Once common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population. There are no data in this work.

This paper seeks to determine the extent to which individuals with borderline personality disorders can be held morally responsible for a particular subset of their actions: disproportionate anger, aggressions and displays of temper. The rationale for focusing on these aspects lies in their widespread acknowledgment in the literature and their plausible primary association with blame directed at BPD patients. BPD individuals are indeed typically perceived as “difficult patients” (Sulzer 2015, Bodner et al. 2011), significantly more so than schizophrenic (...) or depressive patients (Markam 2003). The “responsibility question” for patients with BPD has already been raised (Martin 2010, Zachar & Potter 2009, Bray 2003), but this paper tackles it from a novel perspective. First, I narrow down the category of things for which the responsibility question is specific to individual with BPD. After that, I argue that some of the diagnosis criteria of BPD such as emotional instability or impulsivity might serve as excusing factors targeting the “control condition” on moral responsibility. Second, this paper also considers another widely accepted condition on moral responsibility: the epistemic condition. The view defended in the paper is that the answer to the responsibility question for individuals with BPD, concerning both the control condition and the epistemic condition, hinges on an understanding of their epistemic profile. (shrink)

Several researchers point to disorganized attachment as a core feature of borderline personality disorder (BPD). However, recent studies suggest that specific internal working models (IWMs) of each parent combine to account for child outcomes and that a secure relationship with one parent can protect against the deleterious effects of an insecure relationship with the other parent. It was thus hypothesized that adolescents with BPD are more likely to be disorganized with both their parents, whereas non-clinical controls are (...) more secure with at least one of their caregivers. Thirty-six adolescents with BPD and 30 control participants (aged 13-19) were included. Psychiatrist diagnosis was verified with the SIDP-IV and comorbidity was assessed using the Kiddie-SADS. Reported trauma was assessed with the Childhood Trauma Questionnaire. Attachment IWMs of each parent were assessed with the Attachment Multiple Model Interview (AMMI), which enables separate coding for each attachment figure and in which disorganization is conceptualized as conflicting attachment strategies within a specific relationship. Results of a logistic regression analysis suggested that beyond insecure attachment, being disorganized not just with one but with both parents is particularly characteristic of adolescents with BPD. Conversely, belonging to the non-clinical group was predicted by higher security scores with the father and lower deactivation with the mother. Although higher levels of childhood abuse or neglect were reported by adolescents with BPD, the retained attachment dimensions predicted group membership over and above reported trauma. These findings have important implications for clinical intervention and highlight the protective role fathers may have. (shrink)

Many feminist researchers have been critical of the psychiatric category of borderline personality disorder 1 and have emphasized the gendered nature of the diagnosis. It is estimated that people diagnosed with BPD comprise 1 to 2 percent of the general population in the United States in a given year, and that women represent 75 percent of those diagnosed.2 Critics have argued that the diagnosis reinforces double-binds for women and pathologizes traits associated with both conventional femininity, such as (...) emotionality, dependency, and self-destructiveness, and unconventional femininity, such as rebelliousness and sexual promiscuity (Lester 2013; Potter 2009; Shaw.. (shrink)

Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence and non-maleficence, dependent on the outcomes of the actions of containing or tolerating risk. This article examines the use of crisis intervention through moral duties, intentions and consequences, culminating in (...) an action/consequence model of risk management, used to explore potential outcomes. This model may be useful in measuring adherence and violation of the principles of beneficence and non-maleficence and therefore an aid to clinical decision making. (shrink)

The aim of this work is to contribute to the ecological and phenomenological understanding of people with borderline personality disorder by analyzing the relation to the “limit situations”, a concept that was formulated one century ago by Karl Jaspers. This study makes it possible to go beyond the nosographic debate in which the pathological entity is often confined, by defining it as a disorder “situated” between neurosis and psychosis. The five limit-situations (which have been described by (...) Gabriel Marcel in his introduction to Jaspers’ proposals) – namely, (1) historical situation, (2) love conflict, (3) suffering, (4) guilt, (5) and death – turn out to be crucial situations in which the limit-existence manifests itself in a specific way. In particular, we observe that the peculiarities of the experience characterizing the borderline individual’s limit situations rely on a temporality grounded on instantaneity and immediacy, and imply a specific relationship to others. Finally, the limit state seems to call into question this primordial tendency by suggesting that every man is bound to be part of time, to love, to feel guilty, to suffer and to flee this suffering, to die and to organize his life by considering such a condition of finitude. (shrink)

