Eclectic Structured Psychotherapy for Cluster B Personality Disorder- Borderline Type: A Case Report

Eclectic Structured Psychotherapy for Cluster B Personality Disorder- Borderline Type: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Eclectic Structured Psychotherapy for Cluster B Personality Disorder- Borderline Type: A Case Report Shruti Mohan, Dr Emilda Judith Ezhil Rajan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8038272/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cluster B personality disorders are characterized as having dramatic, emotional, and erratic personality traits with a general lack of empathy for others and poor impulse control. Dialectical behaviour therapy is a known treatment for addressing adaptive behaviours and regulating the patient’s emotions in cluster B personality disorders. The present case study has encountered pathological and psychosocial distress in borderline personality disorder, throughout therapy an eclectic approach was formulated by the use of Dialectical Behaviour Therapy, Rational Emotive Behavior Therapy and contemporary behavioral techniques. The case presents with a complaint of talking to self, alongside dissociative tendencies with depression, and a feeling of distress with increased tendencies of Non-Suicidal Self Injury in addition to difficulties in social life and nicotine dependency. Further, a clinical interview with the family revealed childhood aggressive behaviour with a lack of remorse and difficulty in expressing appropriate emotions. It was indicated that the integration of these techniques showed improvement from the distress caused by maladaptive personality traits and aided in addressing behavioural habituation further enabling social adaptiveness. Weekly sessions were conducted and tracked by maintaining target goals and homework assignments (involving behavioural exploration and conditioning with social languages and interactions). This case report aims to provide a practical approach to the treatment process that can be used when addressing individuals with similar symptoms and presentation. Psychology Borderline Personality Disorder Non-Suicidal Self Injury Dialectical Behaviour Therapy Behaviour Therapy Rational Emotive Behaviour Therapy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 1. Introduction Cluster B personality disorders are often associated with psychopathy in several dimensions, primarily characterized by interpersonal dysfunction, affective instability, erratic behaviors, and antisocial conduct. These traits may contribute to significant societal challenges for the individual. Emotional dysregulation and maladaptive emotional regulation noted along with the traits mentioned above and behaviours are hallmark characteristics of a Cluster B personality disorder. Based on object relations theory, there are three characteristics of a typically developed personality: i) an integrated concept of self and other, ii) a broad spectrum of affective experience and, iii) the presence of an internalised value system. Affect regulation is necessary for full awareness in maintaining impulse control. Internalizing values derived from early parenting further influence external relations, in the form of personal responsibility and realistic self-criticism. In borderline personality disorder, the lack of integration in primitive positive (idealized) and negative (persecutory) segments, is brought out by a split in identity diffusion. This type of organisation of self-concept plays a role in emotional lability, interpersonal chaos, and lack of social reality testing (Clarkin et al.,2007). 1.2 Eclectic Psychotherapy Eclectic Psychotherapy involves utilizing a range of concepts and strategic methods derived from various theoretical frameworks (Garfield et al., 1977 and 1980; Brammer & Shostrom, 1982). There is a flexible and comprehensive strategy for addressing Cluster B personality - borderline type disorders by integrating techniques from diverse therapeutic approaches. Tailoring therapy to individual needs, tackles the intricate and multifaceted aspects of these disorders, facilitating healing, personal development, and enhanced quality of life for those undergoing treatment. Considering the emotional dysregulation, self-harming behaviors, and negative thought patterns associated with Cluster B Personality- borderline type, a combination of interventions from different therapies was assessed as suitable than relying on a singular approach, where individuals to delve into and comprehend the root causes of their personality disorder symptoms, which can include early life experiences, trauma, or attachment issues. (Livesley, 2008). The method specific to this case initially addressed emotional dysregulation. The dialectic philosophy is a balance of both acceptance and change, where the individual is encouraged to tolerate intense emotions along with changes associated with their behavioural response. It consists of stage one addressing the self-harm behaviours, therapy-interfering behaviours and quality of life interfering behaviours. Stage two focused on radical acceptance and reprocessing adverse emotional experiences. Stage three involved skills training, distress tolerance and interpersonal effectiveness, and the final stage was focused on mindfulness training (Dimeff et al., 2001). Dialectical Behaviour Therapy (DBT), based on biosocial theory states that underlying borderline personality disorder is a chronic emotional dysregulation, including increased sensitivity