Abnormal psychology may be defined as the branch of psychology that deals with unusual behavioral patterns, thoughts and emotion of an individual that may or may not be considered as a mental disorder. Personality disorder can be defined as an abnormal behavior that involves an unhealthy and rigid thinking pattern most of the time accompanied with abnormal behavior and functioning. An individual suffering from personality disorder faces trouble while perceiving or relating to another individual and situations (Stepp et al., 2012). Under personality disorders, borderline personality disorder (BPD) is characterized by mental illness that is marked by varying moods, behavior and self-image (Gunderson, Weinberg & Choi-Kain, 2013). These symptoms result in problems and impulsive actions in relationships. People with BPD may experience depression, intense episodes of anger and anxiety lasting from few hours to days. Therefore, the following report involves the study of key features of this abnormal behavior, causes and psychological help required for a BPD individual.
Key features of Borderline Personality Disorder
BPD individuals are unable to manage their emotions effectively especially in the context of relationships. They are thought to be at the border of psychosis facing difficulties in emotional regulation exhibiting high rates of suicides, self-injurious behavior and completed suicide. It is more common in females with 75% as compared to males (Tyrer, Reed & Crawford, 2015).
According to American Psychiatric Association (APA) 2013, there are nine specific diagnostic criteria or symptoms defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-V) (Sellbom et al., 2014). This criterion explains this abnormal behavior into four domains where one must fulfill five out of nine criteria.
Domain A is characterized by emotional instability, irritability, emotional anguish, panic or anxiety attacks. Anger is intense, inappropriate and difficult to control that may be followed by chronic feelings of emptiness. In addition, emotional storms that may be under-reactive and frequent feelings of boredom and loneliness are also the key features of BPD individuals (Anderson et al., 2014).
Domain B comprises of impulsive behaviors where two of the DSM-5 criteria fall in this group. There is recurrent suicidal or self-injurious behavior, threats and gestures like hitting or cutting or any dangerous activity in BPD.
In domain C, the individuals with BPD experience inaccurate perceptions about themselves and high level of suspiciousness. The individuals develop persistent unstable self-image or sense of identity and perceptions about oneself. The individuals become suspicious of others about themselves and paranoid ideation or stress related dissociative episodes where they feel that their surroundings are not real. There is all-or-nothing or split personality where they find it difficult to pull their thoughts so that they make sense and rationale in problem thinking (American Psychiatric Association, 2013).
In last domain D, individuals with BPD experience tumultuous and unstable relationships. The final two key features fall under this DSM-V where individuals are engaged in frantic efforts so that they are able to avoid imagined or real abandonment. Another key feature include unstable, intense and alternate between extremes of undervaluing people or over idealizing the people who are important to them. The individual with BPD may experience clinging behaviors or overly dependent in important relationships. Individuals who fall under this category may expect harmful behaviors or negative attitudes from other people and face difficulty in reasoning clearly in stressful situations (Morey, Skodol & Oldham, 2014).
Apart from these key features, BPD individuals may experience feelings of emptiness that may be followed by difficulty in controlling anger displaying enduring bitterness, extreme sarcasm or verbal outbursts. In addition, this sudden burst of anger is often followed by guilt and shame contributing to their evil behavior. There are also sudden periods of extreme stress or dissociative behavior (depersonalization) that is of insufficient duration of severity warranting an additional diagnosis.
Causes behind borderline personality disorder
There are no specific reasons that why individuals have trouble in BPD. However, a combination of factors comprises of genetic factors, neurobiology, neurotransmitters and traumatic or stressful life events that causes BPD. The subsequent section discusses the literature review explaining some of the causes of BPD.
Amad et al., (2014) conducted a systematic review along with meta-analysis regarding BPD genetics on twin and families and gene-environment interaction. The research objective was to study the interaction between gene and environment that has a role in the genesis of BPD. Two case-control studies that tested same polymorphism were also performed for meta-analysis. For the literature search strategy, systematic search was carried out using Scopus and Medline databases since 2013 using key words, “gene”, “borderline personality disorder”, “haplotype” and “polymorphism”. All English peer-reviewed, full text journals where BPD patients diagnosed under DSM criteria of the age eighteen years were included for the study. The papers that comprised of familial segregation studies, association, twin studies and gene-interaction studies were considered. Meta-analysis where case-control studies showing same polymorphism were considered. For each study, confidence intervals (CI) and odd ratios (OR) were estimated for each study and Cochran Q was used for testing heterogeneity. Statistical analysis was done using MIX 2.0 statistical software. The main findings of the study suggested that there is genetic vulnerability to BPD and gene-environment interaction plays a significant role in BPD genesis.