Louis Charland has argued that the Cluster B personality disorders, including borderline personality disorder, are primarily moral rather than clinical conditions. Part of his argument stems from reflections on effective treatment of borderline personality disorder. In the argument from treatment, he claims that successful treatment of all Cluster B personality disorders requires a positive change in a patient’s moral character. Based on this claim, he concludes (1) that these disorders are, at root, (...) deficits in moral character, and (2) that effective treatment of these disorders requires a sort of moral education rather than clinical intervention. In this paper, I evaluate the argument from treatment through a critical analysis of two psychotherapeutic interventions that have shown recent effectiveness against borderline personality disorder. I suggest that both Dialectical Behaviour Therapy and Mentalization-Based Treatment indicate that borderline personality disorder is, at root, a deficit in non-moral cognitive and emotional capacities. I suggest that these non-moral deficits obscure the expression of an otherwise intact moral character. In light of this, I conclude that effective treatment of borderline personality disorder requires primarily clinical intervention rather than moral edification. (shrink)

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively (...) affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i. e. the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance”, especially in initial sessions. It is also recommendable to strengthen patient to patient relations. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can (...) lead to experiences of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

Mentalizing - the ability to understand oneself and others by inferring the mental states that lie behind overt behavior - develops during childhood within the context of a secure attachment relationship. It is crucial to self-regulation and constructive, intimate relationships. Failure to retain mentalizing, particularly in the midst of emotional interactions, is a core problem in borderline personality disorder and results in severe emotional fluctuations, impulsivity, and vulnerability to interpersonal and social interactions. Mentalization-based treatment for borderline (...) personality disorder is a 'How to Do It' book outlining a clinically proven treatment for Borderline Personality Disorder. Containing illustrative clinical examples, it details precisely how to develop and implement treatment and is a companion to the highly successful book Psychotherapy for Borderline Personality Disorder - mentalization based treatment. This practical guide explains how to treat borderline patients by helping them develop a more robust mentalizing capacity within the context of an attachment relationship. It provides the practitioner with everything they need to know about how to practise mentalizing treatment in day patient and out-patient settings. Enough theory is provided to orientate the clinician and there is step-by-step practical advice on the assessment of mentalizing and interpersonal relationships, how to structure treatment, the use of basic mentalizing interventions and how to apply them, as well as information on what not to do. In addition, it includes a check list to be used in the assessment of mentalizing and a self-rating exercise for practitioners to evaluate their adherence to mentalizing. (shrink)

This paper seeks to determine the extent to which individuals with borderline personality disorders can be held morally responsible for a particular subset of their actions: disproportionate anger, aggressions and displays of temper. The rationale for focusing on these aspects lies in their widespread acknowledgment in the literature and their plausible primary association with blame directed at BPD patients. BPD individuals are indeed typically perceived as “difficult patients” (Sulzer 2015:82; Bodner et al. 2011), significantly more so than schizophrenic (...) or depressive patients (Markam 2003). The “responsibility question” for patients with BPD has already been raised (Martin 2010; Zachar and Potter 2009; Bray 2003), but this paper tackles it from a novel perspective. First, I narrow down the category of things for which the responsibility question is specific to individual with BPD. After that, I argue that some of the diagnosis criteria of BPD such as emotional instability or impulsivity might serve as excusing factors targeting the “control condition” on moral responsibility. Second, this paper also considers another widely accepted condition on moral responsibility: the epistemic condition. The view defended in the paper is that the answer to the responsibility question for individuals with BPD, concerning both the control condition and the epistemic condition, hinges on an understanding of their epistemic profile. (shrink)

Patients with borderline personality disorder (BPD) are overrepresented in compulsory inpatient care for suicide-protective reasons. Still, much evidence indicates negative effects of such care, including increased suicide risk. Clinical guidelines are contradictory, leaving clinicians with difficult ethical dilemmas when deciding on compulsory care. In this study, we analyse the arguments most commonly used in favour of compulsory care of BPD patients, to find out in what situations such care is ethically justified. The aim is to guide clinicians (...) when deciding on compulsory care for BPD patients and reduce the use of potentially harmful care. The arguments analysed are (a) the patients lack decision competence, (b) the patients lack authenticity, (c) compulsory care saves the patient from suicide, (d) compulsory care safeguards against litigation, complaints, or doctor's anxiety, (e) compulsory care is a practical solution in emergencies, and (f) it is better for the caregiver to ‘err on the safe side’. We conclude that compulsory care is not ethically justified in most cases unless the clinician has probable reason to believe that the patient lacks decision capacity by suffering from a severe mental co-morbidity and stands to benefit from such care. (shrink)