and reactivity to emotions, and relatively slower time taken to return to baseline. (Linehan,1993). The second approach- Rational Emotive Behaviour Therapy (REBT), was brought into the framework to address negative irrational thoughts challenging irrational beliefs that lead to emotional distress and replacing them with rational, healthier beliefs. Given the event in the history of the case, it aimed to address the cause of the emotional reaction and beliefs rather than the events faced by the client, which indicated dysregulated ways of thinking, feeling, and behaving. Further addressing individual’s demandingness (believing that things must be a certain way), catastrophizing (believing that negative events are unbearable catastrophes), and global evaluations (believing that one's entire self-worth depends on one aspect of life) (Ellis A,1994) Finally, the component of Behavior intervention was introduced for nicotine dependency. This focused on modifying maladaptive behaviors. The emphasis is on identifying problematic behaviors that are causing distress and impairment in this case the use of nicotine and implementing strategies to change those behaviors in the here-and-now process. (Miltenberger et al., 1998 ) 2. Methodology The case study was recorded at a private hospital in Chennai, India which has a Clinical Psychology department that caters to its nearby urban and rural areas. A qualitative case study method was used to explain the real-life experiences and treatment procedures undertaken. The patient was first admitted to the OP where a detailed case history followed by a mental status examination was performed. Following this, a provisional diagnosis along with a differential was reached, as Cluster B Personality Disorder- Borderline type, this further warranted the formulative intervention based on the eclectic approach of integrating DBT and REBT with additional goals requiring contemporary behaviour techniques. Each session note was followed up by a discussion with the supervisor with a doctorate in clinical psychology. The therapist was a clinical psychology trainee as a part of a super specialty program that is conducted for the licensing of clinical psychologists in India. The therapist was further guided by the supervisor on site with regular clinical supervision and further education. 3. Case History A 24-year-old female presented to the OPD of the clinical psychology department in a private hospital in Chennai with non-suicidal self-injury, feelings of emptiness and increased mood swings for the past seven years. Her self-harm behaviour was reported to have begun at the age of fifteen, and she had been evaluated by a psychiatrist and prescribed medications. Irregular adherence to the prescribed medication regimen was observed. Additionally, despite recommendations for hospital admission from the physician, the patient declined to pursue this option. She was treated in the OP where the irregular adherence was noted. Later during the completion of her postgraduate, she visited the psychiatrist and used medications for a brief period (three weeks). She returned to the psychiatrist two years back, in 2021 due to difficulties dealing with her social situations and interpersonal communication. The familial report indicated that she was an adamant child with increased temper tantrums that would extend to hitting herself and banging on the wall. Extreme behaviour was indicated with her hitting her mother with sharp objects and pinching in inappropriate places and she often expressed being content by exerting pain on others. Invalidating of other’s emotions and distress, and at times exhibiting defiant intransigent behaviours involving dropping food, eating from the floor and threatening to harm herself to get desired objects or actions from family members. She reported a close relationship with her grandmother and had a falling out with her believing that she was given less importance compared to her siblings. She often reported to indulge in behaviours that distressed her grandmother and also refused to extend her help when she was in her deathbed. Lack of emotion was reported after her grandmother’s death. In 2020, she was reported attempted suicide on consumption of sleeping tablets (20 Zolfresh) with a suicide note expressing hatred towards her father and blaming him for her actions. Though no adverse effects occurred, she was precautionary taken to the hospital when she reported this to her parents the next morning. Current history indicated the presence of multiple relationships that would last only for a brief period, with very poor interpersonal connection and extreme emotional dysregulation resulting in social avoidance. She also reports of crying spells and used extremely foul language when situations would not go her way. Furthermore, she had difficulties with her peers about academics due to poor communication and aggressive social demeanor resulting in loneliness/emptiness. She would compensate by indulging in smoking and non-suicidal self-injury. Difficulties in her interpersonal romantic relationships were also reported, where she is not able to accept her partners leaving her, and would lie about taking birth control medicines so that she can make them stay with her by getting pregnant. On performing the mental status examination, she appeared tense and fidgety with a low tone and slow tempo of speech. Further clinical evaluation reported hypnogogic hallucinations on rare occasions, with intact cognition and