Why is CBT not effective for BPD?

Borderline Personality Disorder

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Borderline Personality Disorder (BPD) is a psychological disorder affecting about 1 to 2% of the population. It occurs more frequently in women than in men. BPD is associated with severe emotional suffering and impulsive behavior. Research shows that the symptoms of BPD can be improved significantly over time.

BPD is considered a “personality disorder” by the American Psychiatric Association’s Diagnostic and Statistical Manual, 4th edition (DSM-IV). Personality disorders typically begin in adolescence or early adulthood and continue over many years. Personality disorders often cause a great deal of distress and interfere with a person’s ability to achieve fulfillment in relationships, work, or school. Although personality disorders are usually not formally diagnosed until adulthood, there are often early signs in adolescence. In BPD, such signs could include heightened emotional sensitivity and reactivity, problems maintaining long-term relationships, and intentional self-injury.

Individuals with BPD often suffer from other psychological problems, including depression, substance use, post-traumatic stress disorder, bipolar disorder, and eating disorders. Approximately 75% of individuals with BPD have attempted suicide, and self-injurious behavior (such as cutting oneself) is quite common. Such behaviors contribute to the seriousness of the disorder and often prompt the sufferer – or the individual’s family members – to seek help from a mental health professional. Many individuals with BPD have been hospitalized one or more times, often following a suicide attempt or when professionals think there is a high risk of suicide.

Major Characteristics

The characteristics of BPD mainly fall into five different problem areas:

• Emotion: “Emotion dysregulation” is a core feature of BPD. This is the tendency to experience frequent and intense emotions, and take a long time to recover from emotional experiences. Individuals with BPD sometimes feel like they are on an emotional roller coaster with very quick shifts in mood and emotions. Many individuals with BPD have frequent experiences of intense anger, fear, sadness, and shame, often related to the behaviors described below.
• Behaviors: BPD is commonly associated with impulsive behaviors that are potentially self-damaging, including drug and alcohol use, spending sprees, risky sexual behaviors, and binge eating episodes. Intentional self-injury, including behaviors such as cutting or burning oneself, head banging, or asphyxiation (with or without the intent to die) is frequently seen in people with BPD.
• Relationships: Individuals with BPD often describe their relationships with romantic partners, family members, and friends as stormy, intense, and full of conflict. Relationships tend to have a lot of ups and downs. BPD sufferers often fear abandonment, worrying frequently that loved ones may leave them. As a result, individuals with BPD may beg or plead with loved ones to avoid real or perceived abandonment.
• Identity: Individuals with BPD often feel as though they do not have a clear sense of self. They may have trouble describing who they are. Sometimes this can be seen in frequent changes in jobs, friends, and life goals. In addition, BPD sufferers describe chronic feelings of emptiness.
• Thoughts: Sometimes, individuals who have BPD can experience intense feelings of paranoia (feeling like others are out to get them) or dissociation (feeling spaced out or as though things are unreal; or realizing that they were not aware of what just happened). These types of changes in thinking tend to happen when there is a great deal of stress.

A person with BPD may not have problems in each category listed above and not all the problems may be apparent at any given time.

Causes

There is no known single cause of BPD. Similar to other psychological disorders, BPD is likely caused by a combination of biological, social/environmental, and psychological factors. Many people with BPD, though not all, have experienced emotional, physical, or sexual abuse as children. On the other hand, there are people who were abused as children who do not have BPD.

Can Psychotherapy Help?

BPD was once considered a lifelong, untreatable diagnosis. However, recent studies show that people with BPD often improve significantly over the course of their lifetime. Often this is achieved through some form of psychotherapy, although some individuals report improvement without psychotherapy.

Cognitive-behavior therapists who treat BPD often use a particular therapy, called Dialectical Behavior Therapy (DBT). DBT has been evaluated in several research trials and shown to be effective for reducing suicidal behavior and other BPD characteristics over time. DBT has many components and generally individuals are encouraged to sign on for the full package of treatment for at least 12 months. The full package of DBT includes one-on-one therapy with a professional, skills training, phone consultation with the therapist as-needed, and a weekly consultation team for the therapists. The skills training portion is aimed at helping individuals learn ways to regulate emotions, tolerate distress, and interact with others more effectively.

