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Understanding Borderline Personality Disorder

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Otto F. Kernberg, MD Director of the Personality Disorders Institute  New York-Presbyterian/Westchester DivisionBy Otto F. Kernberg, MD
Director of the Personality Disorders Institute 
New York-Presbyterian/Westchester Division. 

You've surely heard of depression and anxiety and may have read about bipolar disorder. But even though it affects up to two percent of the U.S. population, borderline personality disorder, or BPD – with its erratic moods, relationships and behaviors – is far less well-known.

BPD, one of several severe personality disorders, is marked by a highly unrealistic concept of oneself and of significant others. "The most important symptom is that patients have very unstable, chaotic relationships," explains renowned BPD expert Otto F. Kernberg, MD, Director of the Personality Disorders Institute at New York-Presbyterian/Westchester Division. "They tend to have excessive emotional outbursts, are quite impulsive and their evaluation of themselves and others goes from one extreme to the other – either ideal and wonderful or worthless and despicable. Their feelings are correspondingly intense, with either happiness and elation or deep anxiety and depression."

The negative effects on the social, emotional and professional lives of people with BPD are considerable. In addition to intense anger, anxiety and depression, sufferers often live with a chronic sense of emptiness and loneliness – and fear of abandonment. The disorder can also lead to suicide attempts, self-harming behaviors such as cutting, drug and alcohol abuse and eating disorders.

A combination of factors may heighten the risk of BPD, including an inborn hyper-reactive temperament and serious early childhood issues, such as significant pain from illness, an insecure attachment to the mother, a chaotic family structure and having experienced or been a chronic witness to physical or sexual abuse.

Medications such as antidepressants, the newer atypical antipsychotics, and mood stabilizers may ease certain symptoms, but psychotherapy is essential. "Medication alone won't do the job, but can reduce anxiety, depression, and impulsivity, and the disordered thinking some patients engage in," says Dr. Kernberg.

Two types of psychotherapy are used and both are effective, says Dr. Kernberg. In the first – the dialectic form of cognitive behavioral therapy – therapists strive to validate patients, help them become more accepting of their views and feelings. They also teach them how to deal with their exaggerated emotions and reactions.

In the second type – psychodynamic therapy – "They don't teach a patient directly how to behave but try to help him understand why he's reacting the way he is and why he's wrongly interpreting what other people are doing – and how he can learn to assess these things more realistically," says Dr. Kernberg.

Three Types of Psychodynamic Therapy

Three different types of psychodynamic therapy are used for BPD:

  1. Supportive psychotherapy. "It's a common sense approach in which the therapist tries to study what emotional needs are not being satisfied and what inappropriate defensive maneuvers are used to satisfy those needs," says Dr. Kernberg. "It tries to help patients find better compromises between emotional needs and the need to adapt to the environment."
  2. Mentalization-based psychotherapy, or MBT, helps patients more realistically view themselves and others. Mentalization is the process by which we interpret our actions and those of others based on mental states such as feelings; those with BPD have great difficulty with this.
  3. The newer transference-focused therapy, or TFP, developed by Dr. Kernberg and his colleagues, "focuses on the cause of the personality disorder, rather than the particular symptoms," he explains. By allowing all of a patient's positive and negative experiences and feelings to come up in therapy, "bad experiences lose their terror and ideal experiences appear as exaggerated." Over time, patients learn to create a more balanced view of themselves, others and experiences.

In general, says Dr. Kernberg, cognitive therapy is an ideal first choice for those who suffer mostly from specific symptoms such as self-harm or impulsive anger. "If what predominates are serious breakdowns in all relationships, psychodynamic is the best choice," he explains.

Long-term studies on psychotherapy – with the exception of TFP – show it can help patients improve significantly. "But they still have an impoverished quality of life," says Dr. Kernberg. TFP may "fix the personality long-term," he adds, which is why he and his colleagues continue to research and evaluate its effects.

Posted with permission by the NewYork-Presbyterian Hospital/Westchester Division.  Originally posted on their blog: (http://nyp.org/news/hospital/understanding-borderline-personality-disord...

 

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