Editorial :
If something characterizes the Borderline
Personality Disorder (BPD) is its diagnostic complexity, its comorbidity with
other types of conditions and its high ignorance on the part of many health
professionals, in general, and mental health, in particular. To understand the
BPD, on many occasions, we are going to have to go back to childhood and early
adolescence. If something characterizes the Borderline Personality
Disorder is its diagnostic complexity, its comorbidity with other types of
conditions and its high ignorance on the part of many health professionals, in
general, and mental health, in particular. In this review of the subject we
will try to put some light on this type of psychopathology; a
necessary light, not so much for the professional as for the hidden victim of
this ailment, the great protagonist, not for his stigma of illness, but for his
degree of vulnerability and widespread instability. For example, when a child, adolescent or adult is seen apathetic,
lacking in energy and lacking perspective in current and future life, we might
think that we are facing signs of a mood disorder. But
what happens to those types of people to whom some professionals, out of
ignorance, predict anything and others simply diagnose them of BPD? To understand the BPD, on many occasions, we will have to go back to
childhood and early adolescence of this type of people, since approximately 50%
of those affected already had behavioral disorders in these early stages of
their life, being more frequent in men than in women. An early psychomotor
development, the appearance of disorders such as Attention Deficit
Hyperactivity Disorder in the child or adolescent, and/or the head or end of a
sibling list, may constitute some of the necessary ingredients for an early
onset of the disorder; If we add a poor diagnosis to these cases, we will
obtain the necessary breeding ground for a chronic development of this
psychopathology. Some authors, considering that between 10 and 33% of these people
consume suicide, come to talk about BPD as an equivalent of suicidal personality
or as a disorder characterized by chronic self-injurious behavior. Is this the
reason why this type of patient is supposed to request greater assistance and
hospitalization? Probably, the answer is affirmative, although this does not
imply the greatest guarantees of life and therapeutic success. But, if we were
to draw the robot portrait of the patient with critical BPD, what profile would
we get? It seems that being male, between 30 and 35 years old, with a history
of childhood trauma,
variable self-perception, or what is the same, with an alteration of identity;
Chronic self-destructive behaviors, with manifest efforts to avoid abandonment,
for which, on many occasions, third-party manipulation is used; apparatusity (theatricality),
emotional blackmail, feeling special and center of attraction, along with the
desire for prominence, for which you will use seductive behaviors ... are some
of the genuine behaviors in these types of people. This typology could make us
think that we are facing despicable beings. But, if we add to these aspects
such as the feeling of loneliness and insecurity, the misunderstanding and
hopelessness, the frustration, the confusion and the abandonment that they
probably manifest, we realize that what we really have in front of us is, more
well, an extremely vulnerable and sensitive being (see figure 1). These last two aspects will condition in a peculiar way our future
therapeutic intervention. But we will see that later. Figure: Cognitive-Behavioral
Background and Consequences in the BPD. We might think that, with what has been described so far, we already
know everything about the TLP (Time-Limited Psychotherapy),
but, dear reader, nothing is further from reality, since this is only an
orientation that can help us, of course, a great help. We are facing one of the
most complex disorders to diagnose and address in clinical mental health
centers. This type of disorder, quite frequently, occurs along with other mental
disorders, such as: mood disorders, addictive behaviors, behavioral disorders
and post-traumatic
stress disorder. Some authors add to the previous ones: distress disorders,
psychotic disorders, obsessive compulsive disorder and bipolar disorder. If
this is so, and everything indicates that it is, it seems that the diagnosis,
which a priori might seem like a simple task, is complicated, right? Keep calm
and continue, because we are going to try to put some order to all this
apparent chaos. The BPD can have four possible variations: ·
Psychotic or Unrealized BPD ·
Uncontrolled Impulse BPD ·
Thymic or Affective BPD ·
Dystocia of the I BPD Each of the previous variations presents its particular
characteristics. As the objective of this review is not the depth but the
generalization of the disorder, I will skip talking about the peculiarities of
each of them. Lets stop this short tour to silver some reflections... Could self-injury be considered as a way for the patient to feel alive?
