Module 2
Family Education
Information about Borderline Personality Disorder
Important Considerations
• The disorder is heterogeneous with many “looks” or presentations (over 200
combinations of symptoms).
• Medication effects are usually modest at best, and they can have negative
effects as well (in particular, in negative long-term medical consequences).
Medications often target anxiety, depression, mood swings, and impulsivity.
However, there is no medication that improves relationships, and none
specifically for BPD. No medication has been approved (FDA) to treat BPD
per se.
• BPD rarely stands alone. Many other disorders co-occur.
• BPD affects between 2% and 5.9% of the population (or more). This %
equals or exceeds the number diagnosed with schizophrenia or bipolar I
disorder.
• Estimates are that 10% of psychiatric outpatients and at least 20% of
psychiatric inpatients have BPD.
• BPD affects men and women equally. 75% of patients are women. This
may reflect that women more often seek treatment, that anger is more
acceptable in men, and that men with similar problems often end up in
prison and receive a diagnosis of antisocial personality disorder.
• At least 80% have self-injured (cut, burned, or otherwise injured themselves).
• 65−70% of persons with BPD make at least one suicide attempt. 10% of
BPD patients die by suicide.
• However, most people with BPD do get better with appropriate treatment!
BPD Funding and Resources
(NIMH)
Disorder Funding % of Population
Schizophrenia $300,000,000 0.4%
Bipolar Disorder $100,000,000 1.6%
Borderline Personality Disorder $6,000,000 2%−5.9%
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Treatment Settings for Borderline Personality
Disorder
1. Inpatient Treatment―May be voluntary or involuntary; general psychiatry
typical
2. Residential Treatment―Typically unlocked, 24 hour staff; some are general
psychiatry, while others offer specialty treatment
3. Partial Hospitalization/ Day Treatment―General vs. specialty
4. Outpatient Treatment―General outpatient vs. specialty clinic
Types of Treatment
In addition to the treatment setting, there are also different kinds of treatment.
These include:
1. Dialectical Behavior Therapy (DBT) (Linehan, et al.)―Empirically supported
2. Mentalization (UK) (Bateman, Fonagy, et al.)―Empirically supported
3. “Good” Psychiatric Management (Gunderson, et al.)―Empirically supported
Important considerations regarding treatment:
• Many treatments do not work well (all are NOT equal)
• Specialized treatments always outperform treatment as usual
• “Treatment as usual” typically has the poorest outcomes
© 2021 National Education Alliance for Borderline Personality Disorder
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BPD-specific problems are hard to treat, and even more complicated
in tandem with co-occurring disorders. BPD rarely stands alone.
BPD and Co-occurring Problems
Condition % of BPD Patients Affected
Anxiety 90%
Major Depressive Disorder 60%
Dysthymia ~70%
Eating Disorders (anorexia/bulimia) ~25%
Substance Use Disorders 35%
Bipolar I Disorder 15%
Narcissistic Personality Disorder 25%
Antisocial PD ~25%
PTSD 25-40%
Other Disorders Plus BPD
Condition % of Patients Affected
Major Depressive Disorder 15%
Bulimia 20%
Anorexia 20%
Substance Use Disorders 10%
Dysthymia 10%
Other Personality Disorders 50%
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Expressed Emotion Study
Higher emotional involvement predicted better clinical outcomes. This means that
the more emotionally involved the key relatives were, the better the patient fared
(fewer hospitalizations). (Hooley & Hoffman)
A goal of Family ConnectionsTM is to teach
effective emotional involvement.
Family Member Wellbeing
Families who have a relative with BPD report higher levels of burden, depression,
and grief than do family members who have a relative with schizophrenia.
(Hoffman, et al., 2004)
• How might we understand this?
• What are the sources of stress and burden?
Other Stressors
1. Stressors for Mental Health Care Providers
• Patient suicide attempts, threats of suicide, anger (Hellman, 1986)
2. Stressors for Family Members
• PTSD (mostly around suicide attempts) (Hoffman, Harned, Fruzzetti, 2018)
• Families with a relative with BPD report higher levels of burden,
depression, and grief than do family members with a relative suffering from
schizophrenia. (Hoffman, et al, 2004)
Development of BPD
1. People with BPD likely have temperamental vulnerabilities to the social, cultural
and family environments they are born into, making dysregulation more likely.
2. There are factors in the environment that transact with these vulnerabilities
that may make emotion dysregulation more or less likely.