judgement. Importantly, she is aware that her illness is caused by something unknown in her. 3.1 Case Formulation Diagnosis Impression and Assessment Based on the patient and family history, a provisional diagnosis indicates that she falls into cluster B personality- borderline type with added comorbidities of substance use and historical behavioural. Given the clinical presentation further evaluation was conducted to confirm the pathology and indicators. She was evaluated for organicity, cognition, psychopathology, and projective tests, and the severity of her symptoms was rated on a scale. The assessment was completed with the Bender Gestalt Test, Weschler’s Adult Intelligence Test IV, Millon Clinical Multiaxial Inventory, Sentence Completion Test, Thematic Apperception Test, and Rorschach Inkblot Test. The assessments indicated higher visuospatial ability with the absence of organicity. Her intelligence was evaluated as 111 with the performance quotient being higher than the verbal quotient. Pathological evaluation indicated a depressive personality pattern, masochistic personality pattern in the clinical personality pattern; borderline in the severe personality pathology; dysthymia and anxiety as clinical syndromes. Conflicts were identified with the family, especially with the father. Needs identified were affiliation, deference, sex, succorance, abasement, blame avoidance and retention. The presses identified were lack, uncongenial environment, coercion, imposed task duty, rejection and dominance; further indicating emotional conflicts and constant fear of abandonment. RIBT indicated disturbed thinking patterns, and exaggerated self-involvement with an inflated sense of personal worth dominating her perceptions of the world. Interpretation also revealed antisocial acts with less adaptive interpersonal behaviours and highly impulsive behaviour with a heightened perception of aggressiveness, dramatic behaviour, and low empathy indicative of a Cluster B personality disorder. Importantly, the patient showed symptoms from all four subtypes of Cluster B personality disorder. From a narcissistic perspective, grandiose thoughts that ‘she will be liked by the men around her no matter what’, ‘she is more beautiful than her elder sister’ as well as anger outbursts when told otherwise are present. From a histrionic perspective, mental status examination indicated inappropriate clothing in the hospital with more importance given to her physical looks along with self-dramatization. From a borderline perspective, her self-harm and suicidal gestures are hallmark symptoms along with emotional dysregulation, chronic feelings of emptiness, and inability to have stable relationships. From an antisocial perspective, a lack of remorse and empathy was noted from her childhood, which continued till the present age and manipulative behaviour was also present. As noted, the patient has traits from all four types and hence was diagnosed as having a Cluster B Personality Disorder- Borderline type with supportive evidence from the psychometric assessments. Further, her cognitive assessments show an imbalanced IQ profile with her performance part of the test being greater than the verbal part in WAIS, and this is a rough indicator of a sociopath. Her lack of guilt, empathy, and any emotions with heightened narcissism, further shows the individual does not feel ‘fear’ and the dysregulated emotions, making it easier for her to act on her impulses. Adverse environmental factors such as Adverse or neglected parenting, abuse and trauma have poorly regulated emotional processing and self-control. A key indicator identified was cognitive assessments that demonstrate an imbalanced IQ profile where the individual’s performance part of the test (associated with the right brain) is greater than the verbal part (associated with the left brain) in WAIS. (Duara et al.,1984). This imbalance suggests a right hemisphere superiority in comparison with the left hemisphere, and is noted in abused and neglected children due to the constant fear. The tendency is termed as ‘frozen watchfulness’ and is a right hemisphere motor skill, which develops earlier than the left hemisphere’s language skills. Experience of abuse or neglect during the organizational period of brain development leads to more emphasis on the right brain functioning throughout life. Further, increased dependence on the right hemisphere occurs due to a significant left hemisphere dysfunction. 4. Results The treatment protocol is based on eclectic psychotherapy of DBT, and REBT with behaviour techniques that inculcate strategies aimed at understanding the cognitive conceptualization, addressing emotional regulation, irrational thoughts in belief systems in interpersonal relationships and distress tolerance, as well as improving interpersonal effectiveness and mindfulness. Contemporary behaviour techniques were also adopted to address her addictive behaviours. The first stage of the treatment process was aimed at reducing life-threatening behaviours such as suicidal gestures and other self-harm habits (cutting wrists and medicine overdose). This was specifically identified as NSSI (Non-Suicidal Self-Injury) based on history and psychometric evaluation and further confirmed during therapeutic formulation. This behaviour re-surfaced during the initial stages of therapy, and she reported that this behaviour gives her the feeling of control in any relationship that she pursues. This particular behaviour was addressed by using chain analysis, followed