A neurotransmitter, low levels of serotonin is linked to cause of BPD. If an individual is having low serotonin levels, it can make them angry or severely depressed. Noradrenalin and dopamine also causes same effect as serotonin when the body experience low levels. Neurobiology (executive functioning) can also cause BPD. Soloff et al., (2014) conducted a study to investigate the suicidal behavior and its behavioral expression in BPD related to serotonergic function. For this study, 33 BPD patients and 27 controls participated who were assessed for Axis I and II with DSM-IV. Using standardized measures, impulsivity, depressed mood, temperament and aggression was measured. The binding potential of serotonin-2A receptors was studied through positron emission tomography. Logan graphical analysis was used for data analysis. The results of the study suggested that in BPD patients, aggression, antisocial PD, Cluster B co-morbidity and childhood trauma was associated with altanserin binding. In BPD females, BPND values predicted aggression and impulsivity, but not in males. This contributes to suicide and differences in region-specific binding of serotonin-2A receptor binding are associated with BPD diagnosis and suicidal behavior. This depicts that serotonin differential binding is associated with expression of BPD risk factors.
The three distinct parts of brain; hippocampus, amygdala and orbitofrontal cortex help in making decisions. Abnormality in each of these regulation areas can cause BPD. Hagenhoff et al., (2013) conducted a study to investigate the abnormality in domains of executive function like response inhibition and working memory to cognitive processes in BPD. For the study, 28 participants (BPD patients) were compared to controls (non-patients) on eight tasks. The tasks were embedded in reaction-time-decomposition approach for studying the impairments separately in different cognitive domains and its influence on executive functioning. The main findings illustrated that BPD patients performed tasks with accuracy as compared to control patients except for n-back tasks. The possible reason for this finding is that this task involves use of working memory and as a result, the error rates were high in BPD patients with shorter movement times as compared to controls. The processing was faster in BPD patients in regards to simplest tasks. Therefore, from this finding it can be concluded that BPD genesis is due to deficit in executive functioning domains.
According to Bornovalova et al., (2013) there is causal association between emotional, sexual and physical abuse in childhood and BPD traits. Many children who were victims of physical, emotional or sexual abuse during their childhood and exposure to fear may experience symptoms of BPD in their adulthood. Uninformed or poor parenting also acts as environmental risk factors for the development of BPD in children. When children are exposed to repeated abuse such as environmental trauma can develop BPD. In the study, a longitudinal twin design was used and the results depicted that there is a relationship between BPD traits and childhood abuse stemming from genetic influences. However, the results are not consistent with childhood abuse and BPD genesis as it is suggested that during adulthood, BPD traits are better accounted by heritable vulnerabilities.
A study conducted by Bohus et al., (2013) stated that there is a strong correlation between child sexual abuse and BPD development; however, causation is debated. The environment and family where a child grows greatly affect their personality as bad memories, unresolved fears and anger with disrupted thinking patterns can give lead to BPD. For the study, 74 female patients (childhood abuse with BPD) were randomized to 12-week residential treatment program of cognitive-behavioral therapy. The primary outcomes were reduction in BPD symptoms among treatment groups. From this finding, it is evident that childhood abuse is one of causes of post-traumatic stress disorder (PTSD) and BPD genesis. Although, childhood abuse is not the only reason for BPD development, however, emotional abuse is detrimental with trait vulnerabilities increasing the risk for BPD.
Role of Psychologists in helping patients with Borderline Personality disorder
Psychologists play an important role in the treatment of BPD as these specialists help in diagnosing and treating individuals suffering from this disorder. Psychologists help to understand the behavior of individuals ensuring their safety and management of problematic behaviors. They possess clinical skills that aid in helping them to deal effectively with their mental health issues of varying severity degrees. A combination of medication and counseling is effective along with psychotherapy where a psychologist use practical skills and learning strategies that might be helpful for the patient in relieving anger, anxiety, depression and relationships (Gunderson & Sabo, 2013).
