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Treatment Of Borderline Personality Disorder Nursing Essay

Info: 5459 words (22 pages) Essay
Published: 1st Jan 2015 in Nursing

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AIM: For people with Borderline Personality Disorder, it is often very difficult to find an effective treatment and also to find NHS staff with the correct knowledge about the disorder. The aim of this literature review is to give a brief history of Borderline Personality Disorder and research the effectiveness of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy.

Method: A review of the literature and review of controlled trials and uncontrolled trials.

Conclusion: In the management of Borderline Personality Disorder, there are many problems to consider, out of these problems self-harm and suicidal tendencies are considered the most important to treat. Dialectical Behaviour Therapy has been found to be very effective.

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Chapter 1 – Introduction


Despite the many treatment options for people with Borderline Personality Disorder (BPD), many professionals in mental health services continue to believe that personality disorders are untreatable (NICE, 2009). This literature review provides evidence the effectiveness of Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) with Borderline Personality Disorder.


To understand BPD, I will give a historical overview of BPD.

Philippe Pinel in the 1800s, first described people who engage in deviant behaviour, but with no signs of thought disorder such as hallucinations or delusions as ‘mania without delirium’ or in French ‘manie sans delire’ (Friedel, 2004). Although the meaning of the term has changed through many writings on the subject over time, the writing of Cleckley and his use of the label “psychopath” in The Mask of Sanity brought the term into accepted usage (Meloy, 1998). The Mask of Sanity is a book written by Hervey Cleckley first published in 1941; he gave the most significant clinical description of psychopathy in the 20th century. An expanded edition of the book was published in 1982, when the name was changed from psychopathy to Personality Disorder. In 1972, newer editions of the book reflected a closer alliance with Kernbergs’s (1984) borderline level of personality organization, in particular defining the structural criteria of the psychopath’s identity integration, defensive operations and reality testing.

The diagnosis “borderline” was introduced in the 1930s to label patients with problems that seemed to fall somewhere in between neurosis and psychosis (Stern, 1938). Adolph Stern a psychoanalyst described the symptoms, which are now considered to be the criteria of BPD (Stern, 1938). He suggested the possible causes and what he thought the most successful psychotherapy treatments were. He renamed the disorder, by referring to patients with symptoms as the ‘borderline group’ (Friedel, 2004).

In 1940, the psychoanalyst Robert Knight introduced his explanation theory of borderline disorder (Friedel, 2004). Ego or sense of self psychology deals with mental function, which allows us to effectively combine our thoughts and to develop helpful responses to our life around us. He stated that people with BPD have impairments in a lot of of these functions, and he referred to them as “borderline states” (Friedel 2004).

The next important input was made by the psychoanalyst Otto Kernberg (1967); he introduced the term ‘borderline personality organisation’. He proposed that mental disorders were determined by three distinctive personality organisations: psychotic, neurotic and “borderline personality.” Kernberg has been a strong promoter of modified psychoanalytic therapy for patients with borderline disorder (Friedel 2004).

The first research on BPD was published by Roy Grinker in 1968, which he called ‘Borderline Syndrome’ (Friedel 2004). The next major article was published in 1975 by Gunderson and Singer. They defined the major characteristics of BPD. Gunderson then went on to publish a research instrument to enable an accurate diagnosis. Internationally researchers were then able to verify the validity and integrity of BPD (Friedel, 2004); this followed with BPD becoming a genuine psychiatric diagnosis and appeared in the DSM-111 in 1980.

Personality disorder categories are not firmly grounded in theory, nor are they empirically based (Livesley, 1998). Some critics say that personality disorder categories are so flawed that the best option is to abolish them and start afresh, but most pragmatists recognise that so much has been invested in them that they are very likely here to stay (Blackburn 2000a; Livesley, 1998).

The Nice Guidelines for Personality Disorder (2009) state that ”borderline personality disorder is associated with significant impairment, especially in relation to the capacity to sustain stable relationships as a result of personal and emotional instability” (NICE 2009). The severity of the symptoms, are related to the severity of the individuals personal/social situations. Stone (1993) argues that some people with BPD can still function at high levels in their lives and careers. Paris (1994) stated that about one-third of patients with BPD reported severe abuse involving an incestuous perpetrator; about one-third reported milder forms of abuse; and about one-third do not report abuse.