Individuals with conditions like borderline personality disorder experience chronic, pervasive impairments that interfere with moral functioning. Even in recovery these individuals are plagued by residual symptoms, requiring diligence and management. First, I stipulate that some individuals who recover from BPD act morally. I argue that by acting morally while managing residual symptoms these individuals expand the boundaries of traditional Aristotelian virtue. Individuals who recover from BPD are simultaneously virtuous and outside the boundaries of traditional Aristotelian virtue if (...) they meet the following conditions: they experience marked, unchangeable morally-relevant difference in moral faculties; act morally at approximately the same rate or better than other moral agents; and act morally for the right reasons. These individuals challenge the boundaries of traditional Aristotelian virtue by demonstrating that many views of temperance and virtue are too restrictive. I evaluate multiple interpretations of McDowell’s [1] silencing view and call for a more inclusive virtue ethics that embraces continence in the vein of Foot’s [2] corrective view. (shrink)

People diagnosed with Borderline Personality Disorder (BPD) may engage in what are called self-injurious acts. This paper situates self-injury within a larger cultural context in which body modifications are differently evaluated according to inscribed meanings. To provide a framework for ethical interactions with people diagnosed as BPD who self-injure, I draw on two concepts from theories of meaning: signification and uptake. I suggest possible significations of self-injury, but argue that clinicians have a duty to give uptake to (...) the patient's own interpretations of her behavior. Proper giving of uptake, which involves responding to others' communications such that the communicator's integrity is preserved, is crucial to ethical practices for clinicians, and uptake is never simply neutral or objective. This analysis suggests that sense-making about a client's self-injurious acts involves an understanding not only of the client's own interpretation of her behavior and its meaning, but also of the discursive production and function of such signs in our culture. I offer five maxims to guide the therapeutic process for clinicians working with self-injurious behavior in BPD patients. (shrink)

Borderline Personality disorder is a severe personality dysfunction characterized by behavioural features such as impulsivity, identity disturbance, suicidal behaviour, emptiness, and intense and unstable relationships. Approximately 2% of the population are thought to meet the criteria for BPD. The authors of this volume - Anthony Bateman and Peter Fonagy - have developed a psychoanalytically oriented treatment to BPD known as mentalization treatment. With randomised controlled trials having shown this method to be effective, this book presents the (...) first account of mentalization treatment for BPD. The first section gives an overview of BPD, including discussion of nosology, epidemiology, natural history, and psychosocial aetiology. It additionally summarises the present state of our research knowledge about effective psychotherapeutic treatments and use of medication. The second section outlines the authors' theoretical approach and contrasts it with other well known methods, including DBT, CAT, and CBT. In the extensive final section, the authors outline their clinical approach starting with how treatment is organised. A detailed account of the transferable features of the model is provided along with the main strategies and techniques of treatment. Numerous clinical examples are given to illustrate the core techniques and detailed information provided about how to apply aspects of the mentalization based treatment approach in everyday practice. Aimed at mental health professionals, along with counsellors, psychotherapists, and psychoanalysts, the book will be a valuable tool, providing an effective means of treating those suffering from Borderline Personality Disorder. (shrink)

It is concisely explained what Borderline Personality Disorder is and how it differs from psychopathy.

IntroductionBorderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality.AimTo investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care.Materials and MethodsA questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response (...) alternatives, with room for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis.ResultsThe psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent.ConclusionThe large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time. (shrink)

In this article, I provide a phenomenological exploration of the role played by narrativity in shaping affective experience. I start by surveying and identifying different ways in which linguistic and narrative expression contribute to structure and regulate emotions, and I then expand on these insights by taking into consideration the phenomenology of borderline personality disorder. Disruptions of narrative abilities have been shown to be central to the illness, and I argue that these disruptions are at the origin (...) of a number of alterations of affective experience. In particular, I suggest that due to the narrative “fragmentation” characteristic of the disorder, the emotions experienced by borderline patients are less differentiated and have a predominantly bodily and unregulated character. (shrink)

Borderline Personality Disorder is a diagnosis given to a significant number of people in the Western world. Yet many of the core concepts and symptoms that underlye this diagnosis are questionable. This book presents a compelling analysis of BPD, arguing that it needs to be approached in a new light- one that will benefit patients.

Borderline Personality Disorder is female privilege. It is to be understood primarily in political terms, and only secondarily in psychoanalytic terms.

