One CT conceptualization of Borderline Personality Disorder

Here is a pre-publication draft of the latest version of my conceptualization of BPD. It will appear in the second edition of Clinical Applications of Cognitive Therapy later this year or early 2004. [Please do not quote without checking with me (jpretzer@apk.net) because it may still get rewritten a bit]:

Cognitive accounts of Borderline Personality disorder emphasize the role played by strongly held core beliefs (Arntz, Roos, & Dreessen, 1999; Fossel, & Wright, 1999). Four key assumptions are frequently uncovered in the course of therapy with borderline clients. While the exact phrasing varies from individual to individual, these assumptions typically are: "The world is dangerous and malevolent," "I am powerless and vulnerable", "I am unacceptable," and "No one will take my feelings seriously". These assumptions have an important impact on the borderline's cognition and behavior.

Viewing the world as a dangerous place in which one is relatively powerless has important consequences. It leads directly to the conclusion that it is dangerous to relax vigilance, to take risks, to reveal one's weakness, to be "out of control", to be in a situation where one cannot escape easily, and so on. Not only does this result in chronic tension and anxiety, but vigilance for signs of danger results in the individual's noticing many apparent signs of danger, which tends to perpetuate the view of the world as a dangerous place. Thus, as Mary anticipated the trip to Jamaica she focused on the risks the trip presented, including the risk of having panic attacks as she had on some previous trips. As she thought about the possibility of having panic attacks, her anxiety increased, and she interpreted her increasing anxiety as evidence that she would, indeed, experience panic attacks.

Some persons who view the world as a dangerous, malevolent place believe that the thing to do is for them to be vigilant and on guard and to rely on their own capabilities in dealing with the dangers which life presents (and thus develop a paranoid pattern). However, Mary's belief that she is weak and powerless blocks this alternative. Other persons who see themselves as not being capable of dealing effectively with the risks presented by daily life are able to resolve this dilemma by becoming dependent on someone whom they see as capable of taking care of them (and develop a dependent or histrionic pattern). However, Mary's belief that she is inherently unacceptable leads to the conclusion that dependence entails a high risk of eventual rejection, abandonment, or attack. Thus Mary, like other borderline individuals, faces a serious dilemma, convinced that she is relatively helpless in a hostile world with no safe source of security.

The weak or unstable sense of identity which Millon emphasizes also appears to play an important role in Borderline Personality Disorder. Confusion regarding goals and priorities makes it difficult to work consistently and effectively towards long-term goals, especially in the face of abrupt emotional shifts. A low sense of self-efficacy leads to low motivation and persistence and thus to limited success in the face of adversity. The lack of a clear sense of self makes it difficult to decide what to do in ambiguous situations and also makes it difficult to maintain a clear sense of oneself as separate from the other person in an intimate relationship.

In addition, individuals' interpersonal strategies have a big impact on interactions with others. Many borderline individuals hold a conviction that others will not see their wants, preferences, and feelings as valid and believe that a straightforward, assertive approach to dealing with others entails an unacceptable risk of provoking rejection or retaliation. Often they believe that the only safe, effective ways of influencing others are to covertly manipulate the situation or to react intensely. Mary vacillated between passively tolerating situations which did not meet her needs, attempting to indirectly manipulate the situation in order to get what she wanted, and exploding in anger. She was certain that asking directly for what she wanted would be ineffective or dangerous.

Borderline individuals' interpersonal problems often are greatly aggravated by an intense fear of being abandoned or rejected and an inability to tolerate being alone. The fear of rejection results in vigilance for signs of rejection, intense reactions to perceived signs of rejection, and desperate attempts to avoid rejection. These attempts to avoid rejection can include excessive attention-seeking, a constant demand for signs of caring, and dramatic displays of emotional distress in response to rejection such as dramatic outbursts or threats of suicide. This often results in recurrent crises and great difficulty maintaining stable, supportive relationships.

Cognitive distortions also play an important role in Borderline Personality Disorder. One particular distortion, which Beck refers to as "dichotomous thinking," is particularly common among borderlines and contributes substantially to the extreme reactions and mood shifts characteristic of these clients (Veen & Arntz, 2000). Dichotomous thinking is the tendency to evaluate experiences in terms of mutually exclusive categories (e.g., good or bad, flawless or defective, love or hate) rather than seeing experiences as falling along continua. The end result of this "black or white" thinking is to force extreme interpretations of relatively neutral events. There is no neutral category, only a choice between two extreme categorizations. As a result, persons and events are necessarily evaluated in extreme terms. These extreme evaluations are then accompanied by extreme emotional responses and actions. In addition, dichotomous thinking leads to abrupt shifts in mood and behavior because the absence of intermediate categories means that when the individual's perception of a situation changes, it necessarily changes from one extreme to another. In dichotomous thinking, a person who is believed to be trustworthy is seen as completely trustworthy until the first time he or she falls at all short of expectations. Then he or she suddenly is seen as completely untrustworthy. The idea that a person might be trustworthy most of the time or might be fairly trustworthy would be incompatible with dichotomous thinking.

The combination of dichotomous thinking coupled with the borderline's basic assumptions is particularly potent. We all recognize that the world presents risks and threats, but dichotomous thinking results in the world's being seen as deadly. We all have our faults and shortcomings but the borderline's dichotomous categorization of people as either "okay" or "not okay" leads to the conclusion that he or she is irrevocably "not okay" and must hide this fact from others in order to be accepted. A desire for closeness and security conflicts with this world-view and self-concept; and dichotomous thinking leads easily to the conclusion, "I'll never get what I want. Everything is pointless."

Dichotomous thinking also creates and perpetuates some of the borderline's conflicts. For example, frustration (or anticipated frustration) of the borderline's desire for closeness and dependency often leads to intense anger, which is seen by the borderline as being so devastating that it would destroy any chance of a close relationship if expressed. However, satisfaction of the desire for closeness and dependency is seen as being intolerably dangerous because, in a hostile world, to be dependent is to be helpless and vulnerable. This intense conflict over dependency and anger would vanish if it were possible for the borderline to take a more moderate view and say, "It would be good to be diplomatic in expressing my dissatisfactions so that this doesn't cause additional problems," or, "Depending on someone opens me to the possibility of being hurt or disappointed, so I should try to use good judgment about whom to depend on and how dependent to be". However, without help, borderlines seem to have great difficulty shifting from dichotomous thinking to thinking in terms of continua.

The basic assumptions, dichotomous thinking, and weak sense of identity do not simply each contribute separately to Borderline Personality Disorder. They form a mutually reinforcing and self-perpetuating system which is quite complex. For example, viewing a situation as dangerous may encourage dichotomous thinking; dichotomous thinking can encourage the idea that one is inadequate; and the belief that one is inadequate supports the idea that the situation is dangerous. Similarly, viewing the situation as dangerous discourages risk-taking; avoidance of risk-taking deprives the individual of the experiences that could serve as a basis for a positive sense of self-efficacy; and a low sense of self-efficacy supports the idea that risk-taking should be avoided.

Replies:

Re:One CT conceptualization of Borderline Personality Disorder, by Gerry McCarron, 07/05/03 Re:One CT conceptualization of Borderline Personality Disorder, by GMcCarron, 08/14/03

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