BY VAALPARK MHU | July 21, 2021
Dr Melané van Zyl
Borderline Personality Disorder (BPD) is characterised by instability in all major areas of the personality and life, including interpersonal relationships, self-image, and emotions, and by impulsivity.
Due to these chronic and widespread symptoms, people with BPD suffer immensely. The people closest to them also suffer a lot due to the intricate and ever-changing relationship dynamics.
So, what can be done to alleviate the symptoms? Is there a permanent cure?
We will discuss the two main options we have available to treat mental health problems – medication and psychotherapy and what it entails. And yes, there is hope.
The course of BPD- what happens over time?
Before we look at the treatment options, we need to consider the course of the disorder. As discussed in my first article, BPD is a chronic, long-term disorder that is diagnosed after 18 years of age. Sometimes the signs and symptoms are quite clear from a younger age, but the official diagnosis can only be made after 18 as the personality still develops until 18. The symptoms seem to reach peak intensity in the late adolescence to early adulthood. The point is- by the time the patient starts looking for help he/she has already suffered for years.
Another interesting (and hopeful) fact to consider is that contrary to longstanding beliefs that BPD is a chronic, unchanging condition, studies have found that remission occurred in 45% of patients with BPD over a wide range of follow-up periods.
However, recurrence of symptoms occurs in about 34% of patients who have remitted. BPD is a dynamic condition and people can ‘lose’ the diagnosis. They can also ‘relapse’ and get the diagnosis again- but I do find it a positive thing that we a dealing with a dynamic problem as it gives opportunities for intervention.
BPD Opportunities for Intervention
- Treating BPD is challenging due to the dynamics of the disorder, therefore the relationship between the patient and the psychiatrist and psychologist is also complicated. The doctor and therapist are typically initially idealised. However, the therapist cannot live up to these high expectations, and the patient usually feels rejected and hurt.
- Having to deal with the BPD dynamics including the patient’s anger is exhausting and even traumatising for the therapist.
- Many people with BPD are not ready for treatment, especially in the early stages of the disorder. The mood swings and interpersonal drama fulfill a purpose. It is often only much later when they are at some sort of crossroads e.g. partner gave them an ultimatum, or they have a serious suicide attempt, that brings them for treatment. If the patient is not committed to therapy yet, he/she will often display therapy defeating behaviours e.g. not coming for sessions.
- There is no quick fix. Treatment involves commitment of a period of at least six months, often much longer.
- BPD is a stigmatised condition. Many therapists ‘tiptoe’ around these patients, or if they do consult with them, they often avoid openly discussing the diagnosis.
Challenges to treatment
What are the treatment options?
By the time patients present to a psychiatrist they are usually already on medication such as an antidepressant and or mood stabiliser. This is not wrong, because it is difficult not to prescribe medication to a patient who is suicidal or emotionally unstable. Sadly, medication- especially antidepressants-is not effective to treat BPD.
After a diagnosis is made, considering ‘everything that is currently going on’ with the patient, it can be decided which symptoms to treat with medication. If depression and anxiety are the most prominent symptoms, attention is given first to threat the BPD with psychotherapy. If there is a manic episode or anorexia nervosa present, these conditions are first addressed with mood disorders and medical stabilization, respectively.
For cognitive-perceptual symptoms (dissociation, hallucinations, paranoid ideation) a low-dose antipsychotic can be prescribed. For impulsive- behavioural dyscontrol (self-injury, recklessness, binge eating, aggression) mood stabilizers are most effective. Affect dysregulation (depression, mood swings, anxiety, anger) are best treated with mood stabilisers and low-dose antipsychotic drugs.
Beware of benzodiazepines. Patients can become dependent on them or abuse them to self-harm.
Of course, patients cannot prescribe their own medication. If you do not get better- this applies to any medical condition- go back to your doctor to try something else. And if the side-effects are intolerable, another medication can be tried. Luckily, we have many options available these days.
Psychotherapy is the most effective treatment for BPD. Different modalities can be effective, but in South Africa Dialectical Behavioural Therapy (DBT) is most readily used and available. DBT is also indicated for the most destructive and regressed patients.
DBT is a skill-based program, meaning the focus is on skills training (e.g. practical and didactic) and does not require ‘deep’ techniques such as analysis. However, DBT is not necessarily the only option, and “Good Psychiatric Management” in its broad meaning is also effective.
Psychotherapy can be offered in groups or on an individual basis.
In Part 2 we will look at psychotherapy for BPD in depth.