Self-harm is a potentially lethal symptom of borderline personality disorder (BPD) that often improves with dialectical behavior therapy (DBT). While DBT is effective for reducing self-harm in many patients with BPD, a small but significant number of patients either does not improve in treatment or ends treatment prematurely. Accordingly, it is crucial to identify factors that may prospectively predict which patients are most likely to benefit from and remain in treatment. In the present preliminary study, twenty-nine actively (...) self-harming patients with BPD completed brain-imaging procedures probing activation of the prefrontal cortex during impulse control prior to beginning DBT and after seven months of treatment. Patients that reduced their frequency of self-harm the most over treatment displayed lower levels of neural activation in the bilateral dorsolateral prefrontal cortex prior to beginning treatment, and they showed the greatest increases in activity within this region after seven months of treatment. Prior to starting DBT, treatment non-completers demonstrated greater activation than treatment-completers in the medial prefrontal cortex and right inferior frontal gyrus. Reductions in self-harm over the treatment period were associated with increases in activity in right dorsolateral prefrontal cortex even after accounting for improvements in depression, mania, and BPD symptom severity. These findings suggest that pre-treatment patterns of activation in the prefrontal cortex underlying impulse control may be prospectively associated with improvements in self-harm and treatment attrition for patients with BPD treated with DBT. (shrink)

Borderline personality disorder (BPD) is characterized by severe disturbances in a subject’s sense of identity. Persons with BPD suffer from recurrent feelings of emptiness, a lack of self-feeling, and painful incoherence, especially regarding their own desires, how they see and feel about others, their life goals, or the roles to which they commit themselves. Over the past decade or so, clinical psychologists, psychotherapists, and psychiatrists have turned to philosophical conceptions of selfhood to better understand the borderline-specific (...) ruptures in the sense of identity, which are frequently associated with severe affective instability and turbulence in interpersonal relationships. Fuchs (2007) has suggested that these disturbances in self-experience can best be described and explained by using notions—widely discussed in philosophy and psychology—ofnarrativityandnarrative identity. On such a narrative view, key features of BPD present significant modifications of proto-narrative structures and inhibit the development of a narrative identity, resulting in a disturbed sense of identity. Although the role of narrativity in BPD has been acknowledged by many researchers, some have voiced dissatisfaction with what they take to be limitations of a narrativistic understanding of the disorders of identity characterizing BPD, and have proposed alternative, allegedly non-narrativistic, accounts. In this paper, we critically examine an example of the latter, viz. Gold and Kyratsous’ (2017) account ofthe person as an intrapersonal team reasoner. We defend a narrativistic understanding of BPD identity disorder against their objections. To this end, we propose a broader, and more finely-differentiated, concept of narrativity. On this account, four aspects of narrativity are distinguished, the disordering of which can affect those with BPD. As it turns out, our account implies that even Gold and Kyratsous—in order to ground their approach—must either make use of these aspects or propose an as-yet unarticulated alternative. This casts doubt upon whether their approach is non-narrativistic after all. (shrink)

This critical review of the literature examines recovery from borderline personality disorder to inform a deeper understanding, identifying supports and barriers to recovery, through the exploration of historical and socio-political influences. It critically evaluates research literature for the effectiveness of recovery concept implementation. This review presents the strengths of current evidence and suggestions for future considerations to better support the recovery of whaiora (people seeking wellness) by taking concepts of connection, empowerment, hope, identity and meaning-making, and interweaving (...) them with aspects of established therapies, such as Dialectal Behaviour Therapy, focussing on interpersonal effectiveness, distress tolerance, creating a life worth living, the reconstruction of stable self-image and the use of mindfulness practice. The focus is on developing interventions and responses that support self-management. (shrink)

Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) (...) Ulysses contracts as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient’s decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients. (shrink)

Disturbed identity is one of the defining characteristics of Borderline Personality Disorder manifested in a broad spectrum of dysfunctions related to the self, including disturbances in meaning-generating self-narratives. Autobiographical memories are memories of personal events that provide crucial building-blocks in our construction of a life-story, self-concept, and a meaning-generating narrative identity. The cultural life script represents culturally shared expectations as to the order and timing of life events in a prototypical life course within a given culture. It (...) is used to organize one’s autobiographical memories. Here, 17 BPD-patients, 14 OCD-patients, and 23 non-clinical controls generated three important autobiographical memories and their conceptions of the cultural life script. BPD-patients reported substantially more negative memories, fewer of their memories were of prototypical life script events, their memory narratives were less coherent and more disoriented, and the overall typicality of their life scripts was lower as compared with the other two groups. (shrink)