And as a way to distract your emotional pain from the lack of personal
resources to face it? During this type of episode, could there be a splitting
of the person (of the I) who obeys a superior force, being self-injury a form
of submission or punishment? Lets keep going… Before we can see what we can do before such people on the psychotherapeutic
level, we must warn that, although medicine and pharmacology have gained
prominence in recent times within the field of mental health, it is important
to note that there are no specific authorized drugs available. For the
Treatment of Personality, therefore, they should only be used to alleviate the
symptoms of emotional and affective instability, impulsive-behavioral
control and cognitive-perceptual difficulties. Moreover, without the intention of hurting susceptibilities, I am of
the opinion that the apparent improvement of the patient after the
administration of the new psychoactive drugs
(last generation drugs) may be due to the fact that they act on other types of
comorbid disorders with the BPD, more than the BPD itself. When considering approaching a patient with BPD, we propose twelve
basic and fundamental principles that should be taken into account, if what we
seek is, among other things, to manage the extreme vulnerability and
sensitivity that this type of people present. So, these are the twelve commandments that we propose to the
therapeutic community: ·
Be constant ·
Be patient ·
Dont lose therapeutic north ·
Maintain the improvement ·
Be cautious ·
Don´t transmit doubt ·
Don´t judge ·
Normalize, but not invalidate ·
Keep calm ·
Avoid climbing ·
Flee from emotional contagion ·
Believe in the possibilities of
patient improvement We must work with the treatments that work, trying to adapt and improve
them in each case if it is convenient and/or necessary, without forgetting that
the one who knows most about this type of ailment is the patient himself. So,
let us be aware that the information that the client can provide us can be
crucial for therapeutic progress. Our first objective should be: patient safety and the avoidance of
behaviors that may interfere with the therapeutic process, such as
self-destructive behaviors, self-harm and suicidal ideation. The second objective will be the need to establish a solid therapeutic
alliance and a positive emotional connection, a climate of security and trust
that encourages the exchange of opinions, and ensure that the patient feels as
part of a work team, not as someone to which others must heal or change. Other types of objectives can be raised in patients more functional and
motivated by the therapeutic process, such as: ·
Stimulate reflection, rather than
impulsive action ·
Achieve greater knowledge of
himself and his problems ·
Achieve the hope of leading a
normal life in the near future ·
Achieve the abandonment of
self-destructiveness and self-sabotage ·
Take advantage of the skills that
most patients have. ·
Get the functionality of the
patient We propose a Therapeutic Program of Progressive Approach (TPPA), which
the therapist will try to make more flexible and adapt according to the
capacity and degree of involvement of the patient with respect to the proposed
therapy. This program (TPPA) consists of six parts: Group Therapy may be appropriate, since, through it, you can help
improve the communication and expression of feelings of the patient, and
develop their sense of empathy. Through this technique, the patient can share a
group of equals with their situation and experiences. But, could it not be
counterproductive, if we think that the group can act as a mirror for the
patient? Could this make the diagnosis worse in some less tolerant, more
sensitive or more vulnerable patients? These are questions that oblige us to
keep in mind the aforementioned commandments and, above all, to make each case
more flexible and work in a personalized way. Although Family Intervention is not always necessary, it can be
beneficial in patients who live with their relatives or who depend economically
on them. Our goal will be to avoid any type of interference in therapy.