Other therapies that incorporate cognitive-behavioral techniques to treat BPD include cognitive therapy and schema-focused therapy. Both of these treatments tend to focus more on changing an individual’s patterns of thinking. The patterns that are targeted include working to reduce “black and white” thinking as well as those core beliefs that don’t match reality, like believing you are a terrible person or unworthy of love. The therapist works actively with the client to come up with alternative, healthier, and more adaptive ways of thinking about themselves, others, and the world.

Individuals with BPD also are often treated with psychotropic medications. Presently, there is no medication that is FDA approved specifically for BPD, but there are medications that have been shown to reduce particular symptoms of BPD in clinical trials. For example, mood stabilizing medications may reduce impulsive behavior and mood changes, antidepressant medications may reduce sadness and anxiety, and antipsychotics may reduce paranoid thinking and anger in patients with BPD.

Unfortunately, BPD is associated with three different types of high-risk behaviors: suicidal, impulsive, and self-injurious behaviors. About 8% of people with BPD kill themselves. As noted above, self-injury is often seen among people suffering from BPD and is a particularly serious problem that sometimes leads to unintentional suicide in people with BPD. If you, or someone you know, engage in self-injury, it is important to seek appropriate help as soon as possible.

Resources for Family Members

Family members and partners of individuals with BPD often feel like they themselves need support in dealing with the person with BPD. Family members can feel at a loss for how to deal with individuals when they are so emotionally out of control or when they continue to engage in behavior that seems so self-damaging. Recently, a number of organizations have come into being with the explicit purpose of providing education and resources for family members. These organizations often put on meetings that provide psychoeducation about the disorder as well as tips for interacting with the person with BPD. They also often provide referrals for the family members if they choose to seek therapy for themselves. Here are a few resources that may be useful for family members:

National Alliance on Mental Illness (www.nami.org)

NAMI recently added BPD to its list of mental illnesses that is supported by the organization. Family members can find local support groups and educational opportunities through its website.

National Education Alliance for BPD (www.neabpd.org)

The mission of NEA-BPD is to “raise public awareness, provide education, promote research on borderline personality disorder, and enhance the quality of life of those affected by this serious mental illness.” NEA-BPD frequently has workshops around the country and family members are encouraged to attend. You can also listen to a number of presentations on the NEABPD website by leading experts in the field.

TARA Association for Personality Disorders (www.tara4bpd.org)

The mission of TARA is to “to foster education and research in the field of personality disorder, specifically but not exclusively Borderline Personality Disorder (BPD).” TARA has a number of local chapters throughout the U.S. for family members to join.

Related Fact Sheets

• Suicide

What is Cognitive Behavior Therapy?

Behavior Therapy and Cognitive Behavior Therapy are types of treatment that are based firmly on research findings. These approaches aid people in achieving specific changes or goals.

Changes or goals might involve:

A way of acting: like smoking less or being more outgoing;
A way of feeling: like helping a person to be less scared, less depressed, or less anxious;
A way of thinking: like learning to problem-solve or get rid of self-defeating thoughts;
A way of dealing with physical or medical problems: like lessening back pain or helping a person stick to a doctor’s suggestions.

Behavior Therapists and Cognitive Behavior Therapists usually focus more on the current situation and its solution, rather than the past. They concentrate on a person’s views and beliefs about their life, not on personality traits. Behavior Therapists and Cognitive Behavior Therapists treat individuals, parents, children, couples, and families. Replacing ways of living that do not work well with ways of living that work, and giving people more control over their lives, are common goals of behavior and cognitive behavior therapy.

How to Get Help

If you are looking for help, either for yourself or someone else, you may be tempted to call someone who advertises in a local publication or who comes up from a search of the Internet. You may, or may not, find a competent therapist in this manner. It is wise to check on the credentials of a psychotherapist. It is expected that competent therapists hold advanced academic degrees. They should be listed as members of professional organizations, such as the Association for Behavioral and Cognitive Therapies or the American Psychological Association. Of course, they should be licensed to practice in your state. You can find competent specialists who are affiliated with local universities or mental health facilities or who are listed on the websites of professional organizations. You may, of course, visit our website (www.abct.org) and click on “Find a CBT Therapist”

The Association for Behavioral and Cognitive Therapies (ABCT) is an interdisciplinary organization committed to the advancement of a scientific approach to the understanding and amelioration of problems of the human condition. These aims are achieved through the investigation and application of behavioral, cognitive, and other evidence-based principles to assessment, prevention, and treatment.

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