Genetic and early environmental factors are interwoven in the etiology of Borderline Personality Disorder (BPD). Epigenetic mechanisms offer the molecular machinery to adapt to environmental conditions. There are gaps in the knowledge about how epigenetic mechanisms are involved in the effects of early affective environment, development of BPD, and psychotherapy response. We reviewed the available evidence of the effects of psychotherapy on changes in DNA methylation and conducted a pilot study in a sample of 11 female adolescents (...) diagnosed with BPD, exploring for changes in peripheral DNA methylation of FKBP5 gene, which encodes for a stress response protein, in relation to psychotherapy, on symptomatology and underlying psychological processes. For this purpose, measures of early trauma, borderline and depressive symptoms, psychotherapy outcome, mentalization, and emotional regulation were studied. A reduction in the average FKBP5 methylation levels was observed over time. Additionally, the decrease in FKBP5 methylation observed occurred only in those individuals who had early trauma and responded to psychotherapy. The results suggest an effect of psychotherapy on epigenetic mechanisms associated with the stress response. The finding that epigenetic changes were only observed in patients with early trauma suggests a specific molecular mechanism of recovery. The results should be taken with caution given the small sample size. Also, further research is needed to adjust for confounding factors and include endocrinological markers and therapeutic process variables. (shrink)

Improving emotion regulation is central to borderline personality disorder (BPD) treatment, but little research indicates which emotion regulation strategies are optimally effective and when. Basic emotion science suggests that engagement emotion regulation strategies that process emotional content become less effective as emotional intensity increases, whereas disengagement strategies that disengage from it do not. This study examined whether emotional reactivity to emotional stimuli predicts the effectiveness of engagement and disengagement emotion regulation across self-report, general physiologic (heart rate), sympathetic (...) (skin conductance responses), and parasympathetic (respiratory sinus arrythmia) emotion in BPD, healthy, and clinical control (i.e. generalized anxiety disorder; GAD) groups. 120 participants (40 per group) were exposed to emotion inductions and then instructed to implement engagement (mindful awareness) and disengagement (distraction) strategies while self-report and physiological emotion measurements were taken. In the BPD and GAD groups, higher heart rate or respiratory sinus arrythmia reactivity, respectively, predicted improved mindful awareness effectiveness. Higher skin conductance reactivity predicted worsened distraction effectiveness in BPD. Higher reactivity may potentiate engagement emotion regulation, and exacerbate disengagement from emotional content, in BPD. Future research should examine other domains of emotion regulation that may be influenced by emotional intensity, and other forms of emotional intensity that may influence them. (shrink)

It is often emphasised that persons diagnosed with borderline personality disorder show difficulties in understanding their own psychological states. In this article, I argue that from a phenomenological perspective, BPD can be understood as an existential modality in which the embodied self is profoundly saturated by an alienness regarding the person’s own affects and responses. However, the balance of familiarity and alienness is not static, but can be cultivated through, e.g., psychotherapy. Following this line of thought, I (...) present the idea that narrativising experiences can play an important role in processes of appropriating such embodied self-alienness. Importantly, the notion of narrative used is that of a scalar conception of narrativity as a variable quality of experience that comes in degrees. From this perspective, narrative appropriation is a process of gradually attributing the quality of narrativity to experiences, thereby familiarising the moods, affects, and responses that otherwise govern ‘from behind’. Finally, I propose that the idea of a narrative appropriation of embodied self-alienness is also relevant to the much-debated question of personal responsibility in BPD, particularly as this question plays out in psychotherapeutic contexts where a narrative self-appropriation may facilitate an increase in sense of autonomy and reduce emotions of guilt and shame. (shrink)

Background Previous research on informed consent for research in psychiatric patients has centered on disorders that affect comprehension and appreciation of risks. Little has been written about consent to research in those subjects with Borderline Personality Disorder, a prevalent and disabling condition. Discussion Despite apparently intact cognition and comprehension of risks, a borderline subject may deliberately choose self-harm in order to fulfill abnormal psychological needs, or due to suicidality. Alternatively, such a subject may refuse enrollment due (...) to transference or the desire to harm him or herself. Such phenomena could be precipitated or prevented by the interpersonal dynamics of the informed consent encounter. Summary Caution should be exercised in obtaining informed consent for research from subjects with Borderline Personality Disorder. A literature review and recommendations for future research are discussed. (shrink)

