Schema Therapy for Borderline Personality Disorder. Hannie van Genderen

and devaluation.Identity disturbance: markedly and persistently unstable self‐image or sense of self.Impulsivity in at least two areas that are potentially self‐damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self‐mutilating behavior as covered in criterion 5.)Recurrent suicidal behavior, gestures or threats, or self‐mutilating behavior.Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).Chronic feelings of emptiness.Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).Transient, stress‐related paranoid suicidal ideation or severe dissociative symptoms.

Prevalence and Comorbidity

      BPD is one of the most common mental disorders within the (outpatient and inpatient) clinical population. Prevalence in the general population is estimated at 1.1–2.5% and varies in clinical populations depending on the setting, from 10% of the outpatients up to 20–50% of inpatients. However, in many cases the diagnosis of BPD is made late or not given at all. This might be due to the high comorbidity and other problems associated with BPD, which complicate the diagnostic process.

      The comorbidity in this group of patients is high and diverse. On axis‐I, there is often depression, eating disorders, social phobia, PTSD, or relationship problems. In fact one can expect any or all of these disorders in stronger or weaker forms along with BPD.

      All of the personality disorders can be co‐morbid to BPD. A common combination is that of BPD along with avoidant, dependent, narcissistic, antisocial, histrionic, and paranoid disorders (Layden, Newman, Freeman, & Morse, 1993).

Reviews and studies by Dreessen and Arntz (1998), Mulder (2002), and Weertman, Arntz, Schouten, and Dreessen (2005) have shown that anxiety and mood disorders are treatable when the patient has a comorbidity with a personality disorder. However, in the case of BPD, one must be careful to only treat the axis‐I disorder. BPD is a serious disorder that results in permanent disturbance of the patient's life with numerous crises and suicide attempts, which makes the usual treatment of axis‐I disorders burdensome. Axis‐I complaints and symptoms often change in nature and scope, making the diagnostic process even more difficult. This often results in the treating of BPD taking priority. Disorders that should take priority over BPD in treatment are described in “(Contra‐) Indications” (see Chapter 2).

Development of BPD

      The majority of patients with BPD have experienced sexual, physical, and/or emotional abuse, and emotional neglect in their childhood; sexual abuse in particular between the ages of 6 and 12 (Herman, Perry, & van der Kolk, 1989; Hernandez, Arntz, Gaviria, Labad, & Gutiérrez‐Zotes, 2012; Lobbestael, Arntz, & Bernstein, 2010; Ogata et al., 1990; Weaver & Clum, 1993). It is more problematic to identify emotional abuse and neglect in BPD patients than to identify sexual or physical abuse. Emotional abuse and neglect often remains hidden or not acknowledged by the BPD patient out of a sense of loyalty toward the parents or due to a lack of knowledge of what a normal, healthy childhood involves. These patients don't know what they missed, because they never experienced feelings of being loved, accepted, and cared for. When someone tries to give them love and acceptance later in life, they sometimes react negatively toward that person (i.e., the therapist).

      These traumatic experiences in combination with temperament, insecure attachment, developmental stage of the child, as well as the social situation in which things took place, result in the development of dysfunctional interpretations of the patient's self and others (Arntz, Weertman, & Salet, 2011; Zanarini, 2000). Patients with BPD have a disorganized attachment style. This is the result of the unsolvable situation they experienced as a child, in which their parent was both a menace or threat, as well as a potential safe haven (van IJzendoorn, Schuengel, & Bakermans‐Kranenburg, 1999). Translated into cognitive terms, a combination of dysfunctional schemas and coping strategies results in BPD (e.g., Arntz et al., 2011).

Patients with BPD have a very serious and complex set of problems. Because the patient's behavior is so unpredictable, it exhausts the sympathy and endurance of family and friends. Life is not only difficult for the patients, but also for those around them. At times, life is so difficult that the patient gives up (suicide) or her support system gives up and breaks off contact with the patient. Treating BPD patients is often also fatiguing for the mental health care giver, especially in the absence of effective treatment methods. The good news is that effective treatments have been developed the last decades, and schema therapy is one of the most successful.

      Schema therapy offers BPD patients and therapists a treatment model in which the patient is helped to break through the dysfunctional patterns she has created and to achieve a healthier life. The model helps patients and therapists to understand how early childhood experiences are related to the present problems and offers grip on the otherwise overwhelming and difficult to understand problems. Treating BPD patients with schema therapy makes it relatively easy to comprehend the patient's dysfunctional behavior and it gives the therapist many tools to treat the patient.

2 Schema Therapy for Borderline Personality Disorder

      The Development of Schema Therapy for Borderline Personality Disorder

      Before the development of specialized psychotherapies for BPD, such as schema therapy (ST), BPD was treated primarily from a psychoanalytical perspective. This started to change in the late 1980s when cognitive behaviorists began to study the treatment of personality disorders with cognitive behavioral therapy, and psychodynamic therapists started to develop variants of psychodynamic therapy that were specifically adapted to BPD.

The most important early developments in specialized psychotherapies for BPD that emerged in this era were the formulation and empirical validation of Dialectical Behavior Therapy (DBT; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, 1993), the development of Transference‐Focused Psychotherapy (TFP) (Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989), the development of Mentalization Based Treatment (MBT, Bateman & Fonagy, 2004), and the development of cognitive therapy for personality disorders. The use of cognitive therapy for treating personality disorders was first introduced by Aaron Beck, Arthur Freeman, and colleagues in their work Cognitive Therapy of Personality Disorders (1990). In that same year, Jeffrey Young introduced a new form of cognitive therapy, which he referred to as “Schema‐Focused Therapy,” later “Schema Therapy” (Young, 1990, 1994). He later expanded upon this therapeutic model with the introduction of schema modes (Young, Klosko, & Weishaar, 2003). His theory is based upon a combination of insights derived from cognitive, behavioral, psychodynamic, humanistic, and developmental (including attachment) theories. The actual treatment is mainly based on cognitive behavioral therapy and techniques derived from experiential therapies. There is a strong emphasis on the therapeutic relationship which is used as a means to bring about change, as well as on the emotional processing of traumatic experiences.

      To date, ST appears to be a good method to achieve substantial personality improvements in BPD patients.

Research Results

      Research on traditional psychoanalytical forms of treatment showed high dropout percentages (46–67%) and a relatively high percentage of suicide. Across four longitudinal studies, approximately 10% of the patients died during treatment or within 15 years following treatment due to suicide (Paris, 1993). This percentage is comparable to that of nonpsychotherapeutically treated BPD patients (8–9%: as reported by Adams, Bernat, & Luscher, 2001).

      The first controlled study of cognitive behavioral treatment for BPD was realized by Linehan et al. (1991). The DBT they introduced had lower dropout rates, fewer hospitalizations, and a greater reduction in self‐injury and suicidal behavior in comparison with usual treatment. On