by challenging maladaptive thoughts that led to the development of emotional regulation. Figure 5.2: Illustrates the chain analyses taken into account adapted from www.helpwithdbt.com/behaviour-chain-analysis and modified for the current patient The identification of risk behaviour indicated that there is a learned response to abandonment in the patient and self-harm habit is reinforced by a significant person. Chain analysis indicated the presence of difficulty in relationships, and the tendency for self-harm, which was highlighted by self-destructive behaviours- based on this a verbal agreement was made. Following this the patient expressed intention during therapy but never indulged in it. A thought diary was followed, consisting of situations, thoughts, emotions and the consequent behaviour. This prompted further discussion regarding her relationships. Techniques such as Socratic questioning and self-monitoring identified negative automatic thoughts. She was taught to cope with her automatic thoughts through the process of distraction techniques. With repeated questioning, it was identified that she was impulsive, and also her core belief was that she was not lovable and she had a fear of being alone. Socratic dialogue was used to challenge this, where she was able to attain insight on her thoughts. Following the above exercise, she showed progress in her attempt to work on self-recognition and adapt abilities to self-sustain. Given her self-comfort, the next phase of treatment involved addressing emotion regulation and building distress tolerance. This particular step was initiated based on her beliefs that were built from past childhood experiences that were reported by her to be traumatic (Specific to her paternal grandmother and relation with her sibling). Addressing her emotions, and distress relating to her family members where she felt that they are not comprehensive of her needs and expressions. Thus, we initiated the use of the safe place visualization exercise that would help her distress. She was further followed up with the use of a radical acceptance process involving the identification of distress situation and building new coping thoughts as described below in Table 1 . Table 1 Shows the distressing situation and its corresponding new coping thought S. No Distressing Situation New Coping Thought 1. My roommate has a stable boyfriend who is kind to her I am still young and I can find a partner who will be kind to me 2. My father yelled at me this morning for something that was not my fault That is how he is, he has always been criticizing everyone, it is not my mistake 3. When watching a romantic movie, I feel sad I do not have someone like that It is just a movie; it is not reality and this feeling will soon pass Further steps involved ‘Thought and Emotion Defusion’, the process of detaching from overwhelming thoughts and emotions by indulging in mindfulness exercises that help to overcome and control emotions. This process was enforced by a course of five to six weeks. She was then started with cognitive techniques from REBT to restructure her cognition belief with the existence of an irrational belief system in interpersonal relationships; where it was identified as her having an irrational thought that she needs to be in control in her interpersonal relationships to feel safe. Rational analysis was used when instances were provided to dispute her irrational beliefs, changing language to avoid giving absolutes such as always, never, should, reframing was done to help her re-evaluate the choices of disappointment, concern, distress and shedding light on the positives in a negative situation; alarming her to realize that things can be a lot worse but it’s not; emotive technique of shame attacking - Helping her talk to herself like she would if she was a child, helping her understand that certain things are beyond control and also implementing self-image - by saying nice things about her in the mirror, dressing up and clicking pictures of herself - to celebrate her self. Behavioural management strategies were used simultaneously for managing smoking behaviour because she was having ten cigarettes per day on average, specifically in the mornings, afternoons and before bedtime. The smoking behaviour was also habituated to a place and situation and the displacement techniques were employed in her case. (Miltenberger et al., 1998 ). The patient was educated about this technique and was asked to use her balcony for other stimulating activities except smoking for two weeks using a carefully monitored routine chart. After two weeks, the client reported that she started using her balcony for other activities such as taking a walk during the first smoke of the day (7 AM), eating a snack during the second smoke of the day (5 PM) and finally playing her guitar during the third smoke of the day (8 PM). Gradually, she reported that after engaging in these other activities and conditioning herself, she did not have the urge to smoke whenever she was on her balcony. However, it should be noted that her frequency of smoking per day did not come down but only the association between smoking and balcony reduced. The technique of contingency management (Notley et al.,2019, Ainscough et al.,2017, McPherson et al.,2018) was used in the present case. It is based on the assumption that the consequence of a particular behaviour will reinforce the probability of whether the behaviour occurs again or not, thereby increasing adaptive behaviours and reducing