IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

H.4

OTHER

BORDERLINE PERSONALITYDISORDER IN ADOLESCENTS
2015 Edition

Lionel Cailhol, Ludovic Gicquel & Jean-Philippe Raynaud

Lionel Cailhol MD, PhD
Consultant psychiatrist, Adult
Psychiatry, St Jerome Hospital,
St Jerome & Personality
Disorder Program, Institut
Universitaire de Santé Mentale
de Montréal, Québec, Canada
Conflict of interest: nonereported.

Ludovic Gicquel MD, PhD
Consultant child psychiatrist,
Child Psychiatry, Henri Laborit
Hospital Center, Poitiers &Professor of child psychiatry,
University of Poitiers, France
Conflict of interest: nonereported.

Jean-Philippe Raynaud MD

Janis Joplin
G A Faris & R M Faris (2001) Living in the Dead Zone: Janis Joplin and
Jim Morrison: Understanding Borderline Personality Disorders; Slade
Books.

Consultant child psychiatrist,
Child Psychiatry, University
Hospital Center, Toulouse &Professor of child psychiatry,Paul Sabatier University,
Toulouse, France
Conflict of interest: nonereported.

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2015. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Cailhol L, Gicquel L, Raynaud J-P. Borderline personality disorder. In Rey JM (ed), IACAPAP e-Textbook of Childand Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2015.

Borderline personality disorder H.4

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IACAPAP Textbook of Child and Adolescent Mental HealthBorderline personality disorder (BPD) is characterised by a pervasive andpersistent pattern of instability and impulsivity. BPD has enjoyed muchresearch attention for several decades both in terms of understanding it
and tackling it. Whilst the label of BPD is frequently used in clinic settings dealing
with teenagers its use in the young remains controversial. Nevertheless, many
believe that a set of converging arguments makes its use legitimate in this age
group (Miller et al, 2008).
From a didactic perspective, this chapter uses the concept of BPD as definedin DSM 5. However, readers need to be aware of the risks of this reductionism inrelation to other conceptualizations of the condition. In this chapter we highlightthe high frequency of the disorder in adult and adolescent populations and its
psychosocial consequences. A large section is dedicated to diagnosis and differential
diagnosis. The chapter finishes with a description of useful treatment strategies.

Prevalence

EPIDEMIOLOGY“Borderline patients havelong been to psychiatry
what psychiatry has been
to medicine − a subject ofpublic health significancethat is under-recognized,
undertreated, underfunded
and stigmatized by thelarger discipline. As withpsychiatry and medicine,
this is changing. New
knowledge, new attitudes,
and new resources promise
new hope for persons withborderline personality”(Kernberg & Michels, 2009)

Prevalence of BPD is estimated to be between 0.7% and 1.8% (Swartz etal, 1990; Torgersen, 2001). A general population study involving about 35,000
participants found a lifetime prevalence for BPD of 5.9% using the Alcohol Use
Disorder and Associated Disabilities Interview Schedule-DSM-IV version (Grant
et al, 1995). Within clinical populations, US data show a prevalence of 6.4% in
general medical samples (Gross et al, 2002), and from 10% to 23% in out-patients
suffering from mental health problems (Korzekwa et al, 2008; Swartz et al, 1990),
and 20% among psychiatric inpatients.
Data are scarce for children and adolescents and samples are much smaller.
A French study found a high prevalence of BPD in adolescents (10% in boys and
18% in girls) as measured by the DIB-R (Diagnostic Interview for Borderlines –Revised) adapted for adolescents (Chabrol et al, 2001a). A Chinese study reported
a more modest prevalence of 2% (Leung & Leung, 2009).
Gender and culture
Currently, prevalence in the general population is considered to be similar
for both genders (Leichsenring et al, 2011). In clinical populations, females
represent three quarters of all patients. Some experts hypothesize this may be due
to men’s difficulty accessing care, particularly psychotherapy (Goodman et al,2010). This effect can also be seen in adolescents (Cailhol et al, 2013). This is not
a problem specific to BPD but found in other mental disorders also (O’Loughlin
et al, 2011).
The concept of BPD originated in Western taxonomies (European and then
North American). However, even in its definition, it runs into cultural difficulties.
For example, the threshold for emotional lability can be different in Latin andNordic countries; dissociative symptoms are not interpreted in the same way fromone continent to the next. So, thresholds set by clinicians for each of the criteria
may differ depending on their and their patients’ culture. To our knowledge, thesymptomatic expression of BDP in adolescence according to culture has barely
been explored.

