Byers, Padesky, Beck & Beck -Conceptualization & Treatment BPD

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Since DSM-III, the concept of personality disorder has progressed from a developing clinical agreement to formal standing in the DSM diagnostic system. The proposed DSM-5 classification emphasizes deficits in self and interpersonal functioning as well as the existence of abnormal personality features. This definition retains a visible tension. Researchers favor qualities that can be evaluated in three dimensions, whereas physicians prefer functional process descriptions. Furthermore, the definition suggests that personality disorder functioning is largely consistent over time; yet, the question of what is stable and what is changing regarding personality and personality dysfunction remains an important field of study exploration. This examination of the history of our understanding of BPD reveals that we have made tremendous progress since the 1970s. As we’ve seen, therapeutic experience with these individuals in the 1970s resulted in a phenomenological approach that inspired DSM-III criteria and a phenomenological/structural approach that assumes an underlying psychological organization that directs behavior. Ecological momentary assessment and social neurocognitive science are bringing modern technology to how people with BPD work in the present, moving from attention to specific incoming stimuli, appraisal of these stimuli, and cognitive-affect and behavioral responses. This sequence of functioning is disrupted in certain ways in BPD patients. The field is approaching an integration of the phenomenological approach of Gunderson and the structural approach of Kernberg, with greater precision in detecting the interpersonal behavior of patients with BPD through ecological momentary assessment and the use of fMRI to detect the operation of underlying neurocognitive structures. According to this review, methodological advances have aided in moving us beyond a purely phenomenological approach to an understanding that personality disorder is an emergent end product of interacting processes, with neurobehavioral systems underpinning psychological organization and behavior at another level of the organism. According to this viewpoint, BPD may be viewed as a dysregulated, reflexive approach to dealing with the rejection/trust issue in interpersonal circumstances. Patients with BPD are continually caught in an approach/avoidance dilemma, in which they passionately desire to connect with people while being terrified of rejection. They may, however, exhibit various maladaptive answers to this quandary, resulting in diverse phenomenological subtypes. With the impending release of DSM-5, which will make no modifications to the criteria for personality disorders, and the NIMH’s opposing RDoC approach, it needs to be seen how these two disparate methods can clearly lead us from the research laboratory to clinical practice. There is a serious risk that the clinical and scientific worlds may diverge in certain ways. With a better knowledge of the behavioral repertoire and the underlying neurobehavioral architecture in borderline illness, we may be able to more precisely describe the shifting features of BPD patients as well as those components that remain constant and stable over time. With these advancements, it is feasible that future therapy development may be led less by theory (cognitive behavioral, schema, psychodynamic) and more by empirical comprehension of the sequence of cognitive-affective reactions that disrupt interpersonal functioning in BPD patients.

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