problems in dealing with other people (Dozois, 2019).
The evidence of such stands in understanding personality disorders like BPD made in the
views of Psychodynamics/Psychoanalytics can be well further connected into Attachment
Theory.
The parent–child bond serves as a template for all later relationships that an individual will
make in their future (Bowlby, 1977). It is further added in Bowlby’s Attachment Theory that,
children learn how to relate to others, particularly in affectionate ways, by way in which
their parents relate to them. When the attachment bond between parents and the child is
positive (i.e., the parents are loving, encouraging, and supportive), the child will develop the
skills and confidence necessary to relate effectively to others. However, when this bond is
poor, children will lack confidence in relationships with others (i.e., they will be afraid of
rejection, and they will not have the skills necessary for intimate relationships). And in the
context of BPD such poor relationship development with attachment figures may instill
feelings or beliefs of emptiness, and a lack of understanding of emotions and relationships
with persons they may meet as they grow older in life.

Recommendations

In light of such a case, it is noted that it is the job of a helper to also conduct
recommendations into better investigating and assuring a client of a more accurate
diagnosis. So in light of this, recommendations for a battery of tests would be
recommendable. Tests that explore how areas of functioning like mood, impulsivity,
emotional control and tests that measure a client’s intent to harming themselves and
possible suicide is well recommended. Anxiety measures and tests of feelings of emptiness
may also be used as anxiety and feelings of emptiness do have their relevant roles with
clients of this disorder.

Treatment Plan
Clinicians commonly conclude that clients with a diagnosis of borderline personality
disorder (BPD) are puzzling and demanding to treat. As such, BPD has an identity as a
branded disorder resulting in negative attitudes, trepidation, and worry with regard to
administering treatment (Aviram, Brodsky, & Stanley, 2006; Lequesne & Hersh, 2004; Paris,
2005).
 Below is a presentation of a possible treatment plan if ever a case such as a client with
Borderline Personality Disorder were to ever arise. The following therapeutic treatments
may be applied:

Approach Action/Therapy Purpose of Treatment Goal of Treatment

Psychodynami - Transference-Focused - TFP emphasizes three -Increased impulse
c Approach Psychotherapy primary factors: control and anxiety
interpretation, tolerance, as well as the
maintenance of technical ability to modulate mood
neutrality, and transference and the formation of
analysis. The focus of the secure interpersonal
therapy is on exposure and connections, are all
resolution of intrapsychic treatment aims.
conflict (Barlow, 2014).
-Attachment Therapy
-developed by Bateman - The goal is to improve
(Mentalization therapy)
and Fonagy (2004), is an the client's ability to
intensive therapy grounded recognize the existence of
in attachment theory, with his or her own thoughts
a focus on relationship and feelings, and how
patterns and non-conscious they may be able to
factors inhibiting change. process and understand
Treatment is based on the them further.
theory that individuals with
BPD have an inadequate
capacity for mentalization.
Treatment, therefore,
focuses on bringing the
client’s mental experiences
to conscious awareness,
facilitating a more
complete, integrated sense
of mental agency.

Cognitive- -Cognitive -The focus of treatment on - The goal of this

Behavioral Psychotherapy restructuring thoughts and therapeutic action is to
Approach on developing a collabora- focuses on decreasing
tive relationship through negative and polarized
which more adaptive ways beliefs that result in
of viewing the world is unstable affect and
developed (Beck & destructive behaviors
Freeman, 1990). (Brown, Newman,
Charlesworth, Crits-
Christoph & Beck, 2004).