Borderline personality disorder H.4••

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IACAPAP Textbook of Child and Adolescent Mental HealthThrough the International Classification of Diseases, the World HealthOrganisation has promoted the use of this diagnosis throughout the world, in
addition to validating an international tool for its diagnosis (Loranger et al, 1994).
Nevertheless, the North American model (exemplified by the Diagnostic andStatistical Manual of Mental Disorders, DSM) dominates in research publications(Maffei, 2006). Scientists from different regions of the world continue to use DSM
diagnostic criteria as shown by recent publications, which highlights the issueof diagnosis according to culture (Rossier & Rigozzi, 2008; Wong et al, 2010).
Migration does not seem to increase the risk of BPD (Pascual et al, 2008).
Burden of illness
It was estimated that BPD costs up to 17,000€ a year per patient in
direct and indirect costs in the Netherlands (van Asselt et al, 2007). This includes
treatment, particularly hospitalisation, sick leave and loss of productivity. If
prevalence in the general population is considered, costs would be substantial.
Nevertheless, this European data cannot be extrapolated to the rest of the world as
it reflects the medical-economic context in Western countries.
The consequences of BPD for the people around the sufferer depend on
their vulnerability to the behaviour and demands of BPD individuals. Familiesof adolescents in particular need to tackle their child’s demands for autonomy
whilst protecting the youth and learn to manage worries related to risk-taking
behaviour. This can cause considerable stress (Fruzzetti et al, 2005; Gerull et al,2008; Hoffman et al, 2005).

The concept of BPD has
become part of culturalrepresentations of Western
populations: it has emergedin Facebook® and inartistic works (i.e., the book
"Borderline" by Marie-Sissi
Labrèche, or the film "GirlInterrupted" directed byJames Mangold − based on
Susanna Kaysen’s accountof her 18-month stay in amental hospital).

Apart from physical complications ensuing from self-harming behaviours,
BPD patients are exposed to risks due to their impulsivity, resulting mostly in
accidents, substance misuse, and sexually transmitted diseases (Sansone et al,
1996, 2000a, 2000b, 2001). Finally, instability in emotional and inter-personal
relationships leads to communication problems between parents and children(Guedeney et al, 2008; Hobson et al, 2005, 2009; Newman et al, 2007).
Observational studies of mothers with BPD concerning attitudes towards theirinfants and young children show less availability, poorer organisation of behaviours
and mood, and lower expectations of positive interactions. These mothers aredescribed more often as overprotective/intrusive and less as demonstrative/sensitive(Abela et al, 2005; McClellan & Hamilton, 2006; Newman et al, 2007). Theirchildren experience higher rates of parental separation and loss of employment
compared to those whose mothers suffer from depression or from other personality
disorders.
The psychological development of children with BPD mothers is affected
and they tend to withdraw from their surroundings (Abela et al, 2005; McClellan& Hamilton, 2006). These children are less attentive, less interested or eager tointeract with their mothers, and demonstrate a more disorganised attachment in
the Strange Situation Test (Abela et al, 2005). Children of mothers with BPD
show high rates of suicidal thoughts (25%); the risk of children suffering fromdepression is seven times higher if the mother has a double diagnosis of depression
and BPD (Bradley et al, 2005).

