Borderline Personality Disorder: Cognitive Behavior Perspectives, Diversity, and Treatment
Cognitive behavioral theory, as applied in psychopathology and therapy of psychiatric disorders, was formulated approximately 40 years ago (Beck, 2005). The theory and its application in therapy have continuously been updated with recent development incorporating empirical testing. According to Somers et al. (2007), cognitive therapy has been shown to be effective in a variety of mental health disorders, consequently raising attention among professionals and research. González-Prendes and Resko (n.d) explain that cognitive behavioral theory is based on the principal that the cognition of a person is critical in developing and maintaining behavioral and emotional responses in life.
As mentioned above, cognitive behavior therapy (CBT) has attracted immense levels of interest from various parties such as healthcare professionals and researchers (Somers et al., 2007). Various reasons have contributed to the increased research on CBT. For instance, CBT has been shown to exhibit effectiveness in the treatment of most psychological problems. Moreover, there has been an increase in demand for health care that is effective and cost friendly. CBT meets these requirements and hence need for its application in treatment. CBT has also been revealed to have better treatment effectiveness compared to medication. More so, interest for alternative medication in therapy has been increasing.
This paper seeks to explore the cognitive behavioral theory as it applies to borderline personality disorder (BPD). This exploration involves considering BPD in the perspectives of cognitive behavioral theory. Linehan’s biosocial model, Young’s schema model, and Becks theory are also reviewed as they relate with BPD. The paper also considers the neurobiology aspect of BPD and its diversity. Various aspects of how BPD varies relative to some of the common factors such as gender and race are considered. Moreover, the paper gives a possible treatment approach for BPD relative to the CBT.
Cognitive Behavioral Theory Perspectives on Borderline Personality Disorder
The cognitive theory perceives BPD as object-representation split architecture of a person (Millon et al., 2012). In this case, persons with BPD function well in cases of structured conditions in which case there is a constant object. In the absence of the object, BPD patients’ functioning deteriorates to primitive levels. In summary, cognitive behavior theory accounts for realistic mental functioning in the presence of significant others. Borderline cognition depends on various factors. One such factor is the threats to relationships. In 2012, Millon and colleagues explained that threats to relationships cause BPD patients to switch from secondary to primary thinking. Secondary thinking is based on reality while primary thinking is based on direct drive charge, fantasies, and wishes. Individuals end up transparently exhibiting their needs, rage and demands.
Moreover, borderline cognition is affected by external environmental structure degree (Millon et al., 2012). Structural tests reveal the effect of environmental structure on borderline cognition. BPD patients are presented as being healthy in pencil-and-paper personality tests. In this case, PBD patients borrow environmental structure that they use to organize themselves. On the contrary, projective instruments reveal PBD patients as being unhealthy. BPD patients have minimal internal structure to exploit during these tests and consequently portraying them as being less healthy.
Millon et al. (2012) explain that individuals with personality disorder have a particular cognitive style. For instance, compulsive personality is perfectionist while narcissists have an all knowing perception. Thought and emotional fluidity characterize borderline cognitive style. The degree of the fluidity is dependent on the factors, mentioned above, of relationship and inherent structure of demands. BPD also has a cognitive characteristic of split object-representation. In this case, Millon and colleagues explain that borderlines view of self, others and the world are dependent on the prevailing circumstances. Lawson’s (2000) illustrates this explanation of the thoughts of borderlines in which case he states that they are unpredictable. Borderlines do not have particular rules, and if they do exist, they are not followed. Their actions depend on the prevailing circumstances.
The above section reveals that research on BPD has focused on affective instability and impulsive aggression. BPD patients have difficulty in impulsive control that causes behaviors such as assault, self-mutilation and property destruction (Farber, 2008). Affective instability refers to reversible changes in the affective state of BPD. The two cognitive aspects have been associated with prefrontal cortex (Crowell, Beauchaine & Linehan, 2009). Damage to the orbital frontal cortex has been shown to be the causative factor for angry outbursts and irritability in patients. Moreover, lesions of the prefrontal cortex cause antisocial behavior during childhood while causing aggressiveness later in life (New & Siever, 2002). The disorder results from the frontolimbic circuitry. Other parts of the brain associated with BPD include the basal ganglia, amygdala, anterior cingulate cortex, thalamus and the fusiform gyrus.
