An Overview of Borderline Personality Disorder and Treatment
Rodney L. Mulhollem
Borderline Personality Disorder (BPD) is a disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) under the classification of Personality Disorders. It is considered a “serious psychiatric illness” (Kernberg & Michels, 2009) with its most common characteristics including “hypersensitivity to rejection and their fearful preoccupation with expected abandonment (Gunderson, 2011). An overview of theories of personality allows a better foundational understanding of Personality Disorders, particularly BPD (Feist & Feist, 2009, Mulhollem, 2011, Mulhollem, 2012). Etiology and pathology show childhood trauma having a high correlation and is believed to be one of the major factors (What is borderline personality disorder: [Ulster Edition], 2002). Additional disorders commonly treated with BPD can include: eating disorders, mood disorders, dissociated disorders, anxiety disorders, depressive disorders, and substance abuse. Disorders with commonalities include: histrionic personality disorder, schizotypal personality disorder, paranoid personality disorder, narcissistic personality disorder, antisocial personality disorder, dependent personality disorder, and identify problems. The most common type of psychotherapy currently used is Dialectical Behavior Therapy (Treating people with borderline personality disorder, 2010), but other common types include psychoanalytic, metallization-based treatment, BASE cognitive-affective treatment and schema therapy.
Keywords: borderline personality disorder (BPD), Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV-TR), schizotypal personality disorder (SPD), anorexia, bulimia, EDNOS, dialective behavior therapy, psychoanalysis, mentalization-based treatment, BASE cognitive-affective treatment, schema therapy, hypothalamus, amygdala, prefrontal cortex
An Overview of Borderline Personality Disorder
A General Definition and Epidemiologic Review of Borderline Personality Disorder
Borderline personality disorder is considered a “serious psychiatric illness” (Kernberg & Michels, 2009) with its most common characteristics including “hypersensitivity to rejection and their fearful preoccupation with expected abandonment” (Gunderson, 2011). Research shows this disorder is most common in females at 75% and overall affects 1% – 2% of American adults with a suicide rate of 8% – 10% of those diagnosed (Maddux & Winstead, 2008, What is borderline personality disorder, 2002, Gunderson, 2011, and Tait, 1997). Eight percent to 10% of people suffering from BPD have committed suicide (Gunderson, 2011). Although BPD is difficult to treat, positive outlooks of results are common (Altshuler, 2011). Studies show 25% of patients who are in full remission, are employed full time, with 40% receiving disability even after 10 years of remission (Gunderson, 2011).
Since the incorporation of BPD in the DSM-III, it has become the most frequently diagnosed personality disorder (Gunderson, 2011, Maddux & Winstead, 2008). The DSM-IV-TR considers BPD to be an Axis II cluster B disorder (Kemperg & Michel, 2009). Many associated disorders, such as eating disorders, mood disorders, dissociated disorders, anxiety disorders, depressive disorders, and substance abuse, are considered Axis I. However, many times, it is hard to separate these disorders from BPD. Anorexia, bulimia, and EDNOS, all eating disorders, are diagnosed 90% of the time with BPD (Influence Publications, 2010).
Drug therapy has only been proven to be constructive in treating attached symptoms to BPD including anxiety and depression. However, drug therapy has been unsuccessful in treating the core personality and trait problems (Treating borderline personality disorder, 2010). Successful psychotherapies include: psychodynamic psychotherapy, dialectic behavior therapy, mentalization-based therapy, BASE, and cognitive behavior therapy (CBT) (Altshuler, 2011, Beck, Freeman & Davis, 2003, Farrell, Shaw, Fuller & Silver, 2008, Gunderson, 2009, Kempburg & Michels, 2009, Leichsenring & Leibing, 2005, Oldman, 2007, Tait, 1997, Treating borderline personality disorder, 2010). Each of these therapies will be discussed in detail under the section treatment and therapies. In reference to all psychiatric inpatients, research shows 15% – 20% of these have BPD with 69% – 80% engaging in “suicidal behavior” and a 9% success rate of suicide (Treating borderline personality disorder, 2012).