Personality disorders are common conditions; studies indicate prevalence of 10-13% of the adult population in the community and are more common among younger age groups (24-44 yrs) and equally distributed between males and females (Friedel, 2004). However, the sex ratio for specific types of personality disorder is variable e.g. antisocial personality disorder is more common among males, and borderline personality disorder more common amongst females (DOH, 2003). This chapter will provide to with an outline of Cognitive Behaviour Therapy and Dialectical Behaviour Therapy.

Cognitive Behaviour Therapy (CBT) can be seen as an umbrella term for many different therapies that share some common elements. The earliest form of Cognitive Behavior Therapy was developed by Albert Ellis in the early 1950s. Aaron T.Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s. Cognitive Therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is the primary type of psychological treatment being studied in research today. One specific form of cognitive-behavioural therapy is dialectical behaviour therapy (DBT), a broad-based, cognitive-behavioural programme developed specifically to reduce self-harm in women with borderline personality disorders (Linehan, 1993a; Linehan 1993b). Recent research has shown that dialectical behaviour therapy (DBT) is one of the first therapies that have demonstrated to be effective for treating borderline personality disorder as well as being effective in treating people who display varied symptoms and behaviours associated with mood disorders, including self-harm. DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of mindful-awareness, distress tolerance, and acceptance (Linehan et al, 2001).

1.2 Rationale

As a mental health student coming from a forensic background, I have experience of working with clients with personality disorder. I feel that by getting more of an understanding of CBT interventions, it will make a huge difference to my future practice in the future. McKenna et al (1999) state that it is unacceptable for health care not to be based on sound evidence of its effectiveness, and back up their practice with research-based evidence (NMC, 2008) to ensure effective clinical practice. Often nurses find it frustrating working with disorders of personality. These clients can be manipulative, socially inappropriate and difficult, for these reasons, such clients’ need all the patience and skills nurses have to offer. But despite this service in the NHS, services have been varied and inconsistent (DoH, 2003). ”Besides functional impairment and emotional distress, borderline personality disorder is also associated with significant financial costs to the healthcare system, social services and the wider society” (NICE 2009).

1.3 Aims and objectives

The aim of the review is to instigate current evidence surrounding CBT and DBT and objective of this project is to see if CBT and DBT are effective approaches with people who have Borderline Personality Disorder.

1.4 Methodology and parameters

This literature review was conducted using the following resources

Electronic databases: Cochrane library, CINHAL, Medline, Psychinfo, Psychology and Behavioural Sciences and Academic Search Premier

Key journals were hand searched: British Journal of Psychiatry, Journal of Personality Disorders, Mental Health Practice, Journal of Personality and Mental Health

University and Trust libraries

Google & Google scholar

The following types of literature were sought and reviewed where available

Randomised control trials

Systematic and structured review

Quantitative and Qualitative research studies

Position statements/guidelines from professional bodies

Government policies (NICE (2009), NSF (1999)

Text Books

Inclusion and exclusion criteria

Eligibility for this review was determined by the following criteria:

â- Participants: adults with BPD (diagnosed according to DSM-III/DSM-III-R, DSM-IV, DSM-IV-TR or ICD-10 criteria for BPD), with or without co-morbidity.

â- Intervention: psychological therapies, including CBT, DBT

â- Comparators: CBT/DBT or treatment as usual

â- Outcomes: self-harm, suicide, interpersonal and social functioning

â- Study type: published papers were assessed according to the accepted hierarchy of evidence, whereby systematic reviews of RCT’s are taken to be the most authoritative forms of evidence, with uncontrolled observational studies the least authoritative.

â- Exclusion criteria: papers on personality disorder without separate BPD

subgroup analyses.

The studies were obtained through a number of sources, as above. Searches were performed by entering the key words – “Borderline Personality Disorder”, “Cognitive behaviour therapy” into several databases, which yielded many secondary references of current best evidence. Search filters developed consisted of a combination of subject headings. The topic-specific filters were combined with appropriate research design filters developed for systematic reviews, RCTs and other appropriate research designs. These articles were selected after careful reading of the title and abstract to identify the most useful. I then limited my search to full articles which made my search a lot easier. The definitive text that will be used to aid my search will be NICE Clinical Guidelines for Personality disorder 78. ”This guideline makes recommendations for the treatment and management of borderline personality disorder in adults and young people (under the age of 18) who meet criteria for the diagnosis in primary, secondary and tertiary care” (NICE, 2009).

