Assignment 7.

1: Special Topics Paper 1

Assignment 7.1: Special Topics Paper on Borderline Personality Disorder

Wake Forest University

Michelle White
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Introduction

Borderline Personality Disorder is mental disorder that is characterized by a pervasive

pattern of unstable relationships, self-image, and affect and by marked impulsivity.

Understanding of this disorder is crucial for clinicians and the general public, not just because

it’s a condition that impacts a significant percentage of the population, but also because of its

connections with trauma, substance use, risky behaviors, relationship dynamics, and other

common aspects of the human experience. An incredibly stigmatized condition, even within

medical fields, Borderline Personality Disorder needs an increase in support, especially in terms

of research beyond case studies and funding for treatment programs. This paper will discuss a

brief overview of previously conducted research on Borderline Personality Disorder and provide

a case study outlining a Cognitive Behavioral Therapy case conceptualization and treatment plan

for a client with Borderline Personality Disorder.

Literature Review

In addition to being marked by patterns of instability in interpersonal relationships,

image, and affect and by impulsivity, the condition is indicated by a client demonstrating at least

five of the following criteria: Fear of abandonment, unstable or changing relationships, unstable

self-image; struggles with identity or sense of self, impulsive or self-damaging behaviors,

suicidal behavior or self-injury, varied or random mood swings, constant feelings of

worthlessness or sadness, problems with anger, and/or stress-related paranoia or loss of contact

with reality (American Psychiatric Association, 2013). It is estimated that Borderline Personality

Disorder affects 1.6% of the general population, but this percentage may be as high as 5.9%

(American Psychiatric Association, 2013). Typically manifesting in and being most impairing

during late adolescence or early young adulthood, the tendencies toward intense relationships,
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strong emotions, and impulsivity can affect an individual for the entirety of their lifespan.

However, some studies suggest that the symptoms of Borderline Personality Disorder,

particularly the risk for suicidal ideation and dangerous impulsive behaviors, wane as an

individual ages (American Psychiatric Association, 2013).

Widespread understanding of Borderline Personality Disorder, especially in the clinical

mental health field, is critical due to its frequency of occurring with other disorders. Not only

does this make it difficult to diagnosis Borderline Personality Disorder, it makes it so that many

comorbid conditions cannot be properly treated until the symptoms of Borderline Personality

Disorder are addressed. According to the NIMH-funded National Comorbidity Survey

Replication, which is the largest national study to date of mental disorders in adults in the United

States, about 85 percent of people with BPD also suffer from another mental illness (Piers,

2020). Women with Borderline Personality Disorder are more likely to have co-morbid disorders

such as major depression, anxiety disorders, or eating disorders while men with Borderline

Personality Disorder are more likely to have co-morbid disorders such as substance abuse or

Antisocial Personality Disorder (Piers, 2020).

There is significant variability in the course of Borderline Personality Disorder and the

factors in early life that may create the conditions for the disorder. According to the DSM-5,

Borderline Personality Disorder “is about five times more common among first-degree biological

relatives of those with the disorder than in the general population (American Psychiatric

Association, 2013).” However, studies have found that bio-psychosocial factors may be more of

factor in Borderline Personality Disorder than previous thought. For instance, a study by

Borkum, et. al., discovered that adolescents with Borderline Personality Disorder were less likely

to have experienced childhood protective factors than psychiatrically healthy adolescents

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(Borkum et al., 2017). Winsper shares that Biosocial Developmental Model of Borderline

Personality Disorder, an extension of Marsha Linehan’s original theory, views the development

of the disorder as something like a feedback loop. The article states, “Over time, maladaptive

transactions contribute to negative social and cognitive outcomes, and by mid-adolescence the

individual develops a set of maladaptive coping strategies (Winsper, 2018).” Skaug, et. al. argues

that the original childhood trauma theories of the 1980s have held out despite being consistently

proven as incorrect and as simplifying a complicated condition (Skaug et al., 2022).

Despite the lack of clarity surrounding its origins, the reality of Borderline Personality

Disorder is that it is treatable with psychological intervention. However, far more research needs

to be conducted on methods that are most effective at addressing the symptoms of the disorder.

While DBT is regarded as the prime treatment method for Borderline Personality Disorder, the

literature reflects an abundance of case studies and few empirical studies for any other methods

of treatment.

Case Study

Theo is a 15-year-old, Hispanic male who was brought in for first-time counseling by his

father after discovering the client was self-harming. The client had also been recommended to

attend counseling by his school prior to the self-harming incident that prompted his father to

bring him in. Theo has no history of counseling or psychiatric services and does not currently

take any medications. Following his assessment, the client was diagnosed with an adjustment

disorder with depressed mood and put into an adolescent CBT group. He was also recommended

for individual sessions with a clinician. Theo is always punctual for his individual sessions and is

usually dressed casually, typically appearing in a t-shirt and either sweatpants or shorts. His

affect during our first two sessions was euthymic, leaning toward the euphoric end of the
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spectrum. He presented as distracted, evidenced by his frequent movement around the room, his

pauses to drink from a gallon of orange juice, and his consistent checking-out of the muscle

definition in his arms in the camera of the Telehealth platform. Despite presenting as distracted,

Theo was engaged and willing to answer questions. During our third and fourth sessions, the

client’s affect was flat and constricted. He presented as depressive, as evidenced by avoidance of

eye contact, difficulty concentrating, and moving and speaking more slowly than normal.