History of Borderline Personality Disorder
Prior to 1970, Borderline Personality Disorder was originally considered a type of Schizophrenia. Gunderson (2009) in his article Borderline Personality: Ontogeny of a Diagnosis states that, “patients with neuroses were considered analyzable – and therefore treatable – and those with psychoses were considered not analyzable – and therefore untreatable” (p.530). Kernbert, in 1967, defined BPD as a person, who on one side had psychotic personality organization, yet on the other hand, had neurotic personality organization. He believed patients could be treated with psychoanalytic psychopathology. Afterwards, additional descriptions were added including: stable instability, “a desperate need to attach to others as transitional objects”, instability, distorted sense of oneself, as well as others, the fears of being abandoned by the one attached to, and distorted sense of self and others (Gunderson, 2009, p.531).
During the 1970’s, BPD reached the status of syndrome, as well as being included in the DSM-III as “borderline personality disorder”. Although clarity had already been established that BPD was not a type of Schizophrenia, it was not until the DSM-III incorporated a separate diagnosis of schizotypal personality disorder (SPD) that BPD was truly separated. The distinct difference between BPD and SPD is extreme emotions and interpersonal neediness being present, versus lack of emotion and neediness of a close person, respectively. Treatment during this time consisted primarily of psychoanalytic therapy, which also presented questionable results.
Borderline Personality Disorder diagnosis became increasingly popular during the 1980’s. Partially due to this popularity, the DSM-III was challenged due to poor validity of BPD. Prior to the 1980’s, limited studies and information were published on this disorder. Prior to 1980, less than 15 research reports were published compared to 275 published reports in that decade. Research supported a clear distinction of BPD from Schizophrenia and Depressive Disorder. Borderline Personality Disorder did not show any kind of consistency with any types of medication, which also supported a distinct difference from Depressive Disorders. In addition, research reported 70% of those diagnosed with BPD had a history of experiencing childhood physical or sexual abuse. One of the biggest findings in relationship to therapy for BPD was incorporating empathy and support.
During the 1990’s the DSM-IV was published. Although there were few changes from the previous version, one of the biggest discussions of possible change included the diagnostic integrity of BPD. The main question raised was, “Would a patient be borderline if she remitted from medication?” (Gunderson, 2009 p.533). Although there was poor success with medications, the previous decade brought into consideration the possibility of a client losing the diagnosis of BPD if medication was successful for remission. With BPD validity being, at best, suspect due to the lack of specific pharmacotherapy or neurobiological, these questions are warranted.
In reference to treatment styles, two new therapies were incorporated including dialectical behavior therapy and mentalization-based treatment. In general, dialectical behavior therapy was considered “radical behaviorist” (Gunderson, 2009, p.534). This therapy ran a span of one year and incorporated both group and individual therapy. The goal was to target patients’ suicidal and self-harm tendencies. Mentalization-based treatment incorporated partial hospitalization. The primary focus of this style of treatment was to:
Correct the borderline patient’s underlying handicaps in metalizing by adopting noninterpretive, not-knowing inquisitive stance intended to facilitate the accurate recognition and acceptance of one’s own and other’s mental states (including the therapists’s) (Gunderson, 2009, p. 534).
The decade of 2000 – 2009 brought two major findings in reference to BPD. First was the connection of heritability (Gunderson, 2009). Borderline personality disorder was found to run significantly higher in first generation family members. The second major finding presented an unexpectedly good prognosis (Gunderson, 2009). This combination of findings causes’ stronger belief, that BPS, is not fully environmentally influenced, but more a connection in a brain disease.
