DBTs Biosocial Theory of BPD

DBT organizes the nine DSM-IV criteria for BPD into five broad areas of dysregulation that clarify what skills the patient needs to learn and practice (Linehan, 1993a). These are (1) emotion dysregulation (labile affect and undercontrol/overexpression of anger), (2) relationship dysregulation (stormy, chaotic relationships and fears of abandonment), (3) self-dys-regulation (lack of sense of identity, emptiness), (4) behavior dysregulation (suicidal and self-injurious behaviors, and other impulsive behaviors), and (5) cognitive dysregulation (transient stress-related paranoia, dissociative, or quasi-psychotic symptoms).

The development and maintenance of BPD behaviors are viewed as resulting from a transaction between a biological component, dysfunction of the emotion regulation system, and a social-environmental component, an invalidating environment (Linehan, 1993a). BPD may involve a dysfunction of parts of the central nervous system involved in regulation of emotions. There is evidence for genetic influences on emotion dysregulation and on BPD, and early life trauma can have enduring structural effects on the developing limbic system, which is central to emotion regulation. DBT proposes that individuals with BPD are biologically vulnerable to experiencing emotions more intensely than the average person, and have difficulty modulating their intensity.

In an invalidating environment, the individual's communications about his/her private experiences are frequently met with responses that suggest they are invalid, faulty, or inappropriate, or that they oversimplify the ease of solving the problem. Consequently, the individual may come to self-invalidate and not learn how to label accurately, communicate about, or regulate emotions. Communications of negative emotions may be ignored or punished, but extreme communications may be taken more seriously, so the individual learns to inhibit emotional expression or to respond to distress with extreme behaviors.

Over time, as the individual's behavior becomes more extreme in attempts to regulate emotion or to communicate, he/she is likely increasingly to experience invalidation from the environment, including the mental health system, and in response the sensitive individual is likely to feel even more emotionally vulnerable. Thus, in this transactional model, the individual and those in his/her interpersonal environment continuously influence one another. The individual comes to experience frequent and pervasive emotion dysregulation and has poor emotion regulation skills, often relying on ultimately maladaptive coping behaviors. The intense expression of emotions or associated extreme behaviors typically adversely affect relationships, schooling and careers, and are viewed in DBT as largely giving rise to the other symptom criteria involving dysregulation of relationships, sense of self, and cognition. Difficulty in regulating emotion makes it more difficult to develop skills in interpersonal relationships, as well as in tolerating distress; therefore, all three sets of skills are explicitly taught and practiced in DBT (Linehan, 1993b).

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