There exist various ways of conceptualizing cognitive behavior theoretical perspectives. Such theories include Linehan’s biosocial theory, Beck’s model, and Young’s schema model. The following section summarizes some of the common cognitive behavior theoretical conceptualization of BPD. The prefrontal cortex region of the brain play a critical role in aggressive behavior control (New & Siever, 2002).
Linehan’s biosocial theory
Crowell, Beauchaine and Linehan (2009) portray borderlines as having emotional regulation dysfunction. The dysfunction has two effects on the BPD patients. Beck, Freeman and Davis (2004) explain that borderlines exhibit strong reactions to events that are stressful. Moreover, BPD patients take a long time to return to baseline emotions after stressful reactions. Linehan’s theory also perceives the environment of BPD patients as being invalidating. Lawson (2000) accounts for situations such as denial, punishment and invalid responses to emotional reactions as being the causative factors of BPD problems. This theory proposes the use of dialectical stance in the treatment of BPD. Dialectical stance tries to restore tolerance and regulation of patient’s emotions and validate their emotional reactions.
Linehan’s biosocial theory accounts for the affective instability portrayed by BPD patients. According to Bohus, Schmahl and Lieb (2004), BPD patients exhibit emotion vulnerability. Moreover, patients have accentuated sensitivity to emotional stimuli that is aversive and intense emotional reactions. As highlighted earlier, PBD patients have problems returning to emotional baseline. The emotional dysfunction affects both affective learning processes and executive functions. Consequently, the cognitive, physiologic, experiential and behavioral subsystems are affected. Effects of the subsystems cause BPD patients to have problems coordinating and organizing activities to attain non-mood-dependent goals. BPD may also cause individuals to shut down or freeze under highly stressful situations.
Beck’s formulation of the cognitive behavior theory portrays the BPD patients as having the mentality of being minor as compared to the superior world and others. Beck, Freeman and Davis (2004) explains that BPD has three key assumptions. These include their view of the world as a malevolent and dangerous place and perceiving themselves as being vulnerable and powerless. Moreover, PBD patients assume that they are inherently unacceptable. Consequently, BPD patients have high levels of interpersonal distrust and vigilance due to the first two assumptions. Moreover, BPD is characterized by a weak sense of their identity and dichotomous thinking.
Beck’s theory stipulates that the assumptions and the cognitive characteristics mentioned above are critical to the maintenance of the disease and are also the target for the treatment of the disease. In the treatment, the paradoxical assumptions of dependence and the paranoid assumptions account for the interpersonal behavior of borderlines. On the other hand, the dichotomous thinking causes extreme decisions and emotional turmoil. Therefore, Beck’s theory can be summarized as that which perceives BPD symptoms to result from underlying cognitive characteristics.
Young’s Schema Mode
This cognitive behavior model perceives the pathology of BPD to result from a child being frightened, abused and lonely in a malevolent world. Consequently, the children long for help and safety while still being distrustful fearing subsequent abuse and abandonment. Lawson and Farber (Farber, 2008; Lawson, 2000) adds on this claiming that the children are lost in a dangerous world filled with fraught, contradiction and emotional storms. This model expounds Becks theory. Beck, Freeman and Davis (2004) explain that this model uses the concept of schema modes to conceptualize BPD. Schema mode refers to an organized pattern of behavior, emotions and thinking. Young formulated four schemas for BPD that include the abandoned, impulsive/angry child modes and punitive parent mode. The other modes are the detached protector mode and a fifth mode referred to as healthy adult mode that depicts the healthy side of an adult.