In addition to new findings, this decade also brought new techniques that better helped both the patients, as well as their family. Incorporating psychoeducation, family involvement, and a use of algorithm for medications, showed positive responses and outcomes to BPD. Kernsberg’s original psychoanalytic therapy was also revised. What was once viewed as a disorder that most therapists avoided, was not showing positive results, even to the point of the adoption of the nickname the “good prognosis diagnosis” (Gunderman, 2009, p.534).
The year 2005 was a landmark year for BPD as the U.S. House of Representatives voted unanimously to pass a resolution making May, borderline personality awareness month (Oldham, 2011). “Despites its prevalence, enormous public death costs, and the devastating toll it takes on individuals, families, and communities, (borderline personality disorder) only recently has begun to demand the attention it requires” (Gunderman, 2009, p.530, parenthesis included in the original text). This new demand of attention is allowing more research and studies to be conducted in reference to this disorder. In addition, in better helping appreciate this disorder, a foundational understanding of theories of personalities better allows a more educated and fuller definition of borderline personality disorder.
An Overview of What is Personality and Theories of Personality
Secular Personality Perspectives
To this day, understanding personality is still a heated debate amongst psychologists. The word “personality” originally comes from the Latin word “persna”. At that time, the theater was popular. Actors would wear different masks to portray a different emotion or appearance. The mask was referred to as personality (Feist and Feist, 2009). Even in today’s society, understanding personality is still a major question as Cheung, Vijver, and Leong (2011) presented theories with “three approaches to culture and personality” (p. 593).
Four of the most well know theories include psychodynamic theory, humanistic/existential theory, dispositional theory, and behavior theory (Mulhollem, 2011). Each theory has its own approach and perspective of the foundation of personality. Psychodynamic theories teach a foundation in social constructs. The main theorists and their theories includes: Carl Jung’s psychoanalytic which originated from Sigmund Freud, Melanie Klein’s objective relational theory, Karen Horney’s psychoanalytic theory, Erich From’s Humanistic Psychoanalysis, Harry Sullivan’s Interpersonal theory, and Erick Erickson’s Post-Freudian theory.
Humanistic/Existential theory of personality became popular after World War II by Rollo May’s existential theory. The two major factors of the existential theory are animal instincts and a need to become. Thus, human personality is a biological predisposition with an internally increased desire to become better. Additional theorists in this category of theories include Abraham Maslow with holistic-dynamic theory and Carl Rogers with personal centered theory.
Dispositional theories are best known by Gordon Allport with his dynamic organization theory. The idea that each individual has a distinct personality, which is influenced by common traits (culturally influenced) and personal disposition (a general neurological structure that is adaptive to surrounding), is the foundation of thought for Gordon’s theory (Mulhollem, 2011).
In addition to Allport, Eysenck also had a theory that could fall under the dispositional theories categories. Early in Eysenck’s theory, he believed personality consisted of two major factors; extroversion and neuroticism. He later changed this to three, adding psychoticism. Each of these three constructs was believed to have bipolar factors. He also believed that one fourth of personality was environmentally determined, with the remaining being genetic determinants.
Behavior theory’s foundation started with Burrihus Skinner and his famous classical conditioning and operant conditioning. Skinner believed personality was learned based upon environmental constructs. Albert Bandura is one of the most famous, current personality theorists that originally took the behavior approach. However, Bandura now combines behavior, environmental, and personal factors to personality with his social-cognitive theory.
Biblical Personality Perspectives
Larry Crabb presents a common, biblical perspective to personality. In his book, Effective Biblical Counseling, Crabb introduces five constructs to personality. Included in these constructs are: conscious mind, unconscious mind, basic directive, will, and emotions. Crabb points out that decisions a person makes are not based solely on one construct such as instinct or subconscious thoughts. People have the ability to make decisions.