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BPD is present in 1% of the population, and is most frequent in early adulthood. Women present to services more often than men. BPD is not often formally diagnosed before the age of 18, but the features of the disorder can be identified earlier. Its path is changeable but many people do recover (NICE 2009). This search will comprise both British and international articles. When choosing which articles were going to be relevant, I found it impossible to ignore the amount of articles I had on DBT and as DBT was evolved from CBT and made specifically for BPD, I decided to bring it into my literature review.

The articles are mixed quantitative and qualitative research. The qualitative means of gathering subjective data is centred on an individuals experience, beliefs, empowerment and quality of care and does not solely concentrate on clinical outcomes for the individual. One could argue that this is the most appropriate aspect of research for mental health nurses as mental illness is individual for each person involved in the process and although BPD is not a mental illness. ‘The National Service Framework for adult mental health sets out our responsibilities to offer evidence based, effective services for all those with severe mental illness, including people with personality disorder who experience significant distress or difficulty’ (NIMH 2003). While these can be misconceived as an ‘easy option’ form of research, qualitative research offers rich, reflective and exhaustive data that is invaluable and has a profound contribution to make to take to practice. The qualitative evidence was limited with regards to the treatments reviewed, with an emphasis on DBT. Quantitative research is a formal, objective, and rigorous statistical process for generating information about the world (Burns & Grove 1999), whereby the researcher would gather a range of numerical data in order to answer the research question, or prove, disprove a hypothesis (Parahoo 2006).

Philosophies or schools of thought in research are called paradigms (Parahoo 2006). One such paradigm is positivism. Parahoo (2006) asserts that positivism relies on observations by the human senses to create fact (empiricism), and believe in the unity of science, and the notion of cause and effect (determinism). The positivist researcher will endeavour to test a hypothesis or theory using the deductive process of a course of experiments. This paradigm utilises a quantitative approach in its research methods. For the positivists, quantitative research is believed to provide hard evidence and objective fact that can provide knowledge on which to base best practice (Parahoo 2006).

Efficacy studies focus on the usefulness of a specific helping methodology for a particular kind of problem. Comparisons are made between the methodology in question and some other methodology between clients with some disorder who do receive the treatment and those who do not or between two different methodologies for treating the same disorder. These studies are carried out under controlled conditions. Many of the studies are well designed and demonstrate efficacy. In a healthcare context, efficacy indicates the capacity for beneficial change (or therapeutic effect) of a given intervention.

Chapter 2 – The Literature Review

Having undertaken a critical review of the literature, I have come to explore a number of issues which I feel necessary to consider, key themes emerging from this literature review are the impact of CBT & DBT on suicidal behaviours, the impact of CBT & DBT on self-harming behaviours, and the impact of CBT & DBT on engagement. This chapter sets out to explore these themes in more detail. On the whole the most suitable research design to answer this is the Randomised Controlled Trials (RCT); hence the evidence base reviewed include accessible RCTs undertaken in those with a diagnosis of BPD (NICE, 2009).

The causes of BPD are complicated and remain uncertain, contributing factors may include an inherited vulnerability, a particular temperament, early life experiences and, in subtle neurological or hormonal disturbances (NICE 2009). NICE (2009) state that ”the history of specific psychological interventions designed to help people with borderline personality disorder is intertwined with changing conceptions of the nature of the disorder itself.”