(Fruzzetti, et al, 2005; Fruzzetti & Worrall, 2010)
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High Emotional Sensitivity
1. Pick up on things with an emotional quality that others miss (something like having sensitive
hearing), and people with less emotional sensitivity can be invalidating
2. Low threshold for emotional reaction―react sooner, regardless of how the other person’s
reaction might be
3. Big emotional events hurt more, and less sensitive others often do not understand this and
can be invalidating
4. Because others don’t notice the emotional events, it is easy for others to invalidate sensitive
people
It’s like an open wound on your hand. It feels the intensity of heat more than the rest of the
hand.
High Emotional Reactivity
1. After becoming activated, emotional reactions tend to be big, more intense.
2. High emotional arousal dysregulates thinking, memory, and other cognitive processing, so
that thinking and problem-solving can be impaired.
3. The magnitude of the response to the emotional event or stimuli can be higher than other
people experience, and therefore can be difficult for others to understand.
Slow Return to Baseline
1. Emotional reactions are longer lasting; it takes a longer time for negative emotions to go
down on their own.
2. Slow return means these people spend more time with high, negative emotions. This makes
them more vulnerable to getting dysregulated when the next emotional event happens, and
makes becoming dysregulated more likely over time. It would be like trying to walk on a
broken leg before it heals; it’s more vulnerable to break again.
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Environmental Factors
• 40−71% of BPD patients report having been sexually abused, usually by a
non-caregiver
• Experienced a loss or abandonment as a child (perceived or actual)
• Poorness of fit―difficulty―between the child and one or more of their
environments; the child experiences one or more of these environments as
invalidating
Stigma
• In general, there is stigma about families of persons with mental illness.
• However, there also seems to be “surplus stigma” around BPD in part
because of the issues of abuse.
What is the stigma with BPD and/or with emotion dysregulation?
What stigma have you or your family members encountered?
How Can a Social or Family Environment Be Invalidating?
• De-legitimizes one’s experiences, especially private experiences (emotions,
wants and desires, preferences, values, opinions, thoughts, beliefs,
sensations)
» This can occur frequently when the other person’s experiences are not
only private, but when the other person does not identify or describe
those experiences.
• Invalidates those experiences, ESPECIALLY when they are quite different
from other people’s experiences
• Does not accept or appreciate differences
• Values conformity or values the status quo: Tries to change or control across
a variety of situations when the other person is just different
• Ignores or does not pay attention
• Is critical or judgmental
• Does not communicate acceptance and caring (even if true inside)
• Hinders problem solving, problem management, and coping
• Tries to impose solutions rather than problem solve collaboratively
• Insists on using their solutions to problems, even if there may be other ways
to solve the problems
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Transactional Model
A transactional model means there is ongoing or constant movement with each person affecting
the other (more on this later).
A transactional model for emotion dysregulation, or even BPD, shows how many different factors
transact to result in both dysregulated emotion and dysregulated actions.
Notice the roles of:
• Events (sometimes called prompting events, or just things that happen)―these can be
public or social events, or thoughts, memories, pain, etc.
• Vulnerability to becoming dysregulated – biological, temperamental and previous learning
or conditioning
• Judgments
• Both inaccurate expression and invalidating responses
Transactional Model of the Development of BPD and Related Disorders
Emotional Vulnerability Pervasive History of
(current biology, baseline, Invalidating Responses
& temperament, such as
sensitivity, reactivity, slow
return to baseline) EVENT
Judgments
Dysregulated Behaviors
Heightened
Emotional Arousal
(Emotional Dysregulation)
Inaccurate Expression
Invalidating Responses
(from Others & Yourself)
Adapted from Fruzzetti, Shenk, & Hoffman, 2005; Fruzzetti, 2006
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Practice Exercises
1. What was your relative like when they were a child?
• What adjectives best describe his/her temperament?
• What were they like to “soothe”?
2. What are they like now?
• What adjectives best describe their temperament?
• What are they like to “soothe”?
3. Identify examples of your own emotional vulnerabilities: (Page 2-5)
• High sensitivity
• High reactivity
• Slow return to baseline
4. Think about your relative now in terms of their emotional vulnerabilities:
(Page 2-5)
• High sensitivity
• High reactivity
• Slow return to baseline
5. What family, cultural, social, or other environmental factors do you think were
present for your relative when they were growing up that might not have been a
good “fit” for their temperament? (Page 2-6)
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WORKSHEET
Transactional Model of the Development of BPD and Related Disorders
Pervasive History of
Emotional Vulnerability Invalidating Responses
EVENT
Judgments
Heightened Emotional Arousal
Out-of-Control Behavior
Invalidating Responses
(from Others & Yourself)
Adapted from Fruzzetti, Shenk, & Hoffman, 2005; Fruzzetti, 2006
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