People with borderline personality disorder may benefit from a guided formulation approach to care. It can help them to understand and manage their condition
In this article…
- Explanation of personality disorder diagnosis
- Current and past treatment for BPD
- How guided formulation can help people with BPD
Steven Pack is community psychiatric nurse; Sam Wakeham is personality disorder locality lead; Rachel Beeby is service user consultation; Liz Fawkes and Jane Yeandle are trust leads for personality disorder; Chris Gordon is clinical manager; all at Somerset Partnership Foundation Trust.
Pack S et al (2013) Management of borderline personality disorder. Nursing Times; 109 : 15, 21-23.
This article gives an overview of personality disorders, with a focus on borderline personality disorder. It also describes the setting up of a trust-wide service to treat people with BPD, led by mental health workers and using guided formulation. The role of guided formulation in the management of BPD is explored. It is suggested that this form of treatment can greatly improve outcomes for patients.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Borderline personality disorder, also known as emotionally unstable personality disorder, is the most common personality disorder
- People with BPD often have highly unstable social relationships and their mood and feelings can fluctuate greatly
- Emotional events can trigger the onset of BPD
- Guided formulation can help clients to “make sense” of their experiences, feelings, relationships and behaviour
- Guided formulation can provide the basis for a consistent and cohesive care plan
People learn to recognise personal differences and to predict how others are likely to behave in certain situations; we learn how to respond to others to get the best out of them and ourselves. In our minds, we establish a wide spectrum of behaviour.
Society also creates such a spectrum. Some people display such extreme behaviour that they are regarded as being outside this spectrum. These people are often described as having a personality disorder.
The International Classification of Mental and Behavioural Disorders (ICD-10), defines a personality disorder as “a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption” (World Health Organization, 1992). A more straightforward description is that of personality disorder cluster groups (American Psychiatric Association, 1994) (Table 1).
Despite being less well known than schizophrenia or bipolar disorder, personality disorders are more prevalent, affecting 1-2% of adults (Gibson, 2006). In mental health, people diagnosed with borderline personality disorder (BPD) make up 50% of inpatients and 40% of people receiving community services (National Institute for Mental Health in England, 2003). Women are more likely to be diagnosed with BPD and men more likely to be diagnosed with an antisocial personality disorder. People from ethnic minorities are less likely to attract a BPD diagnosis (Gibson, 2006).
Also known as emotionally unstable personality disorder, BPD is the most common personality disorder. The term borderline was coined by Adolph Stern in 1938 to describe people on a “borderline” between neurosis and psychosis. However, the symptoms are not as simple as this implies. Diagnosis is based on emotional instability, feelings of emptiness, and behavioural and identity disturbance (Jorgensen, 2010), as well as neurosis and psychosis.
Paris (2007) identified having conflicting interpersonal relationships and suicidal thoughts as typical of the disorder. Zanarini et al (2008) noted recurrent suicide attempts in 46-92% of patients and successful suicide attempts in 3-10%.
Persons with BPD often have other mental health problems such as anxiety, depression and substance misuse, generally due to attempts at finding ways to manage emotional distress (Grant et al, 2004). The following symptoms may also be present (American Psychiatric Association, 1994):
- Deliberate self-harm, which can include cutting, biting, burning, repeated overdoses, blood-letting, ligature tying;
- Destructive behaviour such as binge eating, starvation, neglect of physical health and substance misuse;
- Impulsive self-defeating acts such as unprotected sex, risky driving or overspending;
- Extreme feelings of emptiness, sadness, numbness and being uncertain of who they are or what they want from life;
- Becoming intensely angry with others very quickly and finding it difficult to calm down;
- Unstable personal relationships that alternate between idealisation and devaluation;
- Becoming so stressed that they feel threatened or paranoid;
- Dissociation - becoming “spaced out” or losing awareness of what’s going on around them.
A person with BPD may experience intense bouts of anger, euphoria, depression and anxiety within a very short period (Zanarini et al, 1997). These feelings may lead to impulsive behaviour and confusion, and result in changes to long-term goals, career plans, friendships, gender identity and values. People with BPD may feel unfairly treated or misunderstood, bored or empty, and have little idea of who they are. Symptoms are often most acute when current events trigger memories of feelings from past traumatic and unresolved events.
Because they are impulsive, people with BPD often have highly unstable relationships. While they can develop intense attachments, their attitude can suddenly shift from great admiration to intense anger and dislike. They are highly sensitive to rejection, reacting with anger and distress to what others may regard as common occurrences. With staff, these occurrences can include shift changes, sickness, holiday or a sudden change in plans, which can leave people with BPD feeling lost and worthless. Along with expressions of anger, this can result in the patient threatening or even attempting suicide (National Institute for Health and Clinical Excellence, 2009).