This perspective paper aims at discussing theoretical principles that could explain how emotion regulation and physical diseases mutually influence each other in the context of borderline personality disorder (BPD). Furthermore, this paper discusses the clinical implications of the functional relationships between emotion regulation, BPD and medical conditions considering dialectical behavior therapy (DBT) as a well-validated therapeutic intervention, which encompasses these issues. The inflexible use of maladaptive emotion regulation strategies (e.g., suppression, experiential avoidance, and rumination) might directly increase (...) the probability of developing physical diseases through a physiological pathway, or indirectly through a behavioral pathway. Some metabolic and chronic medical conditions could significantly impact emotional functioning through biological alterations involved in emotion regulation. Several empirical studies have shown high co-occurrence rates between BPD and several chronic physical diseases, especially ones linked to emotion-based maladaptive behaviors. DBT addresses physical diseases reported by individuals with BPD reducing problematic behaviors functionally associated to emotion dysregulation and identifying physical health as a goal forBuilding a Life Worth Living. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 29-31 [Access article in PDF] On the Border:Reflections on the Meaning of Self-Injury in Borderline Personality Disorder Robert L. Woolfolk Keywords borderline personality disorder, values, psychotherapy, diagnosis IT IS A PLEASURE to comment on Nancy Potter's elegantly written, provocative paper. Professor Potter raises important and intriguing issues that have not only clinical implications for practitioners, but also (...) are of theoretical significance for those who ponder the conceptual status of mental illnesses and their manifestations.Borderline personality disorder (BPD) is the mental health professional's bête noire. In the diagnostic context, borderline is an adjective that is evocative, albeit imprecise. Persons with BPD tend to the worst of multiple pathological worlds, to fall through the diagnostic cracks, to occupy the boundaries of decorum and safety. Even such intrepid and astute folk as Marsha Linnehan and Otto Kernberg, who have devoted careers to understanding and treating those with BPD, have acknowledged the limited state of current knowledge. Justice Stewart's theory of natural concepts seems to apply to patients to whom we give the label borderline personality disorder: we cannot define the disorder readily, but we know one when we see one. And when we see such a patient it is costly in time and stress and corrosive of one's sense of professional efficacy. So with these patients, any assistance in conceptualizing the problem or in modification of therapeutics is welcome.Professor Potter's phenomenological formulation of self-injury is cogent and helpful in a number of ways. Self-injurious behavior is, when conventionally interpreted, a prototype for irrationality and affliction. It is also dramatic, graphic, and often repugnant. Professor Potter's analysis brings us face to face with what most of us know but sometimes forget or fail to apply: Psychotherapy is a value-laden endeavor. Early on, both Max Weber and Carl Jung were eloquent on this point and we have been reminded often enough of it in the last four decades (Rieff 1966; Woolfolk 1998; Woolfolk and Murphy, in press). Usually it is the moral values residing in the underlying ideologies of treatment and diagnosis that are brought to our attention. The axiological underpinnings of psychotherapy, however, are aesthetic as well as ethical. Professor Potter successfully argues that, as therapists, we may be in the thrall of a parochial aesthetic that produces [End Page 29] a kind of tunnel vision inimical to therapeutic effectiveness and to the ethical treatment of the human beings who are our patients. She has impeccable advice for therapists on this topic: Although none of us can step outside of culture altogether, we can evaluate our attitudes, beliefs, and values from a second-order level (Taylor 1989; Frankfurt 1971). Complete objectivity is an unlikely ideal. But clinicians can, and should, think critically about ways in which prevailing norms and values may be influencing their understanding of the world and their ways of being in it. (Potter 2003, 11) Professor Potter also quite effectively persuades that a comprehensive understanding of disorders that occur mostly in women (e.g., somatization disorder) must effectively comprehend feminist scholarship and the sociocultural realities of gender. The concept of the commodification of the female body has been informative in both the epidemiology and treatment of yet another woman's disorder, anorexia nervosa. And although the linkages of somatic commodification to self-injurious behavior may not appear to be so straightforward, the paper points the way to deeper and possibly richer explanations of phenomena that seem at first glance to be inexplicable.The introduction of the concept of uptake into clinical contexts is also a valuable contribution. Those of us familiar with the traditions of psychotherapy recognize a concept both familiar and central. Uptake has family resemblance to the empathic attitude so extensively discussed by both Rogers and Kohut. Those with hermeneutic leanings will recognize affinities with Verstehen and the Gadamerian anticipation of completeness (Vorgriff der Vollkommenheit). Any truly humanistic approach to treatment or diagnosis must encompass the lived experience of the patient. This is not to... (shrink)

