Borderline_Personality_Disorder_in_a_Forensic_Setting

Borderline Personality Disorder in a Forensic Setting Individuals with Borderline Personality Disorder (BPD) may be some of the most charming people one may ever meet. They may also be some of the most frustrating people one will ever meet. An individual with BPD without a sincere, consistent commitment to viable treatment is destined to live a life at the mercy of his or her emotions, paranoid and distorted thoughts, taking no comfort in friendship or love relationships as he or she wrestles with impulses for self destruction such as suicide. BPD has a greater effect on the world than the empathy and exasperation of those immediately affected by a BPD individual. Although two percent of the population suffers from this personality disorder, 20% of individuals hospitalized and 23-40% of prison population suffer from BPD, making BPD a drain on societies’ resources and a danger to the population at large (American Psychiatric Association, 2000). BPD is a personality disorder not uncommon among the prison population due to the specific nature of BPD which has shown a positive response to dialectical behavioral therapy (DBT) in prison pilot programs. Although an accurate number of the nine million individuals in the worldwide prison population who suffer from a severe mental disorder is unidentified, studies have been conducted that indicate that 65% of male prisoners had a personality disorder including antisocial personality disorder (APD) and borderline personality disorder (BPD), and in female prisoners a diagnosis of BPD was made in 25% of female prisoners. These results suggest that the threat of acute psychotic illness such as a personality disorder like BPD is ten-fold that of the general population and twice the prevalence of those in psychiatric hospitals. Although the data does not confirm whether these statistics are the product or the source of imprisonment the data does engage questions of prisons with limited resources as whether or not proper care can be provided. Additionally the report indicates a greater need for forensic psychiatric research to address these problems and treat these conditions (Danesh, 2002). Treatment of Borderline Personality Disorder Borderline Personality Disorder (BPD) is characterized by a persistent pattern of volatility in interpersonal relationships, self image and affects denoted by impulsivity that begins by early childhood and is present in a multiplicity of contexts. There are many cognitions and behaviors that occur because of BPD. One foremost influence on the BPD individual is the propensity for individuals affected to be motivated in his or her behavior by a real or imagined fear of abandonment or rejection. This fear of abandonment has many negative repercussions for a borderline individual. Even subtle changes in environment such as a short term absence or changes in the schedule structure can cause an extreme reaction in of a BPD individual. This reaction may include avoidance responses such as inappropriate anger, manipulation, clinginess, and impulsivity that can include suicide attempts, mutilation and other attempts at self harm (American Psychiatric Association, 2000). Individuals with BPD move with lightning speed in their interpersonal relationships between attitudes that can be characterized as “I love you/I hate you.” The Borderline individual will immediately put people in their lives on a pedestal, only to dramatically shift and knock him or her off that pedestal the first time the borderline individual perceive a betrayal, such as not caring or giving enough. The BPD individual views any perceived slight as a validation of his or her own shortcomings, and engages in relationships from the beginning as if the betrayal and desertion are inevitable (American Psychiatric Association, 2000). These behaviors are related to the BPD sufferer’s identity disturbances. These individuals are subject to a vacillating self-image which is based on feelings of both isolation and a belief in his or her iniquity. These identity disturbances are also typified by swifts in values, goals, sexual identity and contacts. This leads to underperformance and inefficiency in many areas of his or her life (American Psychiatric Association, 2000). Impulsivity and violent mood swings are also observed in those with BPD. Those with BPD have difficulty with impulse control and are more prone to problems with gambling, promiscuous sexual relations, irresponsible spending, and other risk taking behaviors. Individuals with Borderline also display swift changes in a variety of moods such as dysphoria, anger, anxiety and irritability that may last hours or days. These individuals frequently have difficulty expressing these emotions appropriately (American Psychiatric Association, 2000). Although the treatment available for BPD depends on the population being treated there are several therapy models that are being utilized for this condition. Although treatments that focus on social learning theory and conflict resolution may be beneficial these kinds of treatments fail to properly address the core issues of BPD, such as challenges with expressing emotions and maintain emotional attachments. In addition there are often medications prescribed to help manage symptoms such as depression and disorganized thinking. These medications often consist of antidepressants, anti-anxiety and antipsychotic medications. These medications are often prescribed on a short term basis. Other types of treatments that are available for BPD are psychodynamic approaches, and Cognitive Analytical therapy. These approaches have shown evidential efficacy in community populations. For the prison population pilot programs are being utilized in cognitive behavioral therapy such as Dialectical Behavioral Therapy (Nee & Farman, 2005). Relevant Research Because of the toll taken on both individuals and society as a whole due to BPD much research has been emerging to better understand the possible causes of this disorder, as well as how to better diagnose and treat the disorder. One study focused on the hypothesis that the BPD individual’s problem with fear and abandonment in relationships was associated with childhood maltreatment such as abuse and neglect. The study concluded that the BPD group reporting maltreatment had a greater fear of attachment and dimensional attachment impairment compared with the control group and that these results were