Models of Change in the Psychotherapy of Borderline Personality Disorders

Patients suffering from borderline personality disorders are often difficult to treat, and require specific psychotherapeutic techniques. In current neurobiological models of borderline personality disorder, temperamental factors such as increased emotional reactivity and diminished attentional control figure prominently and account for the psychopathology of this disorder. Here, we follow a different approach and ask the question of how a model of this disorder may account for the modifications of psychotherapy technique that have proven effective in this class of patients. The psychotherapy of this disorder emphasizes work on enriching the semantic repertoire of patients in interpreting their own emotion and other people's motivation for their actions. Based on current psychometric research on distinct factors contributing to individual effectiveness in attentional control (working memory capacity), we propose that the organization of semantic memory may constitute an important and neglected aspect of a neurobiological model of this disorder. Impulsivity and emotional dysregulation resemble the long-term developmental effects of habitual strategies to determine response, which cognitive studies have characterized in terms of the interplay of attentional control capacity, cognitive and emotional load, and semantic organization. Rather than attributing an exclusive causal role to either increased emotional reactivity or diminished attentional control, we propose an account of this disorder as emerging from a self-reinforcing developmental history in which both these factors are intertwined. After mapping these notions onto specific psychotherapeutic interventions, we propose a model through which specific technical strategies result, in the long term, in structural change.