Do I Need Therapy for Borderline Personality Disorder?
Brindusa Vanta, MD, DHMHS
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Personality disorders (PDs) are mental health conditions marked by rigid...
It’s possible to treat borderline personality disorder and help the individual learn to manage distress, reduce self-destructive behaviors, control intense emotions, and improve relationships. But first, it’s important to understand BPD symptoms, causes, and risk factors, as well as various approaches a trained mental health professional may use to treat BPD.
What Is Borderline Personality Disorder (BPD)?
Borderline personality disorder is a mental health condition characterized by intense emotions, fear of abandonment, and hypersensitivity to rejection.(2) Unstable relationships, self-image, affect, and impulsive behavior result in distress and impair the individual’s personal life, work life, identity, and ability to make and carry out long-term plans.(3) Around 1.6% of the general population and 20% of psychiatric inpatients have BPD.(2)
Borderline personality therapy focuses on improving functioning and quality of life. This includes teaching skills for regulating emotions, reducing self-destructive behaviors, and shifting perceptions regarding the self and other people.
What Causes Borderline Personality Disorder?
Scientists believe insecure attachment styles and maladaptive coping mechanisms learned and solidified in childhood form the foundations of the thought patterns in people with BPD.(5) Other causes might include:
Brain chemistry (especially related to those areas of the brain responsible for impulse control and emotional regulation)
Abandonment in childhood or adolescence(6)
Physical, sexual, or emotional abuse
Poor family communication(7)
Unstable family life
Borderline Personality Disorder Symptoms
According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, BPD involves a pervasive pattern of unstable personal relationships, affect, self-image, and marked impulsivity.(8) For a diagnosis, at least five of the following symptoms must be consistently present:
Frantic attempts to avoid real or imagined abandonment. For example, creating a crisis if a romantic partner doesn’t respond to communication immediately due to an irrational, unfounded fear of them ending the relationship.
Viewing people and situations as all good or all bad. For instance, idealizing the people they love until something is triggered. Idealization quickly becomes total devaluation, and the person with BPD now only sees their former loved one as an enemy.
Unstable self-image, which may be the result of increased activation of certain areas of the brain that make it harder for people with BPD to distinguish between themselves and others.(9)
Self-destructive impulse behavior, such as overspending, binge eating, reckless driving, risky sexual encounters, and substance abuse.
Self-harming behaviors, threats of suicide, and suicidal thoughts.
Rapidly shifting mood swings that feel beyond the patient’s control and last for a few hours to a few days.
Chronic feelings of emptiness otherwise described as a disconnection from the self and others.(10)
Intense and inappropriate anger, such as physical fights, frequent displays of temper, or difficulty controlling anger.
Stress-related paranoid ideation, such as undue suspiciousness of other people’s intentions, or severe, stress-related dissociation characterized by changes to memory, identity, perception, and motor control.(11)
Do I Have Borderline Personality Disorder?
People who are concerned that they or a family member might have borderline personality disorder can consider the following questions:
Do they have an intense fear of being alone, which causes them to act in unusual ways?
Is there a pattern of unstable interpersonal relationships in which the individual swings between total adoration and outright rejection of loved ones and family members?
Does their identity seem to shift and change more rapidly than others?
Do they regularly engage in at least two dangerous (excluding direct self-harm and suicidality) behaviors, such as unsafe sex, reckless spending, substance misuse, binge eating, social isolation, lack of hygiene, or consistently underperforming at work?
Are there extreme, rapid mood swings present?
Do they feel empty, lonely and struggle to connect with others?
Is it difficult for them to control their anger?
When triggered, do they get paranoid or temporarily disconnect from themselves, their thoughts, and others?
Have they self-harmed, threatened suicide, or spoken of feeling suicidal?