Swartz (1990) wrote that BPD is more common among drug and alcohol users. And within these dependents there will be more women diagnosed than men. Zanarini (1998) also adds that the disorder is more common in those with eating disorders, and also among people with self-harming behaviours (Linehan et al., 1991)

2.1 Defining Cognitive Behaviour Therapy and Dialectical Behaviour Therapy

NICE (2009) define CBT as a ‘structured psychological treatment that focuses on helping a person make connections between their thoughts, feelings and behaviour.’ Originally CBT was used as a treatment for depression which has now been modified to treat BPD. CBT focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs, to engage in experimental reality testing, and to develop better coping strategies. The goals of these interventions are to reduce the delusional beliefs, and consequently their severity, and to encourage effective coping and decreasing distress. This literature review will assess the contribution of CBT and the disorder by discussing reviews on effectiveness. CBT for BPD was developed with the idea that people with BPD have learned distorted beliefs and thoughts overtime. Distressing emotional responses and behaviours develop as a result. Beck & Freeman (1990) outlined such beliefs, relating to dependency, distrust, and rigid perceptions. The distorted thoughts are modified by monitoring, analysis and questioning.  Davidson (2000), adds that particular attention should be paid to the problems that can disrupt therapy, and so disrupt the therapeutic relationship (NICE, 2009), such as non-engagement, loss of structure, losing focus and lack of compliance. CBT for BPD attempts to create change by ‘improving the attitude of the patient toward treatment, the enhancement of specific skills, and the reduction of hopelessness’ (Friedel, 2004). The therapist and patient will construct a list of problem areas. A set of tasks will be developed that will generate and reinforce new attitudes and behaviours, which will replace the old attitudes and behaviors that have caused problems in the past.

Within the past 15 years, another, newer psychosocial treatment termed Dialectical Behaviour Therapy (DBT) was developed. DBT joins standard cognitive behavioural techniques with acceptance based strategies, as well as strategies designed to keep the therapy balanced between change and acceptance (dialectical strategies). Marsha M. Linehan, a psychologist from the University of Washington in Seattle, developed DBT specifically for people with BPD, especially those who engage in self-destructive and self-injurious behaviours. DBT is based on the belief that the symptoms of BPD result from organic impairments in the brain that control emotional responses. The early behavioural effects of this impairment are exaggerated, as the person with this biological risk factor interacts with people who do not validate their emotional pain and don’t help them learn effective coping skills. DBT has gained significant support in the treatment of BPD because of the results it has achieved in several research studies. It has been shown that DBT can be taught to and used by many, but not all, mental health professionals. For the time being this seriously restricts the use of this helpful treatment approach. DBT seeks to validate feelings and problems, but it balances this acceptance by gently pushing to make productive changes. DBT also deals with other opposing or ‘dialectical’ tensions or conflicts that arise, such as the patient’s perceived need for a high level of dependence on the therapists, and the fear and guilt aroused by such extreme dependency. DBT combines both cognitive and behavioural techniques and designed specifically to treat BPD. It is a combination of individual psychotherapy and psychosocial skills training that has been shown via controlled clinical trial to be effective in treating individuals with BPD (Linehan, 1993b). One of the most limiting factors of treating and delivering therapies is that there is not enough staff in the NHS trained to a high standard (NICE 2009). Cunningham (2004) interviewed fourteen women with BPD to discover why and how DBT is effective. The women were provided with tools to help them deal with their problems and so enabled them to ‘to see the disorder as a controllable part of themselves rather than something that controlled them’ (NICE, 2009). Cunningham (2004) found that although their problems did not disappear, they became more manageable. It also seemed to have encouraging results on their relationship interactions, and, in addition DBT instilled hope and an ability to try to live independently (NICE, 2009)

2.2 Suicidal acts

NICE (2009) define suicidal acts as, ‘deliberate; life threatening; resulted in medical attention; medical assessment consistent with suicide attempt’.