Overview of Personalities
In reference to personality disorders, BPD in particular, understanding the major theories is important. Although each theory has its own uniqueness, there are commonalities as well. Most personality theories have found that much of personality is learned, whether through behavior, environmental, cognitive, or a combination of all the constructs. This is a key aspect with BPD. With the big debate in the psychiatric field focusing on genetic and biological aspects of BPD, it is important to note that most research pinpoints BPD as a psychological disease that is believed to originate from childhood and then be influenced by environmental constructs, such as child abuse (50%) and other unhealthy constructs (Gabbard, 2005, Maddux & Winstead, 2008, Tait, 1997, Treating borderline personality disorder, 2012, What is borderline personality disorder, Ulster Edition, 2002). This does not, however, rule out the possibility of a biological disorder versus a genetic disorder. From conception, a person can have a normal genetic endowment that is hardwired in the human brain. However, the biological factors of the developing human brain can change depending on environmental constructs such as nutrition, rearing practices, and other concepts. A biological disorder therefore, is incorrect and/or an unhealthy development of the biology of the brain itself.
Etiology and Pathology of Borderline Personality Disorder
There are some studies that support the possibility of a genetic factor disposition, as well as mood and impulse disorders (Maddux & Winstead, 2008). However, past trauma in childhood is a common link with almost all cases of BPD. These traumatic events can include, but are not limited to: physical, emotional, and sexual abuse, parental conflict, major loss, and parental neglect (Gunderson, 2009, Maddux & Winstead, 2008, Treating borderline personality disorder, 1997, What is borderline personality: Ulster Edition, 2002, Tait, 1997). Pathogenic mechanisms common with BPD include: abusive relationships with a significant other, intense personality, disruptive behavior, and inability to control anger. Possible contributors believed to add to or significantly increase instability in relationships include built up bitterness, anger, hostility, and the inability to regulate emotions.
Diagnostic Features and Close Associated Disorder of Borderline Personality Disorder
The DSM-IV-TR presents nine criteria for BPD. These include:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Identity disturbance: markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- 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)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Keeping disorders separated is important with any kind of diagnosis. Some of the disorders that can easily be mixed up with BPD include: histrionic personality disorder, schizotypal personality disorder, paranoid personality disorder, narcissistic personality disorder, antisocial personality disorder, dependent personality disorder, personality disorder change due to a general medical condition, and identify problems.
Histrionic personality disorders, like BPD, seek attention from a caregiver, as well as rapidly shifts emotions. Borderline personality disorder is distinguished as being different due to self-destructive behavior and anger within the liaison of the intimate relationship. The person with BPD also has personal feelings of emptiness and loneliness.
Schizotypal personality disorder and BPD, at one time, followed the same definition and were believed to be in the same group as Schizophrenia (Kernberg, & Michels, 2009). However, the DSM-IV made a distinguishable difference between the two as BPD is self-destructive and schizotypal is not. Both BPD and schizotypal personality disorder can have symptoms of, as the DSM-IV-TR states, “paranoid ideas or illusions… these symptoms are more transient, interpersonally reactive, and responsive to external structuring in BPD” (2000, p.709).
Two personality disorders that are also very similar to BPD are paranoid personality disorder and narcissistic personality disorder. These three disorders are similar, as all present angry reactions to minor stimuli. However, both paranoid and narcissistic personality disorder patients possess stability in self-image, self-destructiveness, impulsive reactions, and are not concerned with abandonment.
Antisocial personality disorder presents a manipulative behavior the same as BPD. However, the goal of this behavior is very different. With antisocial personality disorder the maladaptive behavior is for the person to gain something such as profit, power, or other material indulgences. With BPD the goal of this behavior is for gaining concern from the concierge or person that they are in an emotionally intimate relationship with.
Dependent personality disorder is a disorder that, like BPD, has a fear of abandonment. The distinguishing difference between dependent personality disorder and BPD is the reaction towards the concierge or caregiver. With dependent personality disorder the person responds to the caregiver with increased placation and submissive behavior. In addition, the fear of losing the caregiver results in the person with the disorder to seek out a replacement. With BPD, the reaction to the caregiver is fear of emotional emptiness, rage, and demands presented to the caregiver.