Causes of BPD
Although a specific cause is unknown, environmental and genetic factors are thought to be involved (National Institute for Mental Health, 2009). Childhood experiences of verbal, sexual or emotional abuse, neglect of age-appropriate physical needs, parental illness or prolonged early separations and chaotic and dysfunctional situations are all thought to make BPD traits more likely (Zanarini, 2000).
Developing a personality disorder during adolescence increases the likelihood of having poor social functioning and problems with impulse control as an adult (Hooley et al, 2009).
BPD can be triggered by an event or events in adulthood. This could be a normal part of life, such as leaving home or starting an intimate relationship, or something traumatic, such as being injured in a car crash or being sexually assaulted. According to Zanarini et al (1997), such an event could cause someone predisposed to BPD to express the characteristics fully, resulting in their condition being noticed.
Brain mechanisms may be the cause of the impulsivity, mood instability, aggression, anger and negative emotion often seen in BPD. Davidson et al (2000) suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala plays an important role in regulating negative emotions. In response to signals from other brain centres indicating a threat, it triggers fear and arousal. This can be more pronounced under the influence of alcohol or feelings of stress (National Institute for Mental Health, 2009).
History of treatment
Over the past 30 years, there has been a dramatic change in views on treatment of BPD (Gibson, 2006). In the 1970s, long-term psychoanalytic psychotherapy and psychodynamic psychotherapy were the treatments of choice (Gibson, 2006). However, in the 1980s, these were seen as unsuccessful and medication became the standard treatment (Gibson, 2006).
In the 1990s, group and family therapy emerged as potentially useful. Dialectical behaviour therapy had the most significant effects (Linehan, 1993), but research has since shown its effectiveness to be limited (Verheul et al, 2002).
In 1999, psychiatrist Anthony Bateman and psychologist Peter Fonagy pioneered mentalisation. Mentalisation is recognising what is going on in the mind. This therapy is intended to help people to improve their ability to mentalise and be willing to use this ability, especially when feeling intense emotions. The therapist might ask a patient to consider what a person in a difficult situation might have been thinking, then help the patient to go beyond their initial assumption, especially if this is negative.
Increasing the ability to mentalise significantly improves a variety of areas, including deliberate self-harm, suicidal behaviour, anxiety and depression (Gibson, 2006). If a person with BPD is planning to take an overdose, their thought processes tend to confirm this is the “right” thing to do. They can use mentalisation to look at their thinking and analyse whether their thoughts and feelings about the overdose are caused by feelings of negativity; this helps them to come to the decision to hold off the decision until they feel more settled.
Guided formulation was developed by Somerset Partnerships Foundation Trust’s personality disorder service. It forms the core of the care pathway for personality disorders in Somerset.
Guided formulation is a psychologically minded process shared by a patient and a specially trained mental health professional over about 6-8 weeks. The process includes writing a concise, jointly agreed summary document, under the guidance of a clinical supervisor (the guide). This should not be written by the professional without the patient’s input, nor should the patient complete it alone - it provides a structure for discussions between both.
The guided formulation approach helps the patient to look at past experiences and relationships and examine how these affect current feelings and behaviours. It allows the patient and professional to work together to understand patterns of behaviour and where they have originated.
Benefits of guided formulation
Guided formulation can help these patients to begin to make sense of their experiences, feelings, relationships and behaviour. This is a core part of any treatment, as patients often need help with self-reflection. It can also help build empathy and trust between professional and patient, as well as encouraging both to explore the patient’s presentation in a non-judgemental way.
The document is a “live” one that can be updated as circumstances change, as patients start to understand their minds better or practitioners understand an issue more. It is portable - it is “owned” by the patient and can be used for handover to a new team or during a crisis admission, or to help patients to explain themselves to family and friends if they wish. In this way, the guided formulation provides the basis for a consistent and cohesive care plan.
The role of the guide
The “guide” is usually a specially trained clinical supervisor in the personality disorder service or other trained clinical supervisor. It is essential that they are not directly involved with the patient due to psychological and relational issues that arise in a treatment relationship.
Practicalities and anxieties
The approach needs to be discussed and agreed with the patient and regular meetings arranged. It is important to agree a venue where the patient feels comfortable talking about distressing issues and where privacy and confidentiality can be maintained. New interventions can cause anxieties that should be addressed from the start.
People with BPD often have a distorted or limited capacity to self-reflect and can be impulsive, so a risk management and crisis plan is only effective if it is agreed as part of a working relationship. Guided formulation can help people to reflect, make sense of risk and to identify protective factors.
By facilitating relationships, reflection and understanding through guided formulation, frontline mental health workers can help people with BPD address difficulties, maximise strengths and take steps towards recovery with the ultimate aim of discharge from mental health services.
● Guided Formulation is the intellectual property of Somerset Partnership
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