maladaptive behaviours. Firstly, she was psycho-educated on the harmful and long-term effects of smoking regularly. She reported fear of the consequences, expressed her want to put a stop to it and her difficulty in stopping it. She was asked to cut down on three cigarettes per day and instead engage in other distracting activities such as chewing gum, drinking cold water and engaging in physical activity whenever she craves a cigarette. Despite trying to do so, during the next session, she reported that she was not able to stop the craving and ended up smoking the same amount per day. Thus, the principle of contingency management was used where the therapist showed a subtle withdrawal of warmth from the client by sitting back on the chair, looking at the notes, speaking in a more serious tone and discussing the harmful effects of smoking again. The decreased attention from the therapist was noted by the client who reported that she wanted to try the technique again in the next session. The following week, she reported that she was able to cut down two of her daily cigarettes and the therapist expressed pleasure and showed increased attention to the client in terms of their body language. Therefore, by using the techniques of adaptive systematic desensitization and contingency management, the client’s smoking was reduced. With these techniques, she was able to bring down her nicotine usage to two cigarettes per day from ten cigarettes before 4.1 Progress The patient’s current status post ten months has indicated progress both in her behaviour and habits. She stopped indulging in self-harm behaviour and has become more communicative and expressive. She was able to identify triggers in her emotions and progressively used mindfulness training. Her smoking has been reduced to once or twice a day. She has become more compliant in understanding situations from other’s perspectives and can utilize adaptive learning to adjust to stressful situations. Follow-up targets and goals will largely focus on intimate partner relationships, forming bonds and working more on her impulsive behaviour that is often triggered by family. Patient adherence and maintenance throughout the therapeutic process were monitored by her regularity to sessions. Rescheduling was only present in case of examinations and public holidays. 5. Discussion The illustrated case study highlights the process of eclectic psychotherapy used with DBT and REBT in combination with contemporary behaviour techniques for a patient diagnosed a Cluster B personality disorder- borderline type along with sociopathic tendencies that were noted. In the present case, DBT was used in attaining emotional regulation, while REBT was used in restructuring the irrational cognitive belief system in interpersonal relationships and behaviour techniques of displacement and contingency management were used for her nicotine dependency. The given study was taken with an eclectic therapeutic plan as it is needed to embrace the multidimensional understanding of the disorder, acknowledging its various causal pathways. (Livesley, 2008). Behaviours such as hitting self on the wall, hitting the mother showing callous unemotional traits with lack of remorse or guilt and impulsive eating of food from the ground as noted in the present case, can be categorized as deviant behaviours which are known to start before the age of two. Reinforcement of these disruptive behaviours is done by adverse environmental conditions such as abuse and neglect (Rutter M et al.,2008). A lack of awareness of the emotions expressed by others can further contribute to the detached behaviour exhibited by the patient. Such children further learn to cope with the aversive environment, making them vulnerable and inadequate in monitoring social cues thereby increasing the use of coercive solutions (Rutter M et al.,2008). This can be considered as a type of threatening behaviour as the patient is aware of the consequence of this self-harm from the previous attempt of similar self-harm. In the current case, the non-suicidal self-injury and the chronic emotional dysregulation were targeted with chain analysis of the NSSI, and emotional regulation techniques where she was able to manage and identify her emotions better. Non-suicidal self-harm in the form of cutting her wrist and taking an overdose of sleeping tablets in the current case can be explained by Bowlby’s Attachment theory, according to which, a mentally healthy individual should be raised in a warm, intimate and continuous relationship with the mother or any substitute caregiver, such that both the child and the caregiver are satisfied and pleasured (Bowlby,1951). Adult attachments are further shaped by the internal working model that is formed during the early child-mother relationship, which was present with difficulties with the current patient. Such insecurities in attachment can interfere with the latter emotional regulation and in the general mental health. Further, insecure attachment has two discrete dimensions including attachment anxiety and attachment avoidance, and the increase in the former is related to self-injuries. The non-suicidal self-injuries are a type of avoidance of negative emotions. These attachments also help individuals to modify and control their emotional experiences, which may help in regulating their emotions during periods of heightened stress. Thus, a higher prevalence of insecure attachment can be considered a risk factor for an individual to develop non-suicidal self-injury