Treatment for Borderline Personality Disorder
Overview of Treatment
Borderline personality disorder is a disorder where the person commonly attaches to a significant other, at an unhealthy level. This can be an advantage and disadvantage when working with the patient. People with BPD attach themselves to another person on a deep level very quickly. This can allow a therapeutic relationship to be established rather rapidly. However, it is important to remember that these connections or relationships are also unstable, intense, and volatile (Maddux & Winstead, 2008). In considering this, two main considerations need to be focused on. First is the counselor’s possible vulnerability towards a client with this kind of disorder. And second, is the client’s vulnerability and unhealthy attachment towards the counselor. With consideration to BPD, The American Psychiatric Association guidelines suggest a combination of psychotherapy and medication, even though there are no controlled trials to compare this combination (Gabbard, 2005). Types of psychotherapy suggested by the American Psychiatric Association include psychoanalytic/psychodynamic therapy and dialectical behavior therapy (Gabbard, 2005).
A counselor’s goal is to help their client. Part of establishing a therapeutic relationship with a client is to create an environment of compassion and caring. This environment can be misinterpreted by the client where, in return, the client will try to establish a relationship with the counselor as if they are their significant other. Because BPD clients do not understand a healthy relationship, they will automatically try to connect with the counselor the only way they know how.
Because the patient connects to the counselor at this unhealthy level, suggestions for the counselor to consistently connect with a colleague to discuss possible reactions towards the client are suggested (Maddux and Winstead, 2008). Because the client’s understanding of a relationship consists of instability, intenseness, and volativeness, this will be common in the therapeutic sessions. Feelings of anger and frustration can be greater with this kind of patient. The desire to distance, reject, or abandon the client can also be a common feeling with a counselor.
On the other hand, the very opposite reaction is also possible. Counselors need to be careful not to connect too deeply with the patient. Romantic and sexual feelings, as well as, the want to be the client’s rescuer, can be felt by the counselor as the patient’s emotional connection can be very seductive.
The counseling session.
Taking into consideration the possible vulnerability of both the counselor and the client, Maddux and Winstead (2008) give some suggestions on how to structure the counseling session to better help avoid these possible reactions. Sessions are suggested to have six main focusses including (p.238):
- Strong therapeutic alliance
- Monitoring self-destructive behavior
- Monitoring suicidal behavior
- Validation of suffering and abusive experience of the patient
- Having the client take responsibilities for personal decisions
- Monitoring and addressing devaluation of previous therapists, as well as idealization of the current therapist
In addition, the American Psychiatric Association (2001) also presents guidelines for treatment of people with personality disorders. These guidelines are suggested for both psychotherapeutic, as well as pharmacologic. First and foremost, a thorough evaluation for suicidal ideology is priority number one. Secondly, it is important to watch for Axis I disorders that are common with borderline personality disorders. These Axis I disorders can include major depressive disorder, dissociative disorder, and substance disorders.
Overview of Treatment Types
Borderline personality disorder is a more recent disorder that has been separately diagnosed outside of general personality disorders and schizophrenia. Research shows the 1970’s as the first time this disorder was considered to be separated (Gunderson, 2009). As stated above, it was not until the incorporation of BPD to the DSM-III that this disorder was truly diagnosed and treated separately. In the 1970’s the common style of psychotherapy used with general personality disorders was psychoanalysis (Gunderson, 2009). Later in the early 1980’s a new style of therapy called dialective behavior therapy was adopted into the treatment of BPD, with mentalization-based treatment following eight years later (Gunderson, 2009). Most recently, two cognitive-affective treatment approaches called BASE and schema therapy have also been used.
Psychoanalysis therapy style.