a consequence of the childhood mistreatment. Maladjustment in interpersonal relationships is one of the core features used to diagnose BPD (Minzenberg, Poole, & Vinogradov, 2006). Another recent study found the correlation between individuals with BPD and self harm is not only linked to experimental avoidance such as thought suppression, behavioral disengagement and substance abuse but is more closely tied to low distress tolerance. These researchers found that chronic avoidance resulted in excluding the development for tolerance of emotionally evocative stimuli. Because of this low distress tolerance proved to be a more intervening connection between BPD and self harm. The results of this study demonstrate the need to focus on the interrelationship between experimental avoidance, distress tolerance and the BPD individual’s tendency for self harm (Chapman, Specht, & Cellucci, 2005). Research conducted with prison inmates with psychopathy and BPD share similar traits such as an impulsive nature and problems with interpersonal relationships that may lean toward a predisposition for violence, but differ in his or her response to emotional stimuli. The conclusion of this research found that when monitoring electrodermal response as well as electromyographic activity to gauge subjects emotional responses to pleasant and unpleasant stimuli the two groups responded differently. Psychopaths showed little response either in startle modulation or facial expression when exposed to stimuli. Conversely, BPD inmates showed a response comparable to control groups with autonomic response, especially with unpleasant slides. However the BPD group established little facial modulation to any stimuli. The results reveal a limitation in processing affective information (Herpertz, Werth, Lukas, Qunaibi, Schuerkens, Kunert, Freese, Flesch, Mueller-Iserner, Osterheider, & Sass, 2001). Efficacy of a Theoretical and Treatment Approach Dialectical Behavioral Therapy (DBT) has shown some success for individuals with BPD especially as it relates to self-harm rates. This therapy also has statistically substantiated in reducing dissociation experiences and increasing survival and coping beliefs, suicidal ideation, depression and impulsiveness. The therapy consists of examining and eradicating incidents of self harm, accepting and validating the patient’s experience while concentrating on mindfulness training that reduces the need to dissociate. This therapy is conducted in both group and individual therapy sessions. One example of a DBT program used with female offenders is called Systems Training for Emotional Predictability and Problem solving. This DBT program verified efficacy using a combination of cognitive-behavioral and skills training components in a group treatment setting (Black, Blum, Eicheringer, McCormick, Allen, & Sieleni, 2008). A theoretical approach to BPD would be the utilization of psychoanalytical therapy regarding a BPD individual’s use of malevolent object relations from an ego psychological perspective. The extent to which borderline individuals experience relationships is related to his or her affective quality of object relations, often directly influenced by his or her childhood experiences and attachment related behaviors. Examining and reconstructing these object relations may prove to assist therapists in diagnostic evaluation and psychoanalytical treatment of BPD (Nigg, Western, Silk, Lohr, & Gold, 1991). Conclusion Borderline Personality Disorder (BPD) is a devastating, costly, unremitting psychological problem that causes sufferers impulse control problems, unsatisfying and fearful interactions with those in their lives, an unstable sense of self, and high risk behaviors. Many of these symptoms may lead to violence or crimes and sufferers become part of the correctional system where treatment for their affliction may be inadequate. Today research is shedding light on the possible causes for BPD. There are many treatment options available to BPD individuals in a forensic setting such as medication, psychoanalysis, and skills training. Cognitive Behavioral Therapy such as DBT is currently being explored in pilot programs in the prison systems and although more research must be conducted the results of inmates with BPD have proven promising. References American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association. Black, D. W., Blum, N., Eicheringer, L., McCormick, B., Allen, J., & Sieleni, B. (2008, October). STEPPS: System Training for Emotional Predictability and Problem Solving in Women Offenders with Borderline Personality Disorder in Prison-A Pilot Study. Mount Sinai School of Medicine, 13(10), 881-886. Retrieved from http://mbldownloads.com/1008CNS_Black.pdf Chapman, A. L., Specht, M. W., & Cellucci, T. (2005). Borderline Personality Disorder and Deliberate Self-Harm: Does Experimental Avoidance Play a Role' Suicide and Life Threatening Behavior, 35(4), 388-398. Retrieved from http://contextualpsychology.org/system/files/Chapman,2005.pdf Danesh, J. D. (2002, Febuary 16). Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. THE LANCET, 359(1), 545-549. Retrieved from http://www.bulger.co.uk/prison/prisoners_Lancet.pdf Herpertz, S. C., Werth, U., Lukas, G., Qunaibi, M., Schuerkens, A., Kunert, H., Freese, R., Flesch, M., Mueller-Iserner, R., Osterheider, M., & Sass, H. (2001, Aug). Emotion in Criminal Offenders With Psychopathy and Borderline Personality Disorder. Arch Gen Psychiatry, 58(1), 737-745. Retrieved from http://www-psych.stanford.edu/~knutson/fop/herpertz01.pdf Minzenberg, M. J., Poole, J. H., & Vinogradov, S. (2006). Adult Social Attachment Disturbance Is Related to Childhood Maltreatment and Current Symptoms in Borderline Personality Disorder. Journal of Nevous and Mental Disease, 194(1), 341-347. Retrieved from http://ucdirc.ucdavis.edu/people/papers/minzenberg_poole_vinogradov_JNMD2006.pdf Nee, C., & Farman, S. (2005). Female Prisoners with Borderline Personality Disorder: Some Promising Treatment Developments. International Centre For Research In Forensic Psychology, 15(1), 2-16. Retrieved from http://eprints.libr.port.ac.uk/archive/00000038/01/Female.pdf Nigg, J., Western, D., Silk, K. R., Lohr, N. E., & Gold, L. J. (1991, April 1). Malevolent Object Representations in Borderline Personality Disorder and Major Depression. Journal of Abnormal Psychology, 101(1), 61-67. Retrieved from http://www.psychsystems.net/lab/Melevolent%20object%20representations%20in.pdf