606 CHAPTER 13
Targeting Neurological Factors: Medication
Various medications may be prescribed to people with borderline personality disor-
der for a comorbid Axis I disorder or to target certain symptoms, including quickly
changing moods, anxiety, impulsive behavior, and psychotic symptoms (Lieb et al.,
2004). A review of studies suggests that for people with borderline personality dis-
order, SSRIs—compared to a placebo—may diminish symptoms of emotional labil-
ity and anxiety and help with anger management. In addition, antipsychotics can
alleviate psychotic symptoms, and mood stabilizers may help some symptoms (Binks
et al., 2006a). Although medications may reduce the intensity of some symptoms,
psychopharmacology should not be the only form of treatment for people with bor-
derline personality disorder (Koenigsberg, Woo-Ming, & Siever, 2007).Targeting Psychological Factors: Dialectical Behavior Therapy
Marsha Linehan, a pioneer in the treatment of borderline personality disorder, ini-
tially treated such patients with CBT, which focuses on identifying and correcting
faulty beliefs (Linehan, 1993; Beck et al., 2003). Unfortunately, this led some people
to drop out of treatment because they felt that the focus on changing faulty beliefs
implicitly criticized and invalidated them (Dimeff & Linehan, 2001). Linehan (1993)
developed a new treatment for people with borderline personality disorder. From
CBT she incorporated skill development and cognitive restructuring. In addition, in
her new therapy she underscored the importance of a warm and collaborative bond
between patient and therapist; to this mix she addded the following elements:- An emphasis on validating the patient’s experience. That is, the patient’s thoughts,
feelings, and behaviors in a given situation make sense in the context of his or her
life, past experiences, and strengths and weaknesses. - A Zen Buddhist approach. Patients should see, and then without judgment, ac-
cept any painful realities of their lives. Patients are encouraged to “let go” of
emotional attachments that cause them suffering. Mindfulness, or nonjudgmental
awareness, is the goal.
-. A dialectics component Dialecticsrefers to a synthesis of opposing elements; in
this context, it refers to the patient’s coming to accept the situation and aspects of
it that he or she does not feel able to change (e.g., validating his or her experience)
while at the same time recognizing that in order to feel better, change must occur
(Robins, Ivanoff, & Linehan, 2001).
Linehan called this treatment dialectical behavior therapy (DBT), and it entails
both group and individual therapy. The initial priority of DBT is to reduce self-
harming behaviors such as burning or cutting oneself. As these behaviors are re-
duced, treatment focuses on other behaviors that interfere with therapy and with
the quality of life, and also helps patients develop skills to change what can be
changed (e.g., their own behavior rather than the behavior of other people such as
family members). In addition, treatment helps patients to recognize aspects of their
lives that they can’t change: For instance, although patients can learn to change the
way they behave toward their parents, they can’t change the way their parents be-
have toward them. Treatment lasts about 1 year.
Researchers have conducted many studies to evaluate DBT over the years and
have noted impressive results for patients with borderline personality disorder: DBT
does decrease suicidal thoughts and behaviors (Binks et al., 2006b; Bohus et al.,
2000, 2004; Linehan et al., 2006; Shearin & Linehan, 1994) and has lower dropout
and hospitalization rates than other specialized treatments for this disorder (Linehan
et al., 2006). DBT benefi ts people with borderline personality disorder and comor-
bid substance abuse (Linehan et al., 1999; van den Bosch et al., 2005), and it has
been adapted to treat people with Axis I disorders that involve impulsive symptoms,
such as bulimia (Palmer et al., 2003; Telch, Agras, & Linehan, 2001).
Intensive (and manual-based) forms of psychodynamically oriented psychother-
apy have also been shown to be effective for patients with borderline personality
disorder (Bateman & Fonagy, 2004; Clarkin et al., 2007; Gregory & Remen, 2008).