The purpose of this inquiry is to explore the experience of Borderline Personality Disorder with the aim of developing a more liberating approach to its diagnosis and treatment. Eight participants diagnosed with Borderline Personality Disorder were recruited from a psychiatric hospital operated by the Surrey and Borders NHS Trust and an outpatient daycentre based in London, United Kingdom. A narrative approach to methodology was employed to collect and analyse the participants’ life-stories. Themes to emerge (...) from the participant’s narratives were found to coincide with R.D. Laing’s concept of ontological insecurity. Ontological insecurity describes a number of aspects of the participant’s distress. To conclude, some general implications of this research for psychotherapy are briefly explored. (shrink)

Being in the bodily presence of others facilitates important perceptual, social, and informational advantages. For example, it enables direct access to other subjects’ embodied perspectives, motivates intersubjective engagements, and is involved in the construction of shared experiences and joint actions. These advantages are based on and gained through attending to and with others, i.e. they rely on social attention. It is no surprise, therefore, that a growing body of empirical data indicates that social attention is a special attentional state that (...) involves specific behavioral and neural-cognitive properties. Another important feature of the human capacity for social attention, which is highlighted in this article is that in everyday environments social attention considerably extends and enriches the subject’s attentional field. This idea draws on phenomenological considerations and on findings from cognitive science research that suggest that subjects can attend to more than in the center of their attention and that under normal conditions we can gain more features and more situations when attending to the movements, gestures, and facial expressions of others. The influence of others on the structure of our attentional field is evident from situations where others are absent from our daily surroundings. In these circumstances our attentional field narrows and the world transforms into an unfamiliar and sometimes uncanny place. Intriguingly, the same most likely occurs in social pathologies such as BPD and SAD, in which the bodily presence of others does not generate the emotional response we see in healthy humans even though the subject’s basic capacity for social attention is intact. (shrink)

BackgroundFear of abandonment and aloneness play a key role in the clinical understanding interpersonal and attachment-specific problems in patients with borderline personality disorder and has been investigated in previous functional Magnet Resonance Imaging studies. The aim of the present study was to examine how different aspects of attachment representations are processed in BPD, by using for the first time an fMRI attachment paradigm including personalized core sentences from the participants’ own attachment stories. We hypothesized that BPD patients (...) would show increased functional involvement of limbic brain regions associated with fear and pain when presented personalized attachment relevant stimuli representing loneliness compared to healthy controls.MethodsWe examined the attachment classifications of 26 female BPD patients and 26 female HC using the Adult Attachment Projective Picture System. We used an fMRI-adapted attachment paradigm to investigate the neural correlates of attachment. All participants were presented three personalized sentences extracted from their AAP attachment narrative, combined with standardized AAP pictures representing being alone or in interactive attachment situations.ResultsAs expected, the classification of unresolved attachment was significantly greater in BPD compared to HC. BPD patients showed increased fMRI-activation in brain areas associated with fear, pain, and hyperarousal than HC when presented with personalized attachment-relevant alone stimuli. In particular, pictures with monadic attachment situations induced greater anterior medial cingulate cortex, anterior insula, amygdala, thalamus and superior temporal gyrus activation in the patient group.ConclusionThe results point to increased fMRI-activation in areas processing emotional distress and painful experiences in BPD patients. In particular, the emotional cascade reflecting attachment distress was evoked by combining monadic pictures, representing abandonment and aloneness, with the patients’ personalized narrative material. Our results confirmed and replicated previous results that illustrate once again the high relevance of aloneness and feelings of abandonment for BPD in the context of attachment trauma. Moreover, our results support the hypothesis of hypermentalization in response to attachment distress as a core feature of social-cognitive impairment in BPD associated with common treatment implications across different therapeutic orientations. (shrink)

Personal positions and voices of a patient diagnosed with borderline personality disorder and the therapist during long-term psychotherapy were studied aiming to find differences in the patterns formed in these aspects of subjectivity according to the level of elaboration of the change episodes achieved by the patient. This case study considered a stage of qualitative analysis where change episodes of the patient were traced through the Change Episodes Model. Later, through the Model of Analysis of Discursive Positioning (...) in Psychotherapy, the voices and personal positions of the patient and her therapist were identified in each of the change episodes. In the stage of quantitative analysis, dynamic patterns in the voices and personal positions were established, accounting for hypothetical attractors using the Space State Grid technique in each of the three different levels of subjective elaboration that constitute the change episodes. The results established differentiated dynamic patterns in the change episodes, coherent with the patient’s change process, and formation of propositive/reflective specific patterns as the patient evolved in the three different levels of subjective elaboration. The above suggests that a subjective transformation process is displayed, and this is manifested in the different voices and personal positions that emerged as the change episodes evolve. The identified dynamic patterns can be considered nonlinear and emergent subjective exchanges between the patient and the therapist throughout the psychotherapy. (shrink)