However, we must bear in mind that, before starting this step, the patient must
first be known, guaranteeing absolute confidentiality and credibility with
respect to third parties. Psychoeducation about the disorder to relatives is important, since it
is the only way for them to understand what happens to the affected and a way
to avoid interference in therapy; for example, in case of critical comments or
allusions to negative
behaviors, or in case of generalizations that may produce hostility in the
interrelation. Emotional over-involvement and family intrusiveness can also be
harmful, in the same way as attributing the role of the patient or wanting to
be a shaman apprentice trying to read the patients thoughts. For these and
other reasons, the patient-family relationship can range from anger to silence,
having already predictable consequences. Finally, say that a patient with BPD may have episodes of seizures that
we must have previously considered before the end of therapy. Although crises
do not respond to schedules, it is important to help the patient know how to
distinguish between a real crisis and a bad time. Telephone support has proven
to have good results in these types of situations. The purpose is for the
patient to be able to manage himself, without having to resort to the therapist
constantly. In any case, it is advisable to carry out a gradual therapeutic
abandonment to, thus, counteract the fear and insecurity that may arise in the
patient to know and feel that the time has come to ride the bicycle oneself,
without the help of auxiliary wheels (the therapist). Last but not least, add that it will be necessary for the therapist to
develop self-care, since working with mental health patients
can erode our own abilities and interfere with our work to help others. 1.
Mosquera, Dolores. Rough diamonds
Vol. I and II (2004) Madrid. Ed. Pleiades, Spain. 2.
Mosquera Dolores. Evaluation and
Treatment of Borderline Personality Disorder. Virtual course (2005) Sixth
Virtual Congress of Psychiatry, Interpsiquis. *Corresponding
author: Jaime Senabre, Director of SINIF, University of Alicante,
Spain, E-mail: jasenabre@sinif.es Senabre J. The
stable instability of people with borderline personality disorder (2019)
Edelweiss Psyi Open Access 3: 29-31. Borderline personality disorder, Mental health,
Therapeutic approach, Comorbidity, Suicide.The Stable Instability of People with Borderline Personality Disorder
Jaime Senabre
Abstract
In this review of the subject we will try to put some light on this type of
psychopathology; a necessary light, not so much for the professional as for the
hidden victim of this ailment, the great protagonist; not because of its stigma
of illness, but because of its degree of vulnerability and widespread
instability. We will try to outline a characteristic profile of the borderline
personality based on the background and consequences of the individual. Also,
we will glimpse some aspects such as comorbidity, which can make diagnosis
difficult. We will distinguish the different types of BPD and give a few
strokes on the Therapeutic approach, based on: self-observation, self-care,
psychoeducation, intermediate evaluations, emotion management and coping
techniques, written expression and psychoeducation have given the best results
with this type of patients. At last, we emphasize the importance of self-care
of the mental health professional. Full-Text
Introduction
A Look Back
Drawing a Characteristic Profile
of the BPD
Comorbidity of the BPD
Types or Variations in the
BPD
Medicine and Pharmacology
Approach of the Person with
Borderline Personality Disorder
· The engagement in the therapeutic
process, with the conviction that change is possibleAn example
of the Individual Therapeutic Program
Self-observation: Is that the patient reflects
and becomes aware of their behaviors, thoughts and feelings. The use of
evaluation self-records is suggested.
Self-care: Indicated, mainly, to
address destructive and autolytic
behaviors. It is advisable to maintain reasonable limits, firmly set, but
leaving option to flexibility, depending on the circumstances of the patient.
Psychoeducation about BPD: Acts as a complement to
therapy, seeking to provide defense mechanisms for the patient, control their
impulsiveness and the reasons for their destructive behavior, minimize their
emotional vulnerability, lack of limits, alteration of identity and reduce
relational problems, among other aspects.
Intermediate Evaluations: They are proposed as a
measure of controlling therapeutic progress. It is suggested to use the written
self-assessment,
having obtained satisfactory results with this type of practice.
Emotion Management: Mainly, with the
purpose of adapting to thoughts, interpretations, judgments and beliefs. It is
convenient for the patient to distinguish between primary and secondary
emotions.
Coping Techniques: Of all these tools, it seems
that written expression and psychoeducation will
occupy a favorite place in the therapeutic choice, being the most indicated in
this type of patients. Therapeutic
Collective Program
Family
Intervention
Episodes of
Crisis
Professional self-care
References
Citation:
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