The main problem staff face in managing BPD is suicidal behaviour (Paris & Zweig-Frank, 2001). There is also an association between BPD and depression (Skodol et al., 1999; Zanarini et al, 1998), and Solof (2000) adds that the combination of the two disorders increases the number of suicide attempts. People with BPD possibly will take part in a number of negative and reckless behaviours including self-harm, eating disorders and substance misuse. Self-harming in BPD has different meanings to each individual, including relief from feelings and distress, such anger, or to reconnect with feelings after episodes of emptiness (NICE, 2009). Because of the high occurrence of self-harm, the risk of suicide is higher (Cheng et al, 1997), with 60-70% of patients with BPD making suicide attempts at some point in their lives (Oldham, 2006), however, unsuccessful attempts are far more common and the actual rate of completed suicides is estimated at between 8-10%. A specific therapy for BPD, DBT takes a behavioural approach to self-harm and suicidal acts that include ‘skills training in emotional regulation and validation of client experience’ (NICE, 2009). Cognitive-behavioural therapy along the lines of Beck, Freeman, & Associates (1990) has been investigated in at least two uncontrolled trials. Brown, Newman, Charlesworth, and Chrits-Cristoph (2003) found significant decreases on suicide ideation, hopelessness, depression, number of BPD symptoms, and dysfunctional beliefs after 1 year of cognitive-behavioural therapy for suicidal or self-mutilating patients with BPD. Results were maintained at a 6 months follow-up. Effect sizes were moderate (0.22-0.55). Dropout rate was 9.4%. Arntz (1999a) found positive effects of long-lasting cognitive-behavioural therapy in a mixed sample of personality disorders, including 6 patients with BPD. Two patients with BPD dropped out prematurely, but the other four attained good results.

Linehan et al (1991) conducted a randomised controlled trial using 44 chronically parasuicidal women with BPD to assess the effectiveness of DBT. Among the two groups, there was very little difference between measures of depression, hopelessness and suicidal ideation. Overall the group which received DBT had an average of 8.46 inpatient days compared to the controlled group which had 38.86 days. A naturalistic follow up review was conducted on 39 on the women one year later, to determine the effects of DBT. The women that had completed the DBT course had fewer parasuicidal episodes, but after 18-24 months there were no significant differences between the two groups, although psychiatric inpatient days were still lower for the DBT group.

Rathus et al. (2002) went on to conduct a study with a group of 111 suicidal teenagers. 29 were assigned to DBT, while the other 82 had treatment as usual (TAU). It is worth mentioning that the DBT group had far more severe symptoms pre-treatment. The study therefore was not randomised. During the 12 week treatment, the DBT group had fewer inpatient hospitalisations, although the number of suicide attempts made during the treatment did not differ between the groups, but, the attendance and completion was higher in the DBT group.

A smaller case study was conducted by Hengeveld et al (1996); he reported of 9 female patients who were given a 10 week course of CBT, they had all attempted suicide at least twice. Of the 9 women, four of those were diagnosed with BPD. Following up the women 10 months later, by phone or examining medical records, all four BPD patients had reports of further suicide attempts (NICE, 2009).

Linehan et al. (2006) conducted a one-year randomized controlled trial with one year of post-treatment follow up. The objective was to evaluate the hypothesis that unique aspects of DBT are more efficacious compared to treatment offered by non-behavioural psychotherapy experts. The study included 101 female participants with recent suicidal and self-injurious behaviours that met DSM-IV criteria. The subjects who received DBT were half as likely to make a suicide attempt.

2.3 Self-harm

NICE guidelines (2009) use the definition that self-harm is ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’.

Self-harm BPD is connected with a range of diverse meanings for the individual, including release from distress and feelings, such as emptiness and anger, and to reconnect with feelings after an episode of dissociation (NICE, 2009). There have been positive attitudes from patients about DBT, as it has helped improve their ability to control their emotions, improves their relationships and significantly reduces the occurrence of self-harm (NICE, 2009).

In a large sample, Tyrer et al (2003) found that CBT was equivalent to TAU for the treatment of recurrent self-harm and noted that this method was less effective for patients with BPD.

In an uncontrolled study by Brown (2004), patients with BPD with self-harming tendencies received CBT over 12 months; they then stayed in contact with them by phone over the next 6 months. Therapists were on call to emergency phone calls throughout.

A randomised controlled study by Verheul et al (2003) was carried out to compare DBT with TAU for patients with BPD, 58 women received treatment for a year were randomised to DBT or TAU. The results: the 12 month attrition rate (37%) for DBT was substantially lower, compared to TAU (77%); DBT treatment also resulted in a large reduction of self-harming behaviours than TAU.

A follow up review of this study was carried out by Van den Bosch et al (2005), to ascertain whether the previous results were continued over the following 6 months. It was discovered that the benefits of DBT after the treatment were sustained, and levels of self-harm were lower. It must be said, however, that the definitions of self-harm were all slightly different in each of the RCTs, this can make it very difficult to compare results (NICE, 2009).