The abused and abandoned child mode refers to a desperate state of patients due to abuse and abandonment during their childhood years. Therefore, the patients view others as being malevolent and untrustworthy as depicted by Lawson’s (2000) explanation of the thoughts of not trusting others and being lonely. Moreover, the patients portray self-impulsiveness and rage. This mode often cause the onset of the punitive parent mode (Beck, Freeman & Davis, 2004). In this mode, the patients condemn themselves as being evil, bad and deserving punishment. Consequently, the patients end up inflicting punitive acts on themselves or others. The detached protector mode relates to the problematic relationship between the patients with others. Patients perceive attachments to have harmful effects such as pain, punishment and abandonment and hence fail to connect with others. Therefore, patients end up being detached as a way of survival and life control.
There has been concern regarding biases in BPD regarding factors such as gender and race. Moreover, cultural backgrounds of people have been shown to affect BPD prevalence. The following sections evaluate diversity in BPD relative to various factors.
The prevalence of BPD has been shown to be gender biased. Gender bias in BPD has been of concern to clinicians due to its ability to influence assessment and treatment (Samuel & Widiger, 2009; R. Sansone & L. Sansone, 2011). BPD prevalence has been shown to be higher among women as compared to men. Moreover, there exists gender difference in BPD self-harm behaviors. For instance, Samuel and Widiger (2009) explain that males are less likely to be diagnosed as being histrionic or females as antisocial. Moreover, R. Sansone and L. Sansone (2011) explain that BPD male patients are more likely to have explosive temperaments coupled with novelty seeking.
Moreover, BPD male patients are likely to have a history of substance abuse (R. Sansone & L. Sansone, 2011). BPD female patients are more likely to have used more psychotherapy and pharmacotherapy services compared to men. Gender differences are of particular concern to clinicians. As mentioned earlier, they are critical in the evaluation of patients. BPD male and female patients have different treatment and clinical presentation histories.
Ethnicity and cultural variations
McGilloway, Hall, Lee, and Bhui, (2010) found that there exist differences in the prevalence of BPD among the white and the blacks. The black were shown to be at a lower risk of BPD. This difference was, however, likely to be as a result of variances in clinical settings. McGilloway and colleagues explain that the ethnic differences in the prevalence of BPD could be due to the disease being overlooked and hence failure to treat it among the black. Moreover, this ethnic variation of BPD was shown to vary in different countries. For instance, BPD prevalence among the blacks and the whites was found to be similar in the US as compared to the UK where it was different.
BPD treatment aim at reducing impulsiveness, self-mutilating behavior and, if present, eliminate comorbidity (Beck, Freeman & Davis, 2004). Treatment also helps patients to have control of the emotions and have insights on their problems. The treatment sessions should be administered for not less than 1 year. Beck and colleagues explain that long periods of treatment are necessary for effective and broader change of the schema level. During treatment, the therapist should ensure that he/she develops an intense relationship with the patient. As highlighted in the previous discussion, BPD patients have a high level of distrust to others. Long periods of treatment regime will help the therapist use his/her relationship with the patient to help them to overcome their pathological attachment to others as a way of overcoming interpersonal barriers. Moreover, long periods of treatment will enable the therapist to address traumatic memories of the patient’s childhood. The following overlapping stages can guide during BPD treatment.
Creation of a working relationship
The therapist seeks to gain the trust if the patient through this relationship. According to Freeman, Stone and Martin (2005), cognitive behavior therapy (CBT) highly depends on understanding identification of the behavioral patterns and the resultant cognitive processes. Creation of a working relationship will help a therapist to understand these aspects. Moreover, working relationship with the patients helps therapists to influence change in their believes that cause dysfunction and distress.
According to Arntz (1994), patients should be allowed to have control during therapy session as a way of gaining and improving the relationship. Determining goals can achieve such gain and improvement in a relationship during every therapeutic session. The patient should highly influence the goals to ensure that they exercise control. Moreover, the therapist should let his/her interaction be patient-centered. Patients can also be allowed to exercise control by letting them choose the therapeutic method to be used on them and also can terminate subjects of discussion at their will.
