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Running Head: Borderline Personality Disorder
Treatment of Borderline Personality Disorder Using Dialectical Behavior Therapy:
A Review of the Literature
Mark Fields
Wake Forest University
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Abstract
The purpose of this literature review is to explore the subject of borderline personality disorder
and its treatment with dialectical behavior therapy. Does the literature support using a dialectical
behavior therapy approach with borderline personality disorder and with comorbid substance
abuse? Dialectical behavior therapy is introduced in the context of its promise as an emerging
response to the difficulty in treating borderline personality disorder. The methods section will
explain the process of acquisition of the literature used and cited. The primary method was
electronic database search, and useful search terms and databases will be summarized. The
results of the study will describe the DSM IV diagnostic criteria for the disorder, its high cost of
treatment, prevalence, ethnographic statistics, sex differences, and briefly examine causation in
the context of Linehan’s biosocial theory. An overview of dialectical behavior therapy’s history,
techniques, and its effectiveness in treatment of borderline personality disorder alone and
comorbid with substance abuse or dependence indicates that the literature supports the efficacy
of this treatment. The discussion further examines dialectical behavior therapy as a treatment for
borderline personality disorder, highlighting gaps in the literature, suggesting directions for
further study, and discussing the limitations of this study.
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Introduction
Borderline personality disorder (BPD) is an Axis II diagnosis and a cluster B personality
disorder. BPD presents high comorbidity with other diagnoses, both Axis I and Axis II. It is also
commonly associated with substance use and abuse, and individuals with BPD are highly likely
to commit self-harming acts including both attempted and completed suicide (American
Psychiatric Association, 2000). These facts contribute not only to a disproportionate financial
burden on the public in comparison to its relatively low prevalence in the population, but also to
a tremendous financial, emotional, and psychological burden on individuals and their loved ones.
Sufferers of BPD are prolific users of private and public mental health, social, and hospital
services, and professionals and paraprofessionals in these fields will benefit from understanding
the characteristics of this disorder.
Improving treatment methods and availability and streamlining the process of care for this
population could benefit both these individuals and the service providers and systems they
depend on. BPD, not unlike other personality disorders, has been notoriously hard to treat
successfully. In the past two decades, dialectical behavior therapy (DBT) has emerged as perhaps
the most promising treatment developed thus far in addressing the needs of persons with this
diagnosis. In particular, DBT has had success in reducing the occurrence of self-harm and
suicidal behavior, the latter perhaps being the most dire outcome for any mental health diagnosis
(Seligman & Reichenberg, 2012; Freeman, Stone, & Martin, 2004). In addition to presenting an
overview of the disorder, this literature review will examine DBT in the context of addressing its
success in treatment of BPD in limited comparison to other approaches to treatment of BPD.
Focus will be on outcomes and its success in mitigating various symptoms and of the disorder,
including suicide and comorbid substance use and dependence.
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Methods
The research for this review was primarily conducted through database searches of PsycINFO,
PsycArticles, and PubMed. I initially intended to take a broader scope on comparative treatment,
rather than focusing on DBT. Intending to get a broad overview of treatments, my first search of
PsycINFO started with a first subject line “borderline personality disorder” combined by “AND”
with the second subject line “treatment OR therapy OR techniques.” On the first page, this
yielded 17 results, 11 of which were specifically addressing dialectical behavior therapy (DBT)
as a subject. Combing with “AND” a third line “suicide*” yielded 15 of 20 results with
dialectical behavior therapy as the subject, and 2 of the remaining 5 were focused on cognitive
behavior therapy, a DBT precursor. These initial results combined with consultation of texts and
peers in counseling and related fields solidified my focus on DBT.
Moving forward, I searched multiple combinations of terms in these databases, as well as a
cursory search of Google Scholar, to try to narrow the results, combining “borderline personality
disorder” with various secondary and tertiary subjects including, “dialectical behavior therapy,”
“cognitive behavior therapy,” “diagnos*,” “outcome,” “substance use,” “substance dependence,”
“substance abus*,” “opioid,” “alcohol,” “self-harm,” “self-mutilation”, “symptom,” “impuls*,”
“affect.” After vetting sources for their validity and relevance, I followed the reference lists to
older articles, texts, and other sources. In addition, I used texts from the local library and
UpToDate, the largest continuously edited online medical text, for general information on BPD
and treatments and to look for additional cited references.
After reading abstracts or scanning full texts, I tried to isolate those of greatest relevance or
soundest method. Unfortunately, many promising sources had to be excluded due to
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unavailability in a free or affordable full-text format. PubMed yielded much useable information,
but many items were pay-to-view only or did not include full-text links. Because of this,
PsycINFO provided the greatest balance of quality, quantity, and accessibility of the databases
linked to Wake Forest’s library.