when it appears as a result of negative emotions and emotional distress (Paris 2005, Braga,2014). In the present study, behavioural chain analysis was used to reduce her non-suicidal self-injury. Our major aims were to understand her vulnerabilities, triggers and the chain of events leading to her non-suicidal self-injuries and then address them by helping the patient cope better with her triggers. By doing so, awareness of the consequences of such acts was understood by the patient followed by the establishment of a no suicide contract. Here, the patient’s knowledge and education level were the positive factors as the contract could be established and understood by her without much difficulty. She was able to reprocess her emotional experiences and work on emotional regulation and distress tolerance leading to adaptive behaviours. The patient felt intolerance when she perceived that she was alone. Moreover, the incidence or perception of losing someone significant triggers the individual’s ‘hyperbolic’ habit and exaggerates their feelings and emotions. The exaggerated feelings can explicitly convey suicidal gestures and self-harm to get a response from the significant or loved one. The habit thus gets reinforced when the individual receives the attention or the ‘help’ from the significant person (Gunderson,2001). These irrational beliefs contribute to emotional distress, hence REBT was introduced to help in the restructuring of irrational beliefs with rational beliefs that are more flexible, realistic and constructive. Rational beliefs promote emotional resilience and effective coping strategies (Ellis A, 1994 ). Here, an irrational belief of needing to be controlled to not feel abandoned which was compensated with manipulative thoughts was identified and was targeted with REBT techniques. While considering the developmental perspective, the birth order of the patient is taken into consideration. The patient is a middle child having one elder sister and one younger brother. From an Alderian view, a middle child mostly feels left out and hence, attention-seeking qualities are present in them. Studies have shown that middle-born children are more rebellious, less religious and conscientious when compared to their first-born siblings. Further, a perception that circumstances are not in their control and feelings of not belonging are present. (McGowan, 2009). Apart from having a pre-disposing factor of being a middle child, a traumatic event, as reported by the patient’s sister also occurred, during the age of fifteen she felt abandoned by her family when she was admitted to the hospital for indulging in self-harm behaviour of cutting her wrists. The feeling of not fitting in with her family which started due to this event, has been continuing till now. Further, from a social point of view, it should also be noted that the continuous verbal abuse she receives from her father can act as a maintaining factor. This is assumed to be the start of her irrational cognition belief system. The use of dependence-producing substances in an attempt to mitigate emotions perceived as overwhelmingly negative or to replace these with a pleasant state (self-medication hypothesis) is also seen in these patients. The use of addictive substances is also triggered by factors related to the social environment, such as peer pressure. Substances are frequently taken to produce a state of dissociation and hence there are often episodes that follow this kind of substance use. However, the pattern of use shows the same diversity as in the general population. Contemporary behavioural therapy of contingency management and displacement techniques (Petry,2006) for smoking cessation showed improved outcomes by reducing her addictive behaviour. However, further work is needed for complete smoking cessation. DBT proved effective when aided by contemporary behaviour therapy techniques to address these additional factors. Her major challenge was attaining stability with family and an intimate partner relationship. Her impulsiveness and need for immediate gratification played a major role here. (Bender et al., 2005). The therapeutic process for these two key aspects is still being continued because even though she has shown progress, complete and independent control over her nature and behaviour is yet to be attained. 6. Patient Perspective The patient was asked to provide feedback about the management plan for which she reported that she was able to better manage her emotions and act in accordance. Further, she was able to engage in other adaptive coping mechanisms during periods of high stress instead of engaging in self-harming behaviours and was able to bring out a reduction in her smoking behaviour. Overall, the patient reported that the therapeutic management was paced out with a mixture of psychotherapy and techniques and further felt she was able to sense a change in her behaviour pattern after the treatment process. 7. Conclusion The current case study highlights the diagnostic and therapeutic process of using eclectic psychotherapy comprising dialectical behaviour therapy, and rational emotive behaviour therapy in combination with contemporary behaviour therapy techniques for a patient with cluster b personality disorder. The focus of the case discussion is on highlighting the effectiveness of eclectic psychotherapy and further the utility of additional behavioural techniques that can provide a successful outcome in the therapeutic process. Further assertions in therapy will be progressively attempted based on patient needs and the occurrence of target behaviour Declarations The patient consented to participate in the study and in the publication of their case study. References Bateman A, Fonagy P Psychotherapy for borderline personality disorder: Mentalization-based treatment. https://doi.org/10.1093/med:psych/9780198527664.001.0001 Behaviour Chain Analysis [Internet] Help with DBT. 