From a psychological perspective, psychologists involve in a special psychotherapy called intense projection. In this method, psychologists are flexible as they consider negative attributions of the BPD patient instead of quick interpretation of the projection. Psychologists involve in psychological therapies where they engage with BPD patients and help them to manage their condition successfully. They also help BPD patients to recover from distressing symptoms so that they achieve psychosocial functioning to their best potential. They are focused on treating mental and emotional suffering in BPD patients with behavioral therapies and interventions (Gunderson & Sabo, 2013).
Another therapy is Schema-focused Therapy (SFT), an integrative therapeutic approach aimed at treating those patients who entrench self-identity and interpersonal difficulties in BPD. This theory emphasizes on the origin of psychological problems stemming from childhood and early maladaptive behavior during childhood contributes to abnormal cognitive and emotional patterns driven by schemas. BPD patients lack motivation and engagement and in such cases, psychologists help clients in enabling them to conceptualize and find explanations for their emotional distress, disturbing experiences and patterns in maladaptive behavior. Psychologists involve in emotional connectedness that can be helpful in making BPD patients feel valued, respected and convey care through empathetic communication (Sempertegui et al., 2014).
Patients with BPD have difficulty in developing relationships that can act as a significant barrier to treatment. In such cases, psychologists pay attention to the ascertaining situations so that the patient agrees and accepts the treatment plan through alliance building. Psychotherapeutic approaches can also be helpful in the development of working alliance for treatment plan. The two main approaches in psychotherapy are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). Psychologists who work with clients exhibiting BPD undertake this treatment. Mentalisation-based treatment can also be undertaken, although it is less common. Psychologists use variety of evidence-based practices like CBT, Interpersonal Therapy (IPT), Mindfulness, client-centered psychodynamic therapy and positive psychology (Linehan et al., 2015).
CBT targets thinking related or cognitive, action-related or behavioral aspects of a particular mental health condition. Psychologists help in reducing symptoms by changing the way they think or interpret situations as well as actions that they take in their daily life. In CBT, psychologists extensively use DBT useful in reducing BPD where DBT comprises of group and individual therapy sessions focusing on behavioral skills. Psychologists focus on concepts of paying attention or mindfulness to present emotion. DBT teaches skills that help individuals to control intense emotions, managing stress, reduction of self-destructive behavior and improvement in relationships. Psychologists provide a way to solve problem that is used to treat BPD through individual therapy sessions, phone coaching and skill training in groups (Goodman et al., 2014).
Mentalisation-based treatment is also a psychotherapy that focuses on CBT and psychodynamic approaches. MBT is talk therapy designed for BPD patients that enhance mentalization capacity that improves regulation and reduce the chances of self-harm, suicidality and in improving relationships. Through this procedure that includes individual treatment and group therapy, psychologist stimulate mentalizing and foster flexibility in their individual perspective taking. Psychologists encourage and regulate patient’s attachment with psychotherapist in creating attachment bonds with the group therapy (Bateman & Fonagy, 2013).
The above therapies are quite cost-effective and help to understand individual behavior and reason of conflict with others. Most importantly, MBT help in promoting one’s ability to cope effectively with conflict that is a necessary way to correct interpersonal problems. Concisely, psychologists help BPD patients by making them understand their psychological and emotional difficulties and make life changes so that they lead a quality life.
From the above discussion, it can be concluded that personal disorders exhibit abnormal behavior and require psychological interventions to deal with the conflicting situation. BPD is one of the personality disorders that exhibit key features of varying moods, behavior and self-image that result in impulsive problems and actions disrupting personal relationships. People with BPD many experience intense episodes of stress, anger, anxiety and depression with intense emotional trauma. The causes of BPD are a combination of genetic and environmental factors that play a role in the likelihood of BPD condition. Childhood trauma is another major cause of development of BPD where children exposed to trauma, neglect or abuse Psychologists play an important role in helping BPD patients through psychotherapy like DBT, MBT and CBT. Therefore, more research is required that focus on BPD with effective understanding of causes, treatment and nature of this disorder being the ultimate hope for future.
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