Theo indicates that he has been experiencing a wide variety of symptoms for

approximately two to three years now, with many progressively getting worse. He shared that

issues with his memory and quick transitions between states of having lots of energy and feeling

motivated to complete tasks and states of having no energy and feeling down began first. These

symptoms were followed by episodes of self-harming, rapidly changing hobbies/unstable self-

image, not feeling rested after getting an appropriate amount of sleep, and experiencing instances

of what the client describes as “déjà vu” (aka overwhelming moments of feeling like he has

experienced this exact moment – in time, place, and current activity that prompt overthinking).

Theo moved with his family from Mexico to Charlotte approximately 5 years ago. His

mother and father separated after the move. The client now lives with his mother and his

mother’s boyfriend. A year ago, the client and his mother moved from Charlotte to a northern

suburb of the city into rooms rented from Theo’s paternal aunt. The client struggled with the

move, as it changed his school district to one that is more affluent and has students that the client

does not relate to or connect with. Theo also struggles with not feeling like he has freedom to

move around the house he lives in like he wants. The bathroom connected to his room has not

worked for some time and he has to use the one is his mother’s room, but cannot do so when

she’s home. Additionally, the client has a conflictual relationship with his uncle and cousin who
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share the home. Theo describes having two close friends and several cousins whom he spends

time with. The client does not report having any siblings. Theo is spiritual, but has not shared

any specific religious beliefs.

CBT Case Conceptualization

Theo is experiencing both depressive and manic symptoms, such as increased social

isolation, feelings of being down, a lack of energy, and thoughts of low self-worth and esteem

followed by periods of feeling “on top of the world” and like he has the motivation to achieve

any task, self-harming behaviors, and constant energy. These depressive and manic episodes

have been occurring for the past year due to what is perceived as an undiagnosed and unmanaged

Borderline Personality Disorder. The client’s rollercoaster-like emotions, unstable self-image,

and impulsivity all suggest Borderline Personality Disorder, but it is the client’s rapidly shifting

periods of depressive and manic symptoms and his unstable relationships that point to this

disorder over Bipolar Disorder (Bayes & Parker, 2020). The client has only recently

acknowledged his depressive symptoms to an extent. He still holds maladaptive beliefs about

both his depressive and manic symptoms, particularly the latter. He describes his periods with

manic symptoms as being “periods of motivation” or times when he is able to be productive. He

describes his periods of depressive symptoms in a negative light and asserts that he’s becoming

“weak” and should be able to just complete these tasks. Due to his mother’s long work hours and

his rare visits with his father, his symptoms often go unnoticed. Theo’s self-harm was only

recognized after he injured a very visible part of his body.

Theo identifies as a Latino male, but feels increasingly less connected to his ethnic roots.

He shared that he feels this partly due to being primarily raised by his mother. He describes

“having a female perspective” on the world and worries that he is losing strength or toughness.
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The client often feels that some of his behaviors, such as giving up on projects or expressing

certain emotions, are in conflict with who he should be as a young, Hispanic male. Theo also

reports struggling with make friends at his new school because they don’t share similar

backgrounds or values, including not placing a significant emphasis on hard work and loyalty.

He shared that he tends to gravitate toward other Latinos in his classes and feels he it is easier to

connect with them.

Theo has a moderate level of acculturation, as he maintains aspects of his Hispanic

culture (evidenced by his use of Spanish in the household and among friends, emphasis on

importance of family, his incorporation of spirits and ancestors into spirituality, etc.) and also

adopts aspects of the dominant culture (evidenced by his style of dress, use of specific slang

terms, etc.). However, Theo tends to experiences a fairly high level of acculturative stress, as she

struggles to find his place in a new environment that is primarily white and more affluent than

his previous neighborhood and school. While his cultural experience is certainly important and

worth exploring (along with how his cultural experience has impacted family dynamics and his

upbringing), the presenting problem is more likely linked to his personality and psychological

functioning, which will therefore be operative in the development of his treatment plan.

CBT Treatment Plan

The initial counseling work with Theo will be partly psychoeducational as it will seek to

teach him about the symptoms of Borderline Personality Disorder without necessarily diagnosing

him with it. As he is only 15 years old, I believe it is a bit too early on in his development to

label him with such a hefty diagnosis. Focusing on educating the client about his symptoms so he

can better recognize them and their effect on his life will be key. Luckily, Theo is very curious

and has already expressed that “learning about any other disorders he may have” is one of his
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treatment goals. I believe he will be successful in counseling sessions that have a

psychoeducational aspect to them. The counseling work with Theo will also focus on analyzing

his maladaptive beliefs and behaviors. First, we want to address his self-harming and unsafe

behaviors. We will pull from DBT and do a chain analysis of sorts to determine what events and

thoughts lead up to impulsive or self-injurious behaviors. We will explore his family and cultural

background to analyze how these may contribute to his maladaptive beliefs and his depressive

symptoms. Finally, we will work on replacing his maladaptive behaviors and coping skills with

healthy ones.

