The National Institute of Mental Health, NIMH, defines borderline personality sisorder as "A serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior." Until the late 1990s BPD had been considered almost impossible to treat successfully but new advances in the understanding of brain chemistry and function have led to an understanding of the physical causes of BPD and new opportunities to affect symptom suppression if not a cure.
Treatment Issues
Borderline Personality Disorder affects at least 2 percent of the American population with 75 percent of diagnosed clients being female, according to the NHMH data.
As research has increased in the study of neurotransmitters and brain pathway development BPD has come to be understood primarily as a physiological disorder not unlike depression, diabetes or ADD, rather than lack of will power, or a choice to behave in socially destruction ways. This recognition should decrease the stigma attached to the diagnosis and lead to an increase in self referral into treatment.
Medications as First Line Therapy
Paul J. Markovitz M.D., Ph.D., Professor of Psychiatry at Case Western University, College of Medicine, recommends medication be used as the first line of treatment. "Treating BPD with psychotherapy before correcting the imbalances in neurotransmitters seen in BPD is like asking a diabetic to sit down and talk about his inability to make insulin," he wrote in "Pharmacotherapy for the Treatment of Impulsivity, Aggression, and Related Disorders in Impulsivity and Aggression." Markowitz' research indicates that Prozac or other antidepressants are most effective.
In the December 2007 issue of "The American Journal of Psychiatry" Greg Siegel, Ph.D. presented MRI evidence that people with BPD have decreased inhibition of impulse control in the prefrontal cortex. This explains why attention deficit disorder, which also results from decreased activity in the prefrontal cortex, is commonly seen in people with BPD. The addition of medications that increase activity in this region such as Provigil, which increases wakefulness and concentration, are appropriately prescribed for BPD, according to Markowitz.
Once the prefrontal cortex is active it serves to filter impulse more effectively, putting the client in control of her own decisions. A well functioning prefrontal cortex also turns off the impulses coming from the brain's fear center, the amygdala, and this decreases the sense of abandonment that drives many of the behavioral patterns associated with BPD.
After brain functionality has been restored psychological therapies can be used to help the client build a life of healthy choices and mutually beneficial relationships.
Dialectical Behavioral Therapy
In 1991 Marsha Linehan of the University of Washington developed a method of psychological therapy designed to address three issues specific to Borderline Personality Disorder; the low rate of staying in treatment, the long length of treatment needed and the emotional toll this work takes on therapists. She called it dialectical behavioral therapy.
Combining a weekly private session, where one event is analyzed deeply, with a group session aimed at teaching life skills makes dialetical behavioral therapy or DBT, more cost-effective than traditional therapy although the fact that DBT participants have a higher rate of remaining in treatment past the first few sessions will increase costs.
Research in the efficacy of dialectical therapy has concluded that it offers "A significant reduction in suicide attempts and psychiatric hospitalizations but there is no evidence that it improves the quality of relationships or career and professionalism performance." These benefits and deficits in dialectical therapy were noted in the analysis by Dr. Janet Feigenbaum, in the February 2007 issue of the "Journal of Mental Health."
References
- National Institute of Mental Health: Health Topics"; Borderline Personality Disorder
- "Pharmacotherapy of Impulsivity, Aggression,and Related Disorders in Impulsivity and Aggression"; Paul Markowitz, MD, PhD; 1995
- "American Journal of Psychiatry": Brain Mechanisms of Borderline Personality Disorder at the Intersection of Cognition, Emotion, and the Clinic; Greg J. Siegle, Ph.D.; December 2007
- "Journal of Clinical Psychiatry in Clinical Settings"; Pharmacotherapy for Borderline Personality Disorder: A Review of the Literature and Recommendations for Treatment; D.J. Stein, November 1995
