Symptoms of Borderline Personality Disorder: DBT versus DSM-5

Marsha Linehan's early work with individuals with chronic suicidal thoughts and behaviors became the solid foundation for applications of dialectical behavior therapy for individuals with borderline personality disorder.


Dr. Linehan's biosocial model with symptoms of Borderline Personality Disorder


Dr. Linehan viewed the symptoms of borderline personality disorder as a biosocial model of pervasive dysregulation.  Her biosocial approach was atypical, as most treatments for personality disorders were grounded in psychoanalytic and psychodynamic theoretical orientations.  Biosocial combines the biological/physiological and social perspectives to describe the extreme dysregulation and an invalidating environment.  To clarify, dysregulation (prefix "dys-" not + regulation); for example, emotional dysregulation refers to intense feelings and reactions based on the feelings that can fluctuate quickly and can come without a behavioral cue or warning.

1. Emotional Dysregulation (emotional ups and downs)
2. Behavioral Dysregulation (impulsivity)
3. Interpersonal Dysregulation (managing relationships)
4. Cognitive Dysregulation (focusing attention)
5. Self Dysregulation (knowing who you are, owning your identity, what you stand for)

The Diagnostic and Statistical Manual of Mental Disorders 5^th Edition (DSM-5)


DSM-5 is a manual that sets symptoms and threshold levels for the diagnosis of a psychiatric disorder or illness (American Psychiatric Association, 2013).  For the diagnosis of borderline personality disorder, five of the nine following symptoms must be present. 


DSM-5 categorical model of symptoms of Borderline Personality Disorder

1. Frantic effort to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance with markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging: spending (money), risky sex, substance abuse, reckless driving (speeding), binge eating
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilation behavior
6. Affective instability due to a marked reactivity of mood (“mood swings,” intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely for more than a few days
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

The sticky part of the DSM-5 categories for borderline personality disorder is the presentation.  Two individuals with marked, out-of-control behavior may only share a single criterion, but receive the same diagnosis.  Some clinicians and researchers pushed for a dimensional approach to personality disorders, not a categorical approach. 

"What keeps us stuck?" Emotion Mind and Homework

In DBT, clients and skills trainers have homework assignments from week to week.  "Repetition is the mother of understanding."  The intentional practice prompts the client to develop and hone her skills.  The interpersonal effectiveness skills really require practice with others because they involve interactions with others, so it can be difficult to practice by yourself; DEAR MAN, GIVE, and FAST are the main interpersonal effectiveness skills.

In skills groups, there is a designated time for a review of the homework.  This is usually after the mindfulness activity and before the skill lesson. 
Sometimes the homework isn't completed when the clients arrive for group, so there might be clients writing quickly as the other clients talk about their homework.  If skills trainer asks about the unfinished homework, she may ask the client to complete the work and bring it next week and/or to write a chain analysis about what kept her from completing her homework.  

The chain analysis may elucidate the emotional factors and cognitive factors that influenced the outcome.  Sometimes emotional responses hinder the likelihood of completing tasks. It's a difficult process to figure out "what happened when."  

Chain analyses are not punishments and should not be punitive.  They are tools for helping the client identify the behavior(s), what led up to it (emotional vulnerabilities), the prompting event, and what happened as a result of the behavior(s).  It can be dysregulating and difficult to write the chain analysis alone, so it may be helpful to work through a chain analysis with the individual therapist.  She or he can help the client self-soothe and regulate her emotions when filling out the chain.

Looking at factors that keep us from working effectively, procrastination is an application of Emotion Mind.  Fear and anxiety can create a hostile environment for effective task completion.  Randy Pausch described procrastination as one of the hindrances to completing tasks in his lecture, "Time Management;" click here to watch the YouTube video of "Time Management." 

"If you are procrastinating, you've got to find some way to get back into your comfort zone.  Identify why you are not enthusiastic. Whenever I procrastinate on something, there's always a deep psychological reason. Usually it's, I'm afraid of being embarrassed because I don't think I'll do it well, or I'm afraid I'm going to fail at it."

Let's look at homework experiences to see the effects of the anxiety and fear that can come with being in Emotion Mind. 

I don’t want to be avoidant today.

I want to look at the theories book,

pick up it up and say,

I am not going to live in fear.

I will read this

one section at a time.

I can do this.

I may need help

along the way.

You will not define me.

I will not label myself as a

bad, ignorant, or avoidant

student.

I can do this.

In looking at the poem, there is a consistent cheerleading statement: I can do this.  It also has components of goal setting: reading the book one section at a time.  There are also elements of Wise Mind and non-judgmental stance in not wanting to add labels that could increase avoidance, diminish motivation to finish the work, increase the likelihood of living in fear, and keep us from reaching our potential.

Life of Pi

So many individuals who seek treatment are looking for hope and a way out of the darkness.  I know that there is a flicker of hope remaining in even the most suicidal of people.  The flicker of hope can be a sense of longing for something to be different, for someone to leave, for something to come back, for someone to come back.  

This flicker of hope is awesome news because "therapy doesn't work on dead people" (Marsha Linehan, 2011).

I saw "Life of Pi" this afternoon.  His suffering was great and his hope was ebbing away from weeks at sea. 

Pi Patel: [Pi and Richard Parker in the boat when they're about to leave the island] No one has seen that island since, and you'd never read about those trees in any book. And yet, if I hadn't found those shores I would have died, if I hadn't discovered that tooth I would have been lost alone forever. Even when God seemed to have abandoned me, he was watching. Even when He seemed indifferent to my suffering, He was watching and when I was beyond all hope of saving... He gave me rest and gave me a sign to continue my journey... 

It is true, the darkest hour is right before the dawn.  Don't give up on your clients.  Help them find hope.  Help them find healing.

Day One: Biosocial Approach to Borderline Personality Disorder

DBT maintains the biosocial approach to understanding borderline personality disorder.  Biological and environmental factors directly affect behavior.  

"According to Linehan, BPD is primarily a disorder of emotion dysregulation and emerges from transactions between individuals with biological vulnerabilities and specific environmental influences. The dysfunction proposed by Linehan is one of broad dysregulation across all aspects of emotional responding. As a consequence, individuals with BPD have (a) heightened emotional sensitivity, (b) inability to regulate intense emotional responses, and (c) slow return to emotional baseline" (Crowell, Beauchaine, & Linehan, 2009, p. 495).


Emotional dysregulation. . .?

What does this mean?  One definition of emotional dysregulation is "a maladaptive pattern of regulating emotions that may involve a failure of regulation or interference in adaptive functioning" (Hilt, Hanson, & Pollak, 2011, p. 160).  What I like about this definition is that it describes these reactions as a pattern, not just a moment of strong, heightened emotions.  

What does this look like?  Let's look at self-harm.  For some individuals, there is a pattern of dealing with strong emotions by creating physical pain.  The logic may be that the pain moves from an abstract internal event to a concrete physical event; another view is that the emotional energy is channeled and controlled.  This cycle of a need for control and emotional release progresses with increasing distress.

For individuals with borderline personality disorder, their home environments are often invalidating, resulting in emotional dysregulation and the use of coping behaviors.  These coping behaviors could include impulsive decisions that are ultimately maladaptive and destructive but temporarily effective in emotional regulation.