Child trauma plays an important role in the etiology of Bordeline Personality Disorder. Of all traumas, sexual trauma is the most common, severe and most associated with receiving a BPD diagnosis when adult. Etiologic models posit sexual abuse as a prognostic factor in BPD. Here we apply machine learning using Multiple Kernel Regression to the Magnetic Resonance Structural Images of 20 BPD and 13 healthy control to see whether their brain predicts five sources of traumas: sex abuse, emotion (...) neglect, emotional abuse, physical neglect, physical abuse. We also applied the same analysis to predict symptom severity in five domains: affective, cognitive, impulsivity, interpersonal for BPD patients only. Results indicate that CTQ sexual trauma is predicted by a set of areas including the amygdala, the Heschl area, the Caudate, the Putamen, and portions of the Cerebellum in BPD patients only. Importantly, interpersonal problems only in BPD patients were predicted by a set of areas including temporal lobe and cerebellar regions. Notably, sexual trauma and interpersonal problems were not predicted by structural features in matched healthy controls. This finding may help elucidate the brain circuit affected by traumatic experiences and connected with interpersonal problems BPD suffer from. (shrink)

The present study investigated whether scores on the Autobiographical Memory Test (AMT) in 55 patients with borderline personality disorder (BPD) were modified after long‐term psychotherapy and whether the pretreatment AMT scores would predict improvement in depression severity or BPD symptom severity at the end of treatment. In addition, it was analysed whether changes in ratings of mood, thought suppression, dissociation, and BPD symptom severity following treatment were associated with changes in AMT scores. Only patients with BPD and (...) a comorbid diagnosis of depression at time 1, generated significantly more specific memories and fewer categoric memories after 15 months of therapy. Moreover, these changes were unrelated to type of therapy and changes in depression severity, borderline symptom severity, dissociation, or thought suppression. The AMT scores at initial assessment did not predict depression severity at 15 months. The percentage of negative specific memories tended to predict BPD symptom severity. (shrink)

Autistic individuals without intellectual disabilities are sometimes not diagnosed until adolescence/adulthood. Due to increased risk of co-occurring mental health problems, these individuals may initially be referred to general, mental health services and not always be identified as autistic; some may be misdiagnosed with personality disorder prior to identification of autism. To explore possible mechanisms in misdiagnosis of autism, we report on the case of a young man with severe, non-suicidal self-injury and attention deficit disorder who had been (...) diagnosed with and treated for borderline PD prior to being diagnosed with autism. Following reassessment by mental health clinicians with experience of working with autistic individuals, the patient was diagnosed with autism, ADD, and depression—but not PD. Experiences from this case suggest that presence of co-occurring NSSI, depression, and ADD, as well as lack of comprehensive assessment and lack of autism knowledge in general mental health services, may contribute to risk that autism is misdiagnosed as PD. These findings highlight the need for autism expertise in general mental health services to facilitate appropriate diagnosis for autistic individuals who encounter these services, as well as the importance of undertaking comprehensive assessments. (shrink)

The comorbidity of personality disorders and mental disorders is commonly understood through three types of theoretical models: either a) personality disorders precede mental disorders, b) mental disorders precede personality disorders, c) mental disorders and personality disorders share common etiological grounds. Although these hypotheses differ with respect to their idea of causal direction, they all imply a latent variable perspective, in which it is assumed that either personality and mental disorders are latent variables that have certain (...) causal relations [models a) and b)]; or that, as in model c), the common etiology is in fact a latent variable that causes symptomatology of both personality and mental disorders. We aim to provide another perspective on the comorbidity between personality and mental disorders, namely a network perspective. To this end, we investigated Major Depression and Borderline Personality Disorder and hypothesized that symptoms of BPD and MD could interact with one another rather than being caused by a latent variable. To illustrate this theoretical network conceptualization of the comorbidity of BPD and MD we analyzed a cross-sectional clinical dataset of 376 patients who were asked to complete the Structured Clinical Interview for DSM-IV Axis II Disorders and the Beck Depression Inventory II. The results identify direct associations between symptoms of MD and BPD. If we take the links in this empirical network to be ‘substantive', this suggests a radical shift of our current conceptualization of the comorbidity of mental disorders and personality disorders. (shrink)