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Psychiatry Psychol Law 20(3):329–343. https://doi.org/10.1080/13218719.2012.674716 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8038272","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":540399621,"identity":"35e251d8-f1d8-4564-9030-fe5d4c148543","order_by":0,"name":"Shruti Mohan","email":"","orcid":"https://orcid.org/0000-0001-9479-8444","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Shruti","middleName":"","lastName":"Mohan","suffix":""},{"id":540399622,"identity":"0d4cb598-b9b2-459e-869b-8f641ec65d2b","order_by":1,"name":"Dr Emilda Judith Ezhil 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05:42:46","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76795,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/d8c9d64bbfc38f9e10113aaf.html"},{"id":95504097,"identity":"10be0fa8-fa47-49de-8fae-cfd0f7dc8549","added_by":"auto","created_at":"2025-11-10 05:42:50","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":278412,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 1: Shows the timeline from the past episodes till the present episode of care\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/d19a8e95c85de7c9f610c9f5.jpeg"},{"id":95504078,"identity":"fbde8a98-0919-4ef6-b441-1ba59d90e696","added_by":"auto","created_at":"2025-11-10 05:42:46","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":732411,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 2: Shows the psychological assessments and the findings\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/cd5cf46f722b46f4c0a5b1cb.jpeg"},{"id":95504079,"identity":"8771d4a5-ac27-4ea4-8ab8-9b7c5004018a","added_by":"auto","created_at":"2025-11-10 05:42:46","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":488369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 3: Shows the therapeutic framework of goals conceptualized for the patient\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/24c79fda4884cfe15f567482.jpeg"},{"id":95528961,"identity":"4e40c98c-a837-455e-b9af-712d7679e9c8","added_by":"auto","created_at":"2025-11-10 10:16:38","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":599136,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 4: Eclectic psychotherapy goals across the three forms of psychotherapy\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/14d7edb1bdce5dfea112b39c.jpeg"},{"id":95504096,"identity":"90575f9b-b246-4776-9481-8787bcedd556","added_by":"auto","created_at":"2025-11-10 05:42:46","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":802795,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 5.1: Highlights the chain analyses taken into account during therapeutic formulation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 5.2: \u003cem\u003eIllustrates the chain analyses taken into account adapted from www.helpwithdbt.com/behaviour-chain-analysisand modified for the current patient\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/7dfb496b83fd7a3a09eb15ac.jpeg"},{"id":95529532,"identity":"edb56db7-cefb-4641-b8c3-560f3d6c9cf6","added_by":"auto","created_at":"2025-11-10 10:17:12","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":73872,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 6.1: Illustrates her ABCD-Es identified during REBT\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/9a9ce5b5d57faba267202e25.png"},{"id":95504084,"identity":"4bc1489a-c88a-4930-9c2d-88423a8c65c8","added_by":"auto","created_at":"2025-11-10 05:42:46","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":224161,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 6.2: Illustrates the phases of the therapeutic plan for the patient\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/f520989da4abab5c34ddf98a.png"},{"id":95504085,"identity":"6310f5f9-3815-4013-80fb-833d00f83294","added_by":"auto","created_at":"2025-11-10 05:42:46","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":41610,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFigure 6.3 Illustrates the behaviour techniques undertaken for her smoking cessation\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/ad39a55edf128488db73add0.png"},{"id":95531711,"identity":"f7531c97-a1bf-4e26-b25e-fd5e4dfd29e9","added_by":"auto","created_at":"2025-11-10 10:24:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3616752,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8038272/v1/a0e2bb16-c3be-46f8-bd50-8b5428438ed4.