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AGE OF ONSET AND COURSE
DSM-5 recommends that a diagnosis of BPD should not be made before
the age of 18 years. In practice diagnosis is made earlier when symptoms are clear
and persistent.
Follow up studies show that remission is common − 74% after 6 years;
88% after 10 years (Zanarini et al, 2003a; 2006) − questioning the notion that thisis a chronic, unremitting condition. There appears to be two clusters of symptoms,
one (characterised by anger and feelings of abandonment) tends to be stable orpersistent while the other (characterised by self-harm and suicide attempts) is
unstable or less persistent. It should be clarified that in most cases remission actuallymeans a reduction in the number of symptoms below the diagnostic threshold andnot necessarily the complete resolution of the disorder (Shea et al, 2002).
The risk of death by suicide in BPD patients is estimated at between 4%
and 10%, one of the highest of any psychiatric illness. Suicide risk is higher inthe event of co-occurrence with a mood disorder or substance abuse and withincreasing number of suicide attempts (Paris, 2002). Suicide seems to occur late in
the course of the disorder, around 30-37 years of age, and rarely during treatment(Paris, 2002).
These individuals’ functioning is significantly impaired (e.g., Global
Assessment of Functioning scale scores around 50), with frequent job losses,
unstable relationships, and history of rape (Zittel Conklin & Westen, 2005).
Functioning is more impaired than in other personality disorders and depression(Skodol et al, 2002; Zanarini et al, 2005).
Remission is also high when diagnosis is made during adolescence (Biskin
et al, 2011); the peak frequency of BPD symptoms appears to be at 14 years of age(Chabrol et al, 2001b). However, in spite of the high remission rate, the presenceof BPD in adolescence is far from harmless. Apart from the already mentioned
complications inherent to the disorder, diagnosis increases the risk of othernegative outcomes. For example, 80% of teenagers with BPD will suffer from apersonality disorder in adulthood, even though BPD will occur in only 16% ofthem (Deschamps & Vreugdenhil, 2008).

Click on the picture to view
Emily’s history (10:43)

CAUSES AND RISK FACTORSThe cause of BPD is unknown, however, several explanatory hypotheses
can be found in the medical literature. The most widely accepted theories are
psychogenic, mostly following psychoanalytic thinking. One of the initial
explanations was based on the object-relations theory, particularly championed
by Otto Kernberg (Clarkin et al, 2006). More recently, John Bowlby’s attachment
theory provided further insights on the possible mechanisms underlining BPD(Bateman & Fonagy, 2004), while another view emphasizes the importance ofemotional dysregulation (Linehan, 1993). Finally, cognitive theories highlight
dysfunctional thinking patterns learnt in childhood, which are maintained in
adulthood (Young, 1999). All these theories stress the importance of individuals’
emotional development, scarred by trauma and emotional deficits, subsequent toa failure to adapt the environment to a child’s needs.

Borderline personality disorder H.4

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IACAPAP Textbook of Child and Adolescent Mental HealthBorn in 1926; died in 1962in tragic circumstances. She
was an American actressthat became a major sex
symbol. She grew up witha mentally unstable mother
who was financially unable
to care for her. She was two
years below the legal age
when she married her firsthusband. She took numerous
overdoses and had many
passionate relationships.
She underwent several
psychological treatments andpsychiatric hospitalizations.

At an epidemiological level, retrospective research has shown a significant
prevalence of childhood trauma, sexual abuse, prolonged separations and neglect
among patients with BPD (Zanarini et al, 1997). However, these experiences
cannot be construed as direct causes of BPD. Although childhood trauma is highin this population, it is not present in all cases and, when it does exist, it notalways causes a BPD. Nevertheless, the high occurrence of early trauma has beenused to support an alternative model − as a traumatic disorder resulting fromchronic childhood trauma (Golier et al, 2003). Without completely explaining
the disorder, repeated childhood trauma seems to be a frequent element in BPD
populations and among patients with PTSD. It should be highlighted also thatabout half the patients with BPD also meet the criteria for PTSD.
Early maternal separation is associated with both BPD and persistence of
BPD symptoms over time (Crawford et al, 2009). Finally, BPD also has a genetic
component; heritability has been estimated at 47 % (Livesley, 1998). As in almost
all psychiatric disorders, inheritance in BPD is polygenic. Further, interaction
between genes and environment, as described in the preceding paragraphs, makes
it difficult to interpret these data (Steele & Siever, 2010).