Another case study series by Alper (2001), presents data on 15 women in a forensic setting, with a diagnosis of BPD. Nurses in the hospital carried out the DBT, and over 4 weeks there was a significant reduction in the occurrence of self-harm. Alper (2001) also carried out qualitative interviews with the nurses to describe how they felt about the treatment, they were all very positive.

Bateman & Tryer (2004) state that the extensive implementation of DBT is a acknowledgment of its founder, Marsha Linehan, with its mixture of acceptance and change, skills training, manualisation, and an opinion that is willing to embrace this comprehensive approach (NICE, 2009). The evidence strength though, is not justified, however (Tyrer, 2002b), and answers about the long-term success of this therapy as a treatment for BPD are premature. In view of the fact that the original trial, which was handicapped by many methodological limitations, there has only been one study that supports the findings clearly, which was that of Verheul et al (2003) (NICE, 2009).

2.4 Non-engagement

For effective treatment, commitment to therapy is required, and research shows that fewer people drop out of DBT than other therapies (Verheul et al 2003)

Haigh (2003) interviewed service users and according to them the services could be improved if staff recognised and accepted that BPD can be treated; they felt a more positive experience at their preliminary referral would aid further engagement with services; therapeutic relationship endings were dealt with effectively; and when signs of improvement are observed, services should not be removed immediately, as this tends to raise anxiety and discourage future progression (NICE, 2009).

Hodgetts et al (2007) studied five people with BPD. The participants were told that DBT was the only treatment for BPD. This raised expectations and anxieties in the service users. Some preferred the structure of DBT, but others would have preferred a more flexible treatment that is adjusted to each individuals needs. Service users each felt differently about individual therapy and group therapy. One participant dropped out of therapy as she found the challenges too much to deal with. The same lady reported that she was turned away from the crisis team as she was already involved in the DBT group; this was another reason for her departure. All of the participants in this study found that the therapeutic relationship is essential, also they appreciated the importance of collaborative working and sharing their experiences (NICE, 2009).

Other studies have reported quite high drop out rates from CBT, for example up to 37% (Verheul et al, 2003). It is probable that some patients did not engage because they did not find the therapy useful, but ratings from patients who had at least five sessions of CBT suggest that both the patients and therapists view the experience of therapy to have been a positive one. Even so, some patients simply did not attend.

Chapter 3 – Discussion and Conclusion

This literature review has tried to look at research evidence on the efficacy CBT and DBT in the management of Borderline Personality Disorder. This work has been done using the NICE Guideline (2009) as the definitive text. This is because this guideline is main reference document in clinical practice. Borderline Personality Disorder is one of the most challenging entities for today’s therapist; in fact, this category originated as a repository for patients who fail to improve with ordinary treatment methods and whose particular pathology is most likely to provoke a negative emotional reaction in the therapist. Comfort and effectiveness in the treatment of BPD implies mastery both of one’s own emotions and of therapeutic techniques in general. It is not realistic to expect success in every case, and successful treatments are usually long and stormy.

Because the BPD diagnosis have common characteristics with schizophrenia, psychoses, anxiety and depression, Gunderson (2001) believes it to be a ‘wastebasket’ diagnosis, which lacks diagnostic accuracy and strength, and so would only be useful to service users that did not fall into other diagnostic types. It is thought that BPD has responded badly to the treatments, and a lot of health professionals also unfortunately, believe this to be true (Friedel 2004).

It seems that overall the non-RCT outcomes suggest that individual therapies are more suitable to people with BPD. Positive outcomes were shown generally, these need to be compared to the RCTs before definite conclusions can be made (NICE, 2009). It seems that the evidence base is fairly poor for therapies of BPD, the studies are minimal, the number of patients are low and the outcomes too numerous, with very little commonalities between studies (NICE, 2009)

Giesen-Bloo et al (2006) are critical of DBT, stating that it fails to reduce core symptoms related to deeper personality change. The most difficult problem is that DBT is resource-intensive and expensive. Where it is available, there are usually long waiting lists. However, DBT is the treatment of choice for individuals experiencing severe impulse and self-harming behaviours.

3.1 Strengths and limitations of the review

Having never done a substantial piece of work befor


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