Results
According to the DSM-IV (American Psychiatric Association, 2000) Borderline Personality
Disorder (BPD) is a cluster B personality disorder. General criteria for a personality disorder of
any kind highlight patterns of behavior and inner experience that deviate from cultural
expectations. Of four areas: cognition, affectivity, interpersonal functioning, and impulse control,
the pattern must be present in at least two for diagnosis of a personality disorder. Although BPD
cannot, by definition, be diagnosed until adulthood, diagnostic criteria are likely to emerge in
adolescence or childhood. Diagnostic criteria for borderline personality disorder are as follows:
A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity beginning by early adulthood and present in a variety of contexts
as indicated by five or more of the following:
(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
(3) identity disturbance: markedly and persistently unstable self-image or sense of self
(4) impulsivity in at least two areas that are self-damaging (e.g., spending, sex, substance
abuse, reckless driving, binge eating)
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(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
(6) affective instability due to 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)
(9) transient, stress-related paranoid ideation or severe dissociative symptoms. (American
Psychiatric Association, 2000, p. 706)
Borderline personality is estimated to affect between 1% and 2% of the general population at
any given time with a lifetime prevalence of about 6%, but is estimated to account for as much as
20% of psychiatric inpatients and 9.3% of outpatients (Silk, 2013a; Seligman & Reichenberg,
2012; Chapman, 2010; American Psychiatric Association, 2000). Almost all persons with BPD
will use some type of outpatient services. The cost of treatment and of lost productivity for these
individuals is on average substantially higher than for non-personality disorders and diagnoses,
and of other personality disorders only obsessive-compulsive personality disorder has a similar
average cost per year (Silk, 2013a). Results from multiple studies estimate the rate of death by
suicide for this population around 10%, and according to Oldham as cited by Seligman and
Reichenburg (2012), 60-70% will attempt suicide. Hospitalization for self-inflicted physical
trauma extends the cost to the individual and society beyond treatment, while further
destabilizing the life and mental state of the individual.
Understanding borderline personality disorder is of significant importance to counselors, as we
may encounter these individuals, regardless of counseling specialty. Causation of BPD is yet to
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be determined. Correlations between childhood abuse and trauma, genetics, and biological
factors including brain chemistry have been studied, but no single element or combination can be
proved as a cause. Linehan’s biosocial model suggests these individuals may be naturally
emotionally sensitive, unable to regulate response, and slow to return to a baseline (Linehan,
1993; Hampton, 1997; Crowell, Beauchaine, & Linehan, 2009). Precursors to BPD may emerge
due to an invalidating developmental context in which extreme responses are simultaneously
reinforced and chastised and “the child does not learn how to understand, label, regulate, or
tolerate emotional responses and instead learns to oscillate between emotional inhibition and
extreme emotional lability” (Crowell, Beauchaine, & Linehan, 2009, p. 496). If accurate, this
would explain why there is a positive correlation between childhood trauma and abuse and BPD,
while also demonstrating that these are not necessary conditions of its development.
There is little in the literature suggesting any significant statistical correlation between
prevalence of BPD and race, ethnicity, income, or even marital status (Chapman, 2010; Silk,
2013; Paris & Zweig-Frank, 2001). However, a large epidemiological study by Grant, et al. (as
cited in Crowell, Beauchaine, & Linehan, 2009, p. 502) suggests that there may be significant
racial and ethnic differences, and that the general prevalence may be as high as 5.9%. Women
are three times as likely to seek care, which may account for most references declaring that
females represent the significant majority of persons with BPD, but other evidence suggests that
prevalence between the sexes in the general population could be either equivalent or influenced
by ethnicity (Silk, 2013a; Seligman & Reichenberg, 2012; Crowell, Beauchaine, & Linehan,
2009; Paris & Zweig-Frank, 2001). BPD has been shown to affect men and women differently,
as men with BPD are more prone to substance abuse and comorbidity with other personality
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disorders, and women with BPD are more likely to suffer from PTSD and eating disorders (Silk,
2013a).
A range of therapies have demonstrated some success in the treatment of BPD in various
contexts, but there is much empirical evidence for the comparative efficacy of dialectical
behavior therapy, which was one of the only therapeutic methods shown to significantly reduce
suicidal behavior and ideation as well as mediate substance use disorder in BPD patients (Silk,
2013b; McMain, Guimond, Streiner, Cardish, & Links, 2012; Bedics, Atkins, Comtois, &
Linehan, 2012; Axelrod, Perepletchikova, Holtzman, & Sinha, 2011; Neacsiu, Rizvi, & Linehan,
2010; Linehan, et al., 2006; Freeman & Martin, 2004). Dialectical behavior therapy was
originally developed by cognitive behavior therapist Dr. Marsha Linehan to address patients
exhibiting parasuicidal behaviors, and though she did not intend originally to work specifically
with borderline personality disorder, in the course of exploring treatment for suicidal behaviors
she found that DBT showed promise as a treatment for individuals with BPD (Linehan, 1993;
Reynolds & Linehan 2002; Hampton, 1997). DBT “is rooted in standard cognitive and
behavioral protocols, and it remains, first and foremost, a problem-solving, behavior therapy
approach” (Reynolds & Linehan, 2002, p. 621). Although rooted in cognitive behavior therapy,
DBT incorporates ideas as well as mindfulness practices from Zen Buddhist and Western
transcendental philosophy to focus largely on the dualistic qualities that have become inherent to
the patient’s thinking and behavior (Linehan, 1993; Reynolds & Linehan 2002; Neacsiu, Rizvi,
& Linehan, 2010). Reynolds and Linehan (2002, p. 621) assert that “the balance between
acceptance and change is the overarching dialectic of treatment.”