Psychoanalysis therapy was the first type of therapy used with BPD clients. The goal of psychoanalysis therapy is to create a “theory of mind” or to recognize that others have a different mindset from one’s own, while helping the client to understand others’ perspectives based upon facial expressions, tone of voice, and other non-verbal communications. Finally, is to help the client understand others’ beliefs, feelings and motivations (Gabbard, 2005). Although this style of therapy was originally common and still used today, it has been found to average a 50% drop out rate before completion (Farrell, Shaw, Fuller & Silver, 2008).
Dialective behavior therapy.
Dialective behavior therapy is believed to be the most common type of therapy for people with BPD (Treating people with borderline personality disorder, 2010). Maddux and Winstead (2008) point out that dialective behavior therapy was designed from the Zen Buddhist principles of “overcoming suffering through acceptance” (p.238). A two fold focus using two styles of therapy situation (individual and group) are incorporated in dialective behavior therapy. First, the two fold focuses include identification of treatment goals with a focus on the client’s skill building, dealing in the here-and-now, and substantiation. Secondly, therapy is divided into both individual therapy and group therapy. With the individual therapy session, the counselor is viewed as a coach and the focus of this therapy is to stop “self-harm and suicidality” (Gunderson, 2009 and Gunderson, 2011). Group therapy allows the clients to work with others who suffer from the same disorder, as well as see others’ perspectives.
The foundational thinking of this therapy is based on the hypothesis that people with BPD come from a home that was lacking in emotional support or validation. As a result of this disciplinary style, the person grows up with the inability to control acting out or be prone to interpersonal conflicts. Therapy length is usually around two years.
Doctors Peter Fonagy and Anthony Bateman developed mentalization-based treatment with BPD as its primary focus. The theory behind this treatment concludes that people with BPD “suffer from difficulties in their ability to ‘mentalize’ or develop a mental picture of the emotions, feelings, or beliefs of themselves and others” (Treating borderline personality disorder, 2010). Originally this form of treatment was only used in a hospital setting. However, Fonagy and Bateman conducted a study in an outpatient setting against a clinical management program that consisted of supportive counseling and problem-solving behavior. Results presented a high level of success for both styles of treatment in regards to decreasing suicide attempts, hospitalization, and other types of crisis; however, mentalization-based treatment patients showed a significant improvement over the course of the clinical management program (Treating borderline personality disorder, 2010).
BASE cognitive-affective treatment approach.
BASE is a therapy style designed after the cognitive behavior therapy theory. The goal is to help the client learn to change their conscious cognitive processing and observable behaviors. The main goal of BASE is to focus on life threatening symptoms and quality of life. Farrell (2008) points out four main components of BASE including: “psychoeducation, distress management skills, emotional awareness work, and schema throughout.” BASE involved individual therapy, as well as group therapy and commonly met twice a week for group therapy and once a week for individual therapy.
BASE was designed with a dualistic approach with cognitive and affective interventions and limiting parenting approach. The goal of cognitive and affective intervention is to change the client’s original schema that is related to defectiveness, inability to trust, a sense of hopelessness, and maladaptive coping. With limiting reparenting, the counselor’s goal is for the client to experience acceptance, validation, and support (Farrell, Shaw, Fuller, and Silver, 2008), but also to create a family feeling within the group sessions.
After the group therapy has finalized, an anonymous program evaluation is completed. Farrell, Shaw, Fuller, and Silver (2008) concluded results from a group of program evaluations with the number one question being: “what was most helpful about the base program?” as “being in a group of people like me… for the first time (they) felt a sense of belonging… (were) not alone (and) not crazy” (parenthesis included in original text).
Dr. Jeffry Long started the focus of BPD with the hypothesis that when children do not receive base needs, such as safety, acceptance, and love, unhealthy ways of interpretation and interactions or schemas become systematic in the child’s life (Salters-Pedneault, 2008). Schema theory combines techniques and counseling theories from CBT, attachment theory, psychodynamic concepts, personal centered therapy, and emotional-focused therapy. His theory consist of four main goals including: helping the client to stop using maladaptive behavior, heal earlier manipulative schemas, learn to turn off old maladaptive schemes, and to get their emotional needs fulfilled from everyday life events. Although schema therapy is still new, it shows a low drop-out rate and has been shown to work well with people in relapse (Salters-Pedneault, 2008).