Reflection of Webinars/Documentaries
Webinar/Documentary titles:
 HHCI Seminars – Understanding Borderline Personality Disorder
 How to Spot the 9 Traits of Borderline Personality Disorders
The following seminars that I had watched really gave me an eye opening experience in the
field that I strive my best to make a status in. and one thing I learned and had engraved in
my mind was “our diagnostic system is broken… and needs fixing. Hall, 2019”. And its some I
can well agree on, as the ability to diagnose a client is always a problem, and never as
accurate as a client and their family would wish it to be. What compelled me to do a paper
on Borderline Personality Disorder was the interesting elements behind how is it identified,
diagnosed and even treated, as this disorder is commonly miss diagnosed. So it made me
wonder, how does a disorder with an already available and identifiable criterion still get
miss diagnosed?
Now there are many factors that contribute to miss diagnosis, but what intrigued me the
most was how over looked personality disorders are. Although such a situation is different
from that of here in the Philippines, the discussion made me remember an old interview
project I did back in undergrad on the stand of the ability to diagnose in the mental health
field here in Davao city, and during the interview the word competence really resonated
within in my thoughts of the issue in relation to the seminar. The lack of competence can
really affect the hopes of clients and patients in finding an answer to their problems. Though
im sure that this concern of competence is “not” an issue to those in other countries but it
does beg me to reflect on the effectiveness of their overall mental health trainings, on how
such an obvious and noticeable disorder can still be over looked over-and-over again.
As the seminar progressed I was able to gain a deeper understand to what BPD was and
how it functions in an individual. Emotions from what I understand are a very mysterious
topic of discussion because even though we feel emotions every day, even though we feel
the same emotions as others would, how we process, express and regulate these emotions
maybe different. And acting out as feel can present its dangers to the person, and others
around them. Especially if these ae strong negative emotions, as I came to this reflection I
began to think and conclude between the nature vs nurture behind this disorder. As a future
professional in the field I have always held strong to the belief and power of how nurture
influences our every being, and even up learning the different and strong facts given by hall
in her presentation on the genetic line connecting BPD, I still hold strong to the
environmental factors that contribute to this disorder, as I don’t believe we are just born
with emotional dysfunction… I strongly do believe we are shaped and molded by our
environment to developing emotional dysfunction. Over all the presentation of Hall was a
great eye opener to how mental health currently is and how we can better understand the
characteristics of BPD.
After watching the seminar on understanding borderline personality disorder hosted by
Karyn Hall, I became more interested and wanted to learn more on how I, as a future
professional in the field, as a helper, maybe able to identify this such a disorder to the best
of my accuracy? So I then began to watch the documentary on how to spot borderline
personality disorder which was hosted by MedCircle with guest, Dr. Ramani Durvasula. It
was through the second video that I was able to gain a stronger understanding of how
identity plays a role in BPD, because as I was reflecting I never did see much information or
learnings that connected identity to the disorder, and this may have helped me reflect in my
ability to understand the disorder properly back then when I first learned of it, so it was a
great watch to finally understand how identity worked with BPD. The topic on suicide as
well was a great reflection, as it well clarified the difference between someone who will
commit suicide when they have depression, and those who will commit suicide when they
have BPD, the emotional level and intent are both different in levels which can really help
identify the disorder well if ever for diagnosis, which was a great learn.
Overall from my watch of the 2 seminars I can really reflect the importance and need for
understanding personality disorders as they are possibilities in diagnosing a client. The
diagnostic system is also something I wish to reflect and learn well from as this may be able
to change in the near future, may be with me as the starting point (maybe! Hahaha) to sum
this all up, I have no regrets choosing this topic as my theme for this paper, it was a great
learning a reflective experience that will better shape me as a helper in this still evolving and
developing profession.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.).
Bateman, A. W., & Fonagy, P. (2004). Mentalization-based treatment of BPD. Journal of
Personality Disorders, 18, 36–51.
Barlow, D. H. (2014). Clinical Handbook of Psychological Disorder: A Step-by-Step Treatment
Manual.
Beck, A. T., & Freeman, A. (1990). Cognitive therapy of personality disorders. New York:
Guilford Press.
Brown, G. K., Newman, C. F., Charlesworth, S. E., Crits-Christoph, P., & Beck, A. T. (2004). An
open clinical trial of cognitive therapy for borderline personality disorder. Journal of
Personality Disorders, 18, 257–271.
Bowlby, J. (1977). The making and breaking of affectional bonds: 1. Aetiology and
psychopathology in the light of attachment theory. British Journal of Psychiatry, 30, 301–
210.
Dozois, D. J. A. (2019). Abnormal Psychology: Perspectives-Pearson (6 th Edition).
Gunderson, J. G. (2011). Borderline personality disorder. New England Journal of Medicine,
364, 2037–2042.
Gunderson, J. G. (2015). Reducing suicide risk in borderline personality disorder. Journal of
the American Medical Association, 314, 181–182. doi:10.1001/ jama.2015.4557
Hope and Healing Center & Institution. (2019, October 8). HHCI Seminars – Understanding
Borderline Personality Disorder [video]. Youtube. https://www.youtube.com/watch?
v=RaMbG8jV7_A&ab_channel=HopeandHealingCenter%26Institute
Krause-Utz, A., Sobanski, E., Alm, B., Valerius, G., Kleindienst, N., Bohus, M., Schmahl, D.
(2013). Impulsivity in relation to stress in patients with borderline personality disorder with
and without co-occurring attention deficit/hyperactivity disorder: An exploratory study.
Journal of Nervous & Mental Disease, 201, 116–123. doi:10.1097/ NMD.0b013e31827f6462
Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2013). Abnormal Psychology. New
York: Wiley.
Lazarus, S. A., Cheavens, J. S., Festa, F., & Rosenthal, M. Z. (2014). Interpersonal functioning
in borderline personality disorder: A systematic review of behavioral and laboratory-based
assessments. Clinical Psychology Review, 34, 193–205. Retrieved from
http://dx.doi.org/10.1016/j.cpr.2014.01.007
Leichsenring, F., Leibling, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality
disorder. The Lancet, 377, 74–84.
Linehan, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectical behavior therapy for
borderline personality disorder.In D. H. Barlow (Ed.), Clinical handbook of psychological
disorders: A step-by-step treatment manual (3rd ed.). New York, NY: Guilford.
Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant.
New York, NY: Basic Books.
MedCircle. (2018, August 20). How to Spot the 9 Traits of Borderline Personality Disorders
[video]. Youtube. https://www.youtube.com/watch?
v=to5qRLRSS7g&ab_channel=MedCircle
Nevid, J. S., Rathus, S. A., & Greene, B. S. (2017). Abnormal psychology in a changing world
(10th ed.). Pearson.
Whitbourne, S. K. (2020). Abnormal psychology: Clinical perspectives on psychological
disorders.
Santangelo, P., Reinhard, I., Mussgay, L., Steil, R., Sawitzki, G., Klein, C., Ebner-Priemer, U. W.
(2014). Specificity of affective instability in patients with borderline personality disorder
compared to posttraumatic stress disorder, bulimia nervosa, and healthy controls. Journal
of Abnormal Psychology, 123,258–272. doi:10.1037/a0035619
Schulze, L., Schmahl, C., & Niedtfeld, I. (2015). Neural correlates of disturbed emotion
processing in borderline personality disorder: A multimodal meta-analysis. Biological
Psychiatry, 79(2), 97–106. doi: 10.1016/j.biopsych.2015.03.027
Young, J. E. (1999). Cognitive therapy for personality disorders: A schema-focused approach
(3rd ed.). Sarasota, FL: Professional Resource Press.