In order to accomplish these goals, I intend to use guided discovery with Theo. In

particular, I believe Socratic questioning will benefit the client and help aid the process of guided

discovery. For example, I think it would be helpful to use Socratic question to assist guided

discovery when talking about what led up to instances of self-harm or how his cultural

background has affected the beliefs he holds about himself. To learn about his self-harm, I might

ask something along the lines of, “What emotions where you feeling in the hours and minutes

leading up to this incident?” To discuss his cultural beliefs, I might ask, “How has this idea of

masculinity and being strong impacted you?”

While guided discovery would be my main technique, I would also really want to

incorporate mindfulness into my sessions with Theo. Due to his rapidly changing moods and

emotions, I think that emphasizing being in the moment would be very helpful for him. Teaching

him grounding exercises, having him identify things he’s grateful for, and other activities would

be very beneficial. I also believe that having the client take up some form of journaling could be

a good technique. Theo’s moods and thoughts change so quickly that it can be difficult for him to
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remember what he wants to discuss in sessions. Journaling, even just little bullet points, could

help organize his thoughts and his goals for each session.

One of the biggest obstacles to Theo’s treatment is his unwillingness to participate in

things he doesn’t believe are helpful or interesting. In our sessions, the client has shared that he

often doesn’t pay attention in several of his classes because they don’t engage him or he doesn’t

think that they’ll be necessary later on in life. He also reported that he doesn’t pay attention in

his adolescent CBT group for the same reason. Recently, the clinician who leads this group

asked me to reach out to Theo because he stopped attending the group sessions. I plan to use

mindfulness as a way to keep Theo engaged and will pull the idea of getting commitments for

treatment from DBT. However, at the end of the day, the choice of whether or not to participate

is Theo’s.

Advocacy/Legal Considerations

Like many other mental health conditions, Borderline Personality Disorder tends to be

stigmatized and mischaracterized. Due to some of its symptoms, including unstable relationships,

fear of abandonment, explosive anger, and extreme mood swings, people with Borderline

Personality Disorder can be perceived or labeled as abusive, toxic, narcissistic, and many other

negative descriptors. Even in the health field, Borderline Personality Disorder can be stigmatized

and viewed as a flaw in the individual rather than as a mental health condition. For example

(some self-disclosure here), a family member of mine and a friend of mine didn’t mention their

Borderline Personality Disorder diagnoses to their primary care providers for years because they

were worried about that disclosure affecting the quality of their care and the doctor’s willingness

to continue providing the medications they needed to address their depressive and anxious
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symptoms. Society could benefit from more organizations like the National Education Alliance

for Borderline Personality Disorder, who seeks to provide information and support to families

and friends of individuals with the disorder.

Additionally, it is important to keep in mind that Borderline Personality Disorder can

have a profound effect on one’s daily functioning. Therefore, the symptoms of Borderline

Personality Disorder could cause legal troubles, especially if impulsive behaviors like drug

abuse, alcohol use, risky sexual behavior, reckless driving, etc. occur. Should this occur,

counselors have an opportunity to share their expertise in a court of law and recommend

sentences or punishments that will positively benefit the individual and society. For instance, an

individual with Borderline Personality Disorder is more likely to benefit from a Dual Diagnosis

group that addresses mental health issues and substance abuse than a two-week stint in jail.

Counselors have an opportunity to advocate for these individuals and give them access to

treatment they may not have sought for themselves otherwise.

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Cited Sources

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders (DSM-5®). American Psychiatric Publishing.

http://ebookcentral.proquest.com/lib/wfu/detail.action?docID=1811753

Bayes, A. J., & Parker, G. B. (2020). Differentiating borderline personality disorder (BPD) from

bipolar disorder: Diagnostic efficiency of DSM BPD criteria. Acta Psychiatrica

Scandinavica, 141(2), 142–148. https://doi.org/10.1111/acps.13133

Borkum, D. B., Temes, C. M., Magni, L. R., Fitzmaurice, G. M., Aguirre, B. A., Goodman, M.,

& Zanarini, M. C. (2017). Prevalence rates of childhood protective factors in adolescents

with BPD, psychiatrically healthy adolescents and adults with BPD. Personality and

Mental Health, 11(3), 189–194. https://doi.org/10.1002/pmh.1380

Piers, M. (2020, June 15). Home | National Education Alliance for Borderline Personality

Disorder. https://www.borderlinepersonalitydisorder.org/

Skaug, E., Czajkowski, N. O., Waaktaar, T., & Torgersen, S. (2022). Childhood trauma and

borderline personality disorder traits: A discordant twin study. Journal of

Psychopathology and Clinical Science, 131(4), 365–374.

https://doi.org/10.1037/abn0000755

Winsper, C. (2018). The aetiology of borderline personality disorder (BPD): Contemporary

theories and putative mechanisms. Current Opinion in Psychology, 21, 105–110.

https://doi.org/10.1016/j.copsyc.2017.10.005