DIAGNOSIS
Clinical symptoms
In an effort to improve diagnostic reliability, DSM-III (American
Psychiatric Association, 1981) introduced a multi-axial system, placed personality
disorders on a different axis, Axis II − alongside intelectual disability − and described
BPD as a separate diagnosis. DSM-5 (American Psychiatric Association, 2013)

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IACAPAP Textbook of Child and Adolescent Mental Health

Table H.4.1

Criteria for and dimensions of borderline personality disorderDSM-5 CRITERIADIMENSION

6-

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7-

Chronic feelings of emptiness

8-

Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights)

3-

Identity disturbance: markedly and persistently unstable self-image or sense of self.

9-

Transient, stress-related paranoid ideation or severe dissociative symptoms

4-

Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating).

5-

Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

1-

Frantic efforts to avoid real or imagined abandonment.

2-

A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.

Emotional

Cognitive

Impulsive

Interpersonal

reversed this decision abandoning the multiaxial approach. According to DSM5, the main characteristics of BPD are instability and impulsivity, as described
Table H.4.1. To make a diagnosis of BPD according to DSM-5, the presence offive or more of the symptoms listed in Table H.4.1 is required. Also, the patternof behaviour must be enduring, inflexible and pervasive across a broad range of
personal and social situations, and must cause significant impairment or distress.
The International Classification of Diseases, 10th edition (ICD-10)(World Health Organization, 2000), places BPD within the “emotionally
labile personalities” and includes an impulsive sub-type (Table H.4.2). Bothclassifications require that the behaviour pattern be pervasive, begin in adolescenceor early adulthood, and cause significant impairment in functioning.
Subtypes
DSM-5 does not distinguish subtypes within BPD. Subtypes may be
defined by the comorbidities. Nevertheless, some researchers propose two subtypes:

Self-cutting is common in people with BPD

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Table H.4.2 ICD-10 description of emotionally labile personality
F60.3 Emotionally unstable (borderline) personality disorder

A personality disorder in which there is a marked tendency to act impulsively without consideration of theconsequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts
of intense anger may often lead to violence or "behavioural explosions"; these are easily precipitatedwhen impulsive acts are criticized or thwarted by others.
Two variants of this personality disorder are specified, and both share this general theme of impulsiveness andlack of self-control.
Impulsive type:

The predominant characteristics are emotional instability and lack of impulse control. Outbursts ofviolence or threatening behaviour are common, particularly in response to criticism by others.
Borderline type:

Several of the characteristics of emotional instability are present; in addition, the patient's own self-image,aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic
feelings of emptiness. A liability to become involved in intense and unstable relationships may cause
repeated emotional crises and may be associated with excessive efforts to avoid abandonment and aseries of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).