Borderline personality disorder has become increasingly popular over the last 40 years. Just as many styles of therapy have differences, they also have similarities. Most theorists agree that BPD results from abuse in childhood (Gunderson, 2009, Maddux & Winstead, 2008, Treating borderline personality disorder, 1997, What is borderline personality: Ulster Edition, 2002, Tait, 1997). Two newer primary factors of treatment include both independent and group therapy. Incorporating Roger’s personal centered theory also appears to be a key to helping this group.
All theories of personality link a level of exterior constructs in the involvement of construction of personality. Research also shows a high correlation of different kinds of child abuse and other childhood traumas with BPD (Gabbard, 2005, Maddux & Winstead, 2008, Tait, 1997, Treating borderline personality disorder, 2012, What is borderline personality disorder, Ulster Edition, 2002). Neuroscience has also proven that the brain develops during childhood through different methods including cognitive pruning (Carlson, 2011).
The Bible gives a number of references on raising children. Although the Bible is not a science or psychology book, it does, however, present different principles in regards to many aspects of life. Studies have found that children with higher self-esteems, healthy social interactions, and self-reliance usually came from families that consisted of nurturing, and caring (S Coopersmith, 1967; D. Baumrind, 1996 and J. Buri and others, 1988). This description is almost counter of emotional descriptions of people suffering from BPD. This could be helpful in understanding why psychiatry struggles to find key neuroscience abnormalities in the actual brain itself. However, because the brain continues to grow after birth, other factors can play a role in the maturing of the brain and thus, could have a significant impact on brain functioning. Although the brain’s original genetic signature may or may not have predispositions, this does not mean that through brain maturation, the biology of the brain could not have changed. If the brain is capable of learning constructs, such as patience and healthy communication skills, it would make sense that it could also learn dysfunctional constructs as well, even to the point of actual biological damage. This damage may or may not be actual sections of the brain but could also be the communication aspects or neuropath ways between sections of the brain.
From a Christian perspective, if brain maturation during childhood is strongly believed to have a significant role in brain development, then healthy child rearing would be an important construct in healthy and unhealthy human development. Proverbs 22:6 (NIV) encourages Christian parents to “train a child”. Looking at this interpretation from the original, train means to mentor. Ephesians 6:4 (NIV) states that fathers are not to “exasperate your children; instead, bring them up in the training and instruction of the Lord”. Since BPD is commonly associated with instability of emotions, particularly anger, this verse would make a lot of sense as helping a child keep at a general base level during brain maturation would be healthy. Since neuropsychology has proven that children around the age of two can get “locked” into emotional states, such as rage and crying (Carlson, 2011), pushing a child into these stages and dealing with this at an unhealthy level could be a key to the answer to BPD.
The neural connectors joining the lateral nucleus and basal nucleus (part of the Amygdala) to the ventromedial prefrontal cortex, Hypothalamus (through the central nucleus), and ventral striatum dorsomedial nucleus of thalamus (projects to prefrontal cortex) is believed to be play a major role in emotions (Carlson, 2011). Through MRI imaging, studies with women suffering from BPD show a possible malfunction in the amygdala and hippocampus (Driessen, Hermann, & Stahl, 2000). Making the connection of certain unhealthy constructs in childhood is a possible key to, not only understanding BPD, but therapy as well.
When considering the types of therapies that have shown a level of success with BPD, Roger’s personal centered theory appears to be a major key factor that separates original therapy styles with more current successful styles. In addition, group therapy appears to create a family type environment, as well as the counselor being viewed as a healthy parental figure.
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