Creation of a working relationship may be hindered due to the nature of borderlines of fearing to be hurt or rejected while still desiring to be helped and accepted. Therapists are expected to have boundaries while letting patients have control.
Management of symptoms
This stage uses an approach that is symptom-directed (Arntz, 1994). This stage aims at replacing harmful behaviors with harmless ones. In achieving this, the therapist identifies the patient’s background and determining a common denominator of the various problematic behavior. The therapist then guides the patient to replace harmful behavior such as self-mutilation and aggression with less harmful behavior such as singing and placing hands in water.
The discussion above shows that BPD patients act in a normal way until when under stressful situations during which they have mood-dependent goals (Bohus, Schmahl & Lieb, 2004). Consequently, BPD patients become aggressive, abusive and mutilate themselves or other. This stage aims at improving the patient’s freedom of choice to help them avoid having the impulsive harmful actions by doing harmless actions (Arntz, 1994). Consequently, BPD patient will ba able to cope with emotions in a better way. Success at this stage leads to the next phase of modifying errors in the patient’s thinking.
Thinking errors modification
Freeman, Stone and Martin (2005) explain that at the end of the therapy, the patient’s beliefs that cause dysfunction and distress should be changed. Such change requires a change in the understanding, perception and response to such belief stimulus. This goal of changing the motive would be achieved at this stage. In 1994, Arntz explained that changing motive requires identifying the misinterpretations that lie at every symptoms root. Dichotomous thinking is the key thinking error associated with BPD (Beck, Freeman & Davis, 2004). Due to dichotomous thinking, borderlines perceive themselves as being bad while others are either trustworthy or not (Lawson, 2000). Arntz (1994) explains that dichotomous thinking is the cause of the varying judgments and emotions in borderlines.
The therapist helps the borderlines to correct dichotomous thinking with structured thinking that is more nuanced and multidimensional (Arntz, 1994). Therapists also need to change the thinking error of personalization. BPD patients have egocentric thinking that causes them to condemn themselves. Moreover, the therapist ought to help the patient correct the problem of differentiating between demands and demand and fear of catastrophes to occur if they fail to meet others wishes. Once the thinking errors have been changed, the therapist ought to change the patient’s schema.
Changing schema and processing of trauma
BPD behavior is associated with their traumatic childhood experiences. These childhood experiences result in the development of the key assumptions of BPD (Beck, Freeman & Davis, 2004). This stage will be of critical importance in changing how borderlines deal with their traumatic childhood experiences (Arntz, 1994). Changing the schema requires extinction of fear that result from their traumatic childhood experiences. This extinction necessitates exposing borderlines to the emotions and traumatic memories. The patient is required to have control during such exposures, and they should proceed slowly. Childhood interpretations causing the assumptions of the borderlines are identified and then modified using a role-play. The patient is allowed to play the role of the child opening the childlike interpretations (egocentric) leading to the patient formulating alternative interpretations from their adulthood insights. Patients then use the developed alternative interpretations to analyze the traumatic experiences. Palmer (2002) explains that this stage is critical in helping borderlines to move to ordinary unhappiness and happiness.
Improving social functioning and elimination of incompleteness
Borderlines are often victims of social isolation. The therapist should hence help the borderlines to improve on their social life. Improving social isolation requires that the earlier stages are met to remove cognitive, behavioral and emotional problems causing limitation to the patient in finding support from others (Slee et al., 2007). According to Palmer (2002) this stage should also incorporate extinction of the feeling of incompleteness.
Maintenance of the treatment progress
There is need for maintenance of the therapy session to avoid a relapse of the condition. Prevention of relapse requires the therapist to be able to handle situations in which borderlines defensiveness, guardedness, and suspiciousness seem justified. In such instances, the therapist and the borderlines need to formulate a plan to deal with such situations. Achievement of such capability of the patients requires them to be exposed to actual similar instances for them to practice how to deal them.
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