dependent and impulsive. The former would be characterised by ambivalent,
unstable relationships; the latter by a pattern of impulsive acts in multiple areas,
including breaking the law. ICD-10, on the contrary, describes an impulsive and aborderline subtype (see Table H.4.2).
Presenting symptoms
It is rare for patients to go to see their doctor complaining of BPD, eventhough publicity about the disorder in the media and Internet has started to makepeople more aware of this illness. Presentation is often prompted by anotherproblem (i.e., substance misuse, mood swings), problematic behaviour (i.e.,
abnormal eating, self-harm), or relationship problems. While self-harm decreases
over time, it is a particularly useful identifying symptom in adolescence.
From a categorical to a dimensional concept of BPD
If we were to follow the DSM criteria to the letter, BPD would only bediagnosed in adults (Gicquel et al, 2011). However, some clinicians consider
that this diagnosis can be made in adolescents with the proviso of accepting alower predictive power than for adults (Bondurant et al, 2004). Aware of theshortcomings of current taxonomies, there has been a trend towards a dimensional
conceptualization of the disorder. Table H.4.1 shows the DSM-5 diagnostic criteria
and the four dimensions that have emerged from these criteria.
Within this framework, personality disorders would lie at the extreme endof personality traits, ranging from normal to pathological. Research by Zanarini etal (2007) highlight the stability of the disorder, the average duration of symptoms
and the potential for remission and recovery, this is summarised in Table H.4.3.

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SYMPTOMSAVERAGE DURATION

•
•
•
•

Para-psychotic manifestations
Risky sexual behaviour
Regression linked to treatment
Counter-transference problems, “special” treatment
relations0 – 2 years

•
•
•
•
•

Abuse, dependence on psychoactive substances
Self-harm
Repeated suicide attempts
Demandingness
Severe identity disorder2 – 4 years

•
•
•
•
•
•

Stormy relationships
Manipulation, sadism, devaluation
Emotional instability
Unusual perceptual experiences, strange thoughts
Feelings of abandonment, annihilation, collapse
Non hallucinatory paranoid experiences

•
•
•
•
•
•
•

Major depressive episode, chronic depression
Chronic feelings of despair, guilt
Chronic anxiety
Overall impulsivity
Cannot bear to be alone
Conflict around dependence on care
Dependency, masochism••

Chronic anger, frequent bouts of anger
Chronic feeling of solitude, emptiness

Acute symptoms

Table H.4.3 Evolution of borderline personality disorder symptoms over time.

6 – 8 years

Temperamental symptoms

4 – 6 years

8 – 10 years

It remains to be seen whether some adolescents experience “borderline
moments” and others show marginal functioning or organisation. It is a fact that
not all marginal adolescents develop BPD. This raises the question of the futureof adolescents with marginal functioning. In this line, Bornovalova et al (2009)highlight the risk of diagnostic “labelling” of personality disorders in adolescents,
a population undergoing many developmental changes.

DIFFERENTIAL DIAGNOSIS
Comorbidity
An international French-speaking study in adolescents led by the European
Research Network on BPD (EURNET-BPD), found that BPD is very oftencomorbid with depression (71.4%), anorexia (40.2%), bulimia (32.9%), alcoholabuse (23.5%) and substance abuse (8.2%). In particular, comorbid ADHD
may be an indicator of severity (Speranza et al, 2011). These data are similar tothat reported for adults (Zanarini et al, 1998a). Data from the EURNET-BPD

Borderline personality disorder H.4

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IACAPAP Textbook of Child and Adolescent Mental Healthgroup found that the highest comorbidity with other personality disorders wasfor antisocial (22.3%) and avoidant (21.2%), also similar to those found in adults(Zanarini et al, 1998b); there are gender differences in both adolescents and adults
with a predominance of comorbid antisocial personality among boys.
Psychometric evaluation
Many instruments exist to evaluate personality disorders in adults. These
are some of the most widely used:•

SIDP-IV (Structured Interview for the Diagnosis of DSM-IV Personality
Disorders) (Stangl et al, 1985). The DSM-IV version is widely usedinternationally (Pföhl et al, 1995) and has been used for adolescents(Chabrol et al, 2002)•

SCID-II (Structured Clinical Interview for DSM-IV) (First et al, 1997),
complimenting SCID-I, which is used to diagnose Axis I disorders•

The IPDE (International Personality Disorders Examination; (Loranger
et al, 1994) is a semi-structured interview that generates personality
disorder diagnoses according to both ICD-10 and DSM-IV•

DIB-R (Diagnostic Interview for Borderline-Revised; Zanarini et al,1990) is a semi-structured interview with 129 items. Although it does
not diagnose DSM-IV BPD, it has satisfactory convergent validity with
DSM-IV•CAPA (Child and Adolescent Psychiatric Assessment) may also be
relevant for BPD diagnosis (Renou et al, 2004).

