Loneliness is a key driver in the maintenance of borderline personality disorder (BPD), Harvard researchers argue. Thus, many patients cite increased social connection as a primary treatment goal. In the Harvard Review of Psychiatry, part of the Lippincott portfolio from Wolters Kluwer, Lois W. Choi-Kain, MD, MEd, DFAPA, of Harvard's McLean Hospital, and colleagues call for BPD treatment to extend beyond exclusive therapeutic relationships to help patients build durable connections with others in the community.

"Any support in building small connections can provide some relief from loneliness and work against cycles of dependency, exclusivity, and volatility in social relations," the authors emphasize. "Additionally, benefits achieved through community resource-driven interventions are valuable in a landscape in which demand for traditional psychotherapeutic treatment drastically outweighs supply."

Loneliness is core to BPD, but current interventions do not address it comprehensively

In a review of scientific literature, Dr. Choi-Kain's team found that, compared with healthy controls, individuals with BPD consistently report higher levels of loneliness, which is defined as a subjective feeling of insufficient social connection distinct from the person's objective degree of social isolation. Moreover, social networks of people with BPD include more intense and exclusive relationships, such as romantic partners and therapists, and fewer acquaintances.

Loneliness often persists when clinical symptoms remit, indicating that it is integral to BPD. In the general population, loneliness has been linked to numerous chronic health conditions and premature mortality. Therefore, loneliness should be targeted as a general health intervention in BPD.

The team, however, identified multiple studies demonstrating that dialectical behavior therapy, which concentrates on emotional dysregulation and skill deficits, does not result in adequate functional improvements in roles that can provide a positive sense of self. Major psychodynamic approaches, such as mentalization-based treatment and transference-focused psychotherapy, focus on enhancing accurate and mature social cognition and insight, but do not always focus on social integration in the community.

General psychiatric management promotes self-reliance and community engagement

In addition to noting the shortfalls of current treatment approaches, Dr. Choi-Kain and her co-authors critique colleagues for "advocating sequential migration of patients through multiple intensive specialist psychotherapies." They point out, "this practice of stringing together lengthy and inaccessible therapies continuously socializes patients into dyadic caregiving in treatment settings rather than emphasizing self-reliance in the real world."

A better option, the group says, is the general psychiatric management (GPM) model, which considers hypersensitivity to interpersonal stressors to be the core dysfunction in BPD. In addition to harnessing psychoeducation to help patients more realistically understand their social interactions, GPM emphasizes developing self-esteem and identity through work and other forms of responsibility. The idea is to expand patients' social networks by helping them form low-stakes relationships through role-bound, scheduled, activity-directed interactions such as:

Group therapy, which allows patients to practice social behavior in a supportive environment, provides a forum for explicit instruction on rules and community values, and balances the intense and exclusive relationships that people with BPD tend to form Connection to nonclinical community resources, including organized activities in line with patients' genuine interests, such as gardening, sports, and the arts, as well as engaging in individualized pursuits in a shared space Vocational interventions to increase patients' self-reliance by participating in daily activities and structured relationships with others Peer support, which appears to benefit both patients and peer support specialists

Dr. Choi-Kain's group urges more attention to the long-term recovery period for patients with BPD, beyond initial symptom reduction. "Greater investment in this later treatment phase is critical and requires further research to help patients work independently, among peers, and in relationship with others to solidify and stabilize their personality functioning."

Source:

Journal reference:

Mermin, S. A., et al. (2024). Borderline Personality Disorder and Loneliness: Broadening the Scope of Treatment for Social Rehabilitation. Harvard Review of Psychiatry. doi.org/10.1097/hrp.0000000000000417.