Therapy for Borderline Personality Disorder
In the past decade, access to effective treatments for borderline personality disorder and other mental health conditions has improved significantly.(12)
The modalities that show the most promise aim to treat specific symptoms of BPD by helping clients learn adaptive coping skills to replace existing maladaptive ones. This is usually in combination with some form of integrated psychotherapy led by a therapist who helps the person with BPD feel understood, seen, and valued.(13)
Some individuals respond better to certain forms of therapy for BPD than others. Finding the combination that works best for any person might take some trial and error.
Online Therapy for Borderline Personality Disorder
It’s easier than ever to receive evidence-based online therapy for BPD from a trained professional online. Impulsivity, emotional regulation problems, and difficulties establishing trusting relationships contribute to making dropout a notorious problem for people with BPD.(14)
The intensity of the therapeutic experience may be challenging for some people with a diagnosis and may explain the high dropout rates.(15) However, the therapist-patient relationship is even more critical when treating PDs than other mental illnesses such as anxiety and depression.
In-person talk therapy is accepted as the most effective form of treatment for borderline personality disorder, and there are now several approaches specific to BPD.(16) There’s around an 85% higher chance of adults with borderline PD receiving face-to-face psychotherapy reporting improvements than those who aren’t in treatment.
Below are four widely used evidence-based psychotherapy models for treating people with a borderline personality disorder.
Cognitive Behavioral Therapy (CBT) for Borderline Personality Disorder
CBT is well-suited to addressing the underlying issues that people with BPD experience.(17) Experts believe that personality disorders result from maladaptive beliefs that have been reinforced to the point of rigidity. Additionally, individuals with PDs lack the skills to respond to negative or impulsive feelings in a healthy manner.
A therapist can use CBT to help individuals with BPD through behavior modification, cognitive restructuring (interrupting unhelpful thoughts and shifting them to helpful ones), psychoeducation, exposure, and skills training. Crucially, a collaborative and supportive relationship with the therapist must be established.
Schema-Focused Therapy for BPD
Schema-focused therapy (ST) is an integrative psychotherapy, which means it draws from a variety of concepts and approaches.(18) It’s based on two ideas. First is that dysfunctional and self-defeating thoughts, behaviors, and effects that form during childhood persist throughout adulthood. These Early Maladaptive Schemas (EMS) develop when there’s a mismatch between the child’s environment and their basic needs.
Second is the notion that there are four maladaptive modes or states that people with BPD get into when triggered. ST involves teaching the patient about schema and modes and how they relate to that individual’s lived experiences. The goal of therapy is for the therapist to guide the client through the process of learning how to self-soothe, identify needs, and set boundaries when triggered.
Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder
DBT is considered the gold standard of BPD therapies, with 77% of participants in one study going into remission following treatment.(19) It’s a long-term approach that aims to help people with the disorder manage symptoms that are challenging to treat and usually take at least two years to complete.
During a mixture of group and individual sessions, a therapist helps the client learn a wide range of skills that fall into the following four categories:
Transference-Focused Psychotherapy (TFP) for BPD
Transference-Focused Psychotherapy (TFP) revolves around helping people with borderline personality disorder shift their incoherent and disordered perceptions of themselves and others.(20) Because they tend to see people and situations as all good or all bad (splitting), their behaviors and emotions often seem disproportionate when they’re stressed. This is especially true when it comes to interpersonal relationships.
In TFP, the therapeutic relationship is very strong and prioritizes helping the patient view conflicting elements in how they view themselves and others. As the symptoms of BPD play out in the therapy sessions, the client engages in the process of change in real time under guidance from a licensed therapist.
Do I Need Therapy for Borderline Personality Disorder?
Borderline personality disorder is unlikely to get better on its own. Other high-risk co-occurring behaviors, such as substance abuse and self-harm, are common among people with a diagnosis.(21) Up to 10% of people with BPD die by suicide.(22)
However, well-structured therapy using methods specifically designed for BPD is an effective treatment for most patients.(23) As such, anyone concerned that they or someone they love might be struggling with borderline personality disorder should seek professional help from a healthcare practitioner.