•

There are also self-report questionnaires that can be useful as screening
instruments, such as the MSI-BPD (McLean Screening Instrumentfor BPD) and the PDQ-4+ (Personality Diagnostic Questionnaire)(Zanarini et al, 2003b, Hyler et al, 1989).

TREATMENT
Several treatment guidelines for BPD are available, i.e., by the American
Psychiatric Association (2001) and by the National Institute for Health andClinical Excellence (NICE, 2009). Most have few recommendations specificallyfor adolescents.
Aims
Setting a treatment plan and treatment goals is the first step in management,
which will be influenced by the patient's instability. In practice, this will entail
monitoring the patient's progress, working from a crisis management approach todeal with crises and to manage harmful behaviour, progressing towards long term
work on the personality aspects. At each stage a therapeutic contract is set up afterneeds and reasons for change are determined. Individualised aims would follow ahierarchy that needs to be explained to the adolescent. For example, reducing therisk of death would take precedence over treating symptoms or improving qualityof life. Furthermore, adult caregivers need to be involved and assist in management(e.g., by removing toxic substances).

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IACAPAP Textbook of Child and Adolescent Mental HealthCare framework
Treatment of adolescents with BPD should usually be delivered as
outpatient. A sequential and eclectic approach offers a pragmatic solution to theclinical diversity and the natural evolution of the disorder (Gunderson, 2001).
Determining the care framework thereby involves different aspects:
•
•
•
•
•
•
•

Risk evaluation
Mental state
Level of psychosocial functioning
Aims and motivation of the patient
Social environment
Comorbidity andPredominant symptoms.

Click on the picture toaccess the NICE guideline

In practice, inpatient treatment can be considered for cases with severecomorbidity (e.g., addictions, severe depression) and when crisis management or
day hospitalisation are unable to contain the patient. The short term managementof suicide risk by admission to hospital is undermined by the absence of effectivenessdata and the risk of patients’ regression.
As outpatient, treatment can be by an individual clinician, as a partnership
between a treating psychiatrist and a psychotherapist, or in a day hospital setting,if available. It is helpful if psychotherapy and medication prescription are provided
by different clinicians. Finally, the school can also play a role in the management ofadolescents with BPD by offering stability and a place where they can build theiridentity and relationships, essential ingredients for these patients’ improvement.
Biological treatments
According to the NICE (2009) guidance, drug treatment should not be
used specifically for borderline personality disorder or for the individual symptoms
or behaviours associated with the condition (for example, repeated self-harm,marked emotional instability, risk-taking behaviour, and transient psychotic
symptoms). However, comorbid disorders may require medication treatment. In
addition, side effect profiles, compliance, and the risk of incorrect usage limit theusefulness of medication. Finally, to our knowledge, no drug has been approved for
BPD treatment for adults or adolescents. These precautions highlight the limited
role of psychotropic drugs in the overall care of BPD.
Apart from expert opinion, several meta-analyses provide guidance (Binkset al, 2006a; Ingenhoven & Duivenvoorden, 2011; Mercer, 2007; Nose et al,
2006; Rinne & Ingenhoven, 2007; Stoffers et al, 2010). The substances studied
include neuroleptics, antidepressants, omega-3 fatty acids, and anticonvulsants.
However, the short duration of the trials, the low number of studies, the highnumber of participants lost to follow up, the absence of comparative studies, andrestrictive inclusion criteria in most of the controlled trials limit the interpretationof the results.
As far as benzodiazepines are concerned, they can be used in one-off
situations but have considerable risk for addiction or for disinhibiting these patients(American Psychiatric Association, 2001). In general, sedative treatments should
not be prescribed for more than a week to deal with a crisis (National InstituteBorderline personality disorder H.4

Click on the picture toaccess the National Healthand Medical ResearchCouncil of Australia’s 2012
Clinical Practice Guideline
for the Management of
Borderline Personality
Disorder. This guideline
contains a considerable
amount of information
about adolescents.