While rooted in cognitive behavior therapy, Linehan (1993) wished to improve upon this
treatment method for persons expressing suicidal tendency. Behavioral approaches to counseling
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and psychology are often criticized for treating symptoms or behavior while ignoring aspects of
causation and lacking emphasis on the therapeutic relationship, but “in contrast to many
behavioral approaches, DBT places great emphasis on the therapeutic relationship as a
mechanism of change” (Reynolds & Linehan, 2002, p. 624). DBT employs four modes of
treatment: individual psychotherapy, group therapy focused on skills training, weekly
collaboration between therapists and other professionals that include monitoring the counselor’s
own mental health, and telephone consultation with the client between sessions (Linehan, 1993;
Hampton, 1997). These elements are meant to enhance client/counselor relations through
frequent and meaningful contact and reduce early termination and other negative reactions to
therapy. DBT attempts to reverse maladaptive patterns by concurrently validating a client’s
emotional and affective responses while replacing them with a new acceptable pattern of thought
and behavior. Neacsiu, Rizvi, and Linehan (2010) demonstrated that developing and utilizing
these adaptive skills with BPD persons fully mediated suicide attempts, anger control, and
depression and partially mediated self-harm at a four-month follow up compared to a control
group.
DBT has shown promise not only in the treatment of BPD, but also in use for comorbid BPD
and substance use disorder, and for substance abuse in general (Bornovalova & Daughters, 2007;
McMain, Sayrs, Dimeff, & Linehan, 2007; Rosenthal, Lynch, & Linehan, 2005). Substance
abuse treatment alone for BPD and comorbid substance use disorder (SUD) can be ineffective in
mitigating either disorder (McMain, Sayrs, Dimeff, & Linehan, 2007; Rosenthal, Lynch, &
Linehan, 2005). Comparing DBT to a 12-step treatment method for individuals with comorbid
BPD and opiate abuse, Linehan, et al. (as cited in Rosenthal, Lynch, & Linehan, 2005, p. 617)
stated that “in the last 4 months of treatment, those in the DBT-SUD condition maintained
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treatment gains, whereas those in the comprehensive validation condition had a significant
increase in opiate use during this period.” In this case, the 12-step treatment actually had
detrimental results versus positive gains in the group that received DBT. In a separate
randomized trial, Linehan, et al. (as cited in Rosenthal, Lynch, & Linehan, 2005) obtained
positive comparative results at a 16 month follow-up for DBT over treatment as usual not only in
reduction of substance abuse behaviors, but also in positive measures of global and social
adjustment.
Discussion
The findings regarding the use of dialectical behavior therapy with borderline personality
disorder appear to be overwhelmingly positive. Of particular importance is evidence that DBT
can reduce the frequency of suicide. Further evidence supporting DBT as a treatment for
comorbid substance abuse is also of import to this population.
A level of skepticism should remain, as there is not yet available data on the longer term
benefits of the treatment. Few studies with extreme long term follow-up have been conducted
with the BPD population in general, but Paris and Zweig-Frank’s (2001) 27-year follow up study
implied that for most individuals the disorder slowly dissipates in intensity. Perhaps sample
groups for research studies should be controlled for age, as data indicates that improvements
occur naturally into middle and late adulthood. Of the patients on whom they were able to gather
data throughout Paris and Zweig-Frank’s study, most at the 27-year mark no longer retained the
diagnostic criteria for the disorder, though lesser diagnoses and certain affects remained for
many.
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Suggested areas of continued research include isolating the aspects and techniques of DBT that
alleviate the symptoms of BPD and/or are effective in decreasing substance use. With the
exception of the study by Neacsiu, Rizvi, and Linehan (2010), I could find few examples of
empirical design to test specific aspects of the treatment. Many studies focused specifically on
the female population because, as referenced earlier, the disorder is commonly accepted to be
more common in women. More research on men with the disorder would shed light on some of
the gender differences between these populations and possibly could suggest alternative
treatment methods for the sexes. I would also like to investigate strategies to improve
interpersonal relationships for the BPD population, as Paris and Zweig-Frank (2001) found over
half of their cohort living alone or not in an intimate relationship after 27 years.
In essence, the literature supports the continued use of dialectical behavior therapy as an
effective treatment for borderline personality. Although more data should and will be collected
and analyzed through its continued application, current indications suggest it should remain an
accepted approach. Until causation for the disorder is fully understood, preventative measures
and responsive treatments may not be perfected. Continued study of the relevancy of Linehan’s
biosocial theory could augment the current information. The data currently available suggests
DBT is an effective treatment and appears to be superior to some other treatments, but this
should not necessarily exclude other approaches.
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