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eEclectic Structured Psychotherapy for Cluster B Personality Disorder- Borderline Type: A Case Report\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCluster B personality disorders are often associated with psychopathy in several dimensions, primarily characterized by interpersonal dysfunction, affective instability, erratic behaviors, and antisocial conduct. These traits may contribute to significant societal challenges for the individual. Emotional dysregulation and maladaptive emotional regulation noted along with the traits mentioned above and behaviours are hallmark characteristics of a Cluster B personality disorder. Based on object relations theory, there are three characteristics of a typically developed personality: i) an integrated concept of self and other, ii) a broad spectrum of affective experience and, iii) the presence of an internalised value system. Affect regulation is necessary for full awareness in maintaining impulse control. Internalizing values derived from early parenting further influence external relations, in the form of personal responsibility and realistic self-criticism. In borderline personality disorder, the lack of integration in primitive positive (idealized) and negative (persecutory) segments, is brought out by a split in identity diffusion. This type of organisation of self-concept plays a role in emotional lability, interpersonal chaos, and lack of social reality testing (Clarkin et al.,2007).\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Eclectic Psychotherapy\u003c/h2\u003e\u003cp\u003eEclectic Psychotherapy involves utilizing a range of concepts and strategic methods derived from various theoretical frameworks (Garfield et al., 1977 and 1980; Brammer \u0026amp; Shostrom, 1982). There is a flexible and comprehensive strategy for addressing Cluster B personality - borderline type disorders by integrating techniques from diverse therapeutic approaches. Tailoring therapy to individual needs, tackles the intricate and multifaceted aspects of these disorders, facilitating healing, personal development, and enhanced quality of life for those undergoing treatment. Considering the emotional dysregulation, self-harming behaviors, and negative thought patterns associated with Cluster B Personality- borderline type, a combination of interventions from different therapies was assessed as suitable than relying on a singular approach, where individuals to delve into and comprehend the root causes of their personality disorder symptoms, which can include early life experiences, trauma, or attachment issues. (Livesley, 2008).\u003c/p\u003e\u003cp\u003eThe method specific to this case initially addressed emotional dysregulation. The dialectic philosophy is a balance of both acceptance and change, where the individual is encouraged to tolerate intense emotions along with changes associated with their behavioural response. It consists of stage one addressing the self-harm behaviours, therapy-interfering behaviours and quality of life interfering behaviours. Stage two focused on radical acceptance and reprocessing adverse emotional experiences. Stage three involved skills training, distress tolerance and interpersonal effectiveness, and the final stage was focused on mindfulness training (Dimeff et al., 2001). Dialectical Behaviour Therapy (DBT), based on biosocial theory states that underlying borderline personality disorder is a chronic emotional dysregulation, including increased sensitivity and reactivity to emotions, and relatively slower time taken to return to baseline. (Linehan,1993).\u003c/p\u003e\u003cp\u003eThe second approach- Rational Emotive Behaviour Therapy (REBT), was brought into the framework to address negative irrational thoughts challenging irrational beliefs that lead to emotional distress and replacing them with rational, healthier beliefs. Given the event in the history of the case, it aimed to address the cause of the emotional reaction and beliefs rather than the events faced by the client, which indicated dysregulated ways of thinking, feeling, and behaving. Further addressing individual\u0026rsquo;s demandingness (believing that things must be a certain way), catastrophizing (believing that negative events are unbearable catastrophes), and global evaluations (believing that one's entire self-worth depends on one aspect of life) (Ellis A,1994)\u003c/p\u003e\u003cp\u003eFinally, the component of Behavior intervention was introduced for nicotine dependency. This focused on modifying maladaptive behaviors. The emphasis is on identifying problematic behaviors that are causing distress and impairment in this case the use of nicotine and implementing strategies to change those behaviors in the here-and-now process. (Miltenberger et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1998\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThe case study was recorded at a private hospital in Chennai, India which has a Clinical Psychology department that caters to its nearby urban and rural areas. A qualitative case study method was used to explain the real-life experiences and treatment procedures undertaken. The patient was first admitted to the OP where a detailed case history followed by a mental status examination was performed. Following this, a provisional diagnosis along with a differential was reached, as Cluster B Personality Disorder- Borderline type, this further warranted the formulative intervention based on the eclectic approach of integrating DBT and REBT with additional goals requiring contemporary behaviour techniques. Each session note was followed up by a discussion with the supervisor with a doctorate in clinical psychology. The therapist was a clinical psychology trainee as a part of a super specialty program that is conducted for the licensing of clinical psychologists in India. The therapist was further guided by the supervisor on site with regular clinical supervision and further education.\u003c/p\u003e"},{"header":"3. Case History","content":"\u003cp\u003eA 24-year-old female presented to the OPD of the clinical psychology department in a private hospital in Chennai with non-suicidal self-