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IACAPAP Textbook of Child and Adolescent Mental Healthfor Health and Clinical Excellence, 2009). This explains the need for intensive
monitoring and regular treatment review to identify unhelpful medications andtheir cautious and gradual removal. Antipsychotic drugs, in particular, should not
be used for medium- or long-term treatment (National Institute for Health andClinical Excellence, 2009). However, in the short-term, antipsychotics can havebeneficial effects on cognitive-perceptual symptoms, anger, and mood lability(Ingenhoven & Duivenvoorden, 2011).

Tips for treatment•

Support. Given thehigh demands thesepatients place on
clinicians, working in ateam makes it easier
to manage them. If ateam is not available,
regular supervision oraccess to colleagues
for advice is highly
recommended.

•

Continuity.
Continuity of careover time is essential
since treatment usually
lasts years rather thanweeks or months.
Building a therapeutic
relationship requires
reliability from theprofessionals providing
care.

•

Clear framework.
Both clinician andpatients must have aclear understandingof their work, its limits
and how they will go
about it.

•Responsibility.
While patients’behaviour and evendiagnosis encouragesystems (family,
therapists, institutions)to take responsibility
away from patients, it
is useful to rememberthat increasing theiremotional control
involves graduallyaccepting more
responsibility.

Psychotherapy
Psychotherapies used to treat BPD share many aspects. For example,
most highlight the importance of drawing a care contract at the start of therapy,
including ways of dealing with risk situations, particularly suicidal crises, andcontact between sessions (e.g., telephone), which must be agreed upon.
When considering psychological treatment for a person with BPD,
clinicians should take into account (National Institute for Health and ClinicalExcellence, 2009):• Patients’ choice and preference• Degree of impairment and severity• Patients’ willingness to engage with therapy and their motivation tochange• Patients’ ability to remain within the boundaries of a therapeutic
relationship• The availability of personal and professional support.
A variety of psychotherapy approaches have been used for BPD including
individual, group, and crisis treatments. There is no evidence to suggest that one
specific form of psychotherapy is more effective than another (Binks et al, 2006b;
Leichsenring & Leibing, 2003; Leichsenring et al, 2011).
Schema Focused Therapy (SFT) seeks to extend CBT principles to thetreatment of personality disorders by placing greater emphasis on the therapeutic
relationship, affect and mood states, lifelong coping styles (e.g., avoidance andovercompensation), entrenched core themes (i.e., maladaptive schemas, whichdevelop when specific, core childhood needs are not met), and more discussion ofchildhood experiences and developmental processes. One study found that after
three years of treatment SFT was more effective than a psychodynamically basedtransference-focused psychotherapy for participants with BPD (Giesen-Bloo et al,2006).
Among the group treatments, the Systems Training for Emotional
Predictability and Problem Solving (STEPPS; Blum et al, 2002, Blum et al,2008) is based on a systems approach. The program includes two phases: a 20-weekbasic skills group, and a one-year, twice-monthly advanced group program. In thismodel, BPD is understood as a disorder of emotion and behaviour regulation. The
goal is to provide the person with BPD, other professionals treating them, andclose friends and family with a common language to communicate clearly about
the disorder and the skills used to manage it. This helps to avoid “splitting” (aprimitive defence mechanism in which the person externalizes internal conflicts byseeking to draw others around them into taking sides or being “good” or “bad”).

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Mentalization-Based Treatment (MBT)MBT is a psychodynamic psychotherapeutic program based on
attachment theory. It assumes that disorganised attachment promotes
a failure in the capacity of mentalization. MBT was first designed for
BPD patients. It is currently used for broader indications such as otherpersonality disorders or depression. The treatment consists on grouptherapy combined with individual therapy, both on a weekly basis, usuallyin the framework of a day hospital. It aims to enhance the patient’s capacity
to represent their own and others’ feelings accurately in emotionallychallenging situations. The main aims of MBT are to improve affectregulation and behavioural control. It allows patients to achieve their life
goals and develop more intimate and gratifying relationships.
Unlike in other psychodynamic approaches, the focus is not ontransference or past relationships, the aim is not to develop biographicalinsight but to recover the capacity of metallization. Therapists seek topromote a secure attachment bond between members of the group andbetween clients and therapists. This safe attachment provides a relationshipcontext in which to explore one’s mind and those of others.

Figure H.4.1: Comparative summary of different psychotherapies for the treatment ofborderline personality disorder.

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Click on the picture toaccess a New York Times
article on Marcia Linehan’s
struggle with her BPD
and the birth of Dialectical
Behavior Therapy

Mentalization Based Treatment (MBT) is a psychodynamic therapy
developed by Bateman and Fonagy (1999, 2004). “Mentalization” in this modelmeans the ability to differentiate and separate out one’s own thoughts and feelings
from those around us. The various aspects of mentalization are emphasized snd are
reinforced and practiced within a supportive psychotherapy setting. Because theapproach is psychodynamic, therapy tends to be less directive than in CBT.
Transference Focused Psychotherapy (TFP) is another psychodynamic
approach. TFP assumes there is a psychological structure that underlies the specificsymptoms of BPD. In such a psychological organization, thoughts and feelings
about self and others are split into dichotomous experiences of good or bad, blackor white, all or nothing. Since these either/or states determine the nature of thepatient’s perceptions, splitting leads to chaotic interpersonal relations, impulsive
self-destructive behaviours, and other symptoms of BPD. Treatment – consistingof twice weekly individual psychotherapy sessions – focuses on the transference
because it is believed that patients live out their predominant object relations dyads
in the transference (Clarkin et al, 2007).
In adolescents, Cognitive Analytic Therapy (CAT; Ryle, 2004, Ryle &Beard, 1993) demonstrated similar efficacy to a “manualised good clinical care”
treatment (Chanen et al, 2008). The CAT is a relatively brief treatment lasting 16
to 24 sessions.
It remains to be seen whether the gap between the number of treatments
and their availability in clinical practice widens or narrows. Lack of support forthese treatments at the front line may dishearten clinicians and lead them to ignore
or reject psychotherapy options. It is important to remember at this point that acompetently delivered treatment – meaning one that adheres to recommendations

Borderline personality disorder H.4

Click on the image toaccess information about
mentalisation based therapy

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IACAPAP Textbook of Child and Adolescent Mental Health– seems to produce results that are as good as those obtained with more complex
treatments (McMain, 2007).
Other treatments
Many teams are working all over the world trying to develop shorter
treatments that cost less and are more acceptable to patients than the traditional
long term psychotherapeutic ones (see Figure H.4.1). Condensed forms of longterm treatment may be able to offer help to a maximum number of patients. In
the same vein, psycho-education and consumer groups may provide valuable
alternatives at a lower cost. Setting up a permanent hotline to offer support indifficult times, perhaps at the level of a health region or even a country, may be
useful. Finally, prevention services may develop strategies to help parents with aview to reducing the incidence of these disorders in children.

Click on the picture above
to access the TARA websitethat provides information
for sufferers and families(English).
Click on the picture below
to access a website thatprovides information in
French.

CONCLUSION
BPD is a disorder that can be found in adolescents; it has the range ofsymptoms and problems found in adults. However, BPD is even more changeable
in this age group. A psychotherapeutic approach would result in a reduction ofsymptoms in many cases. The challenge is to detect the patients that are most at
risk of developing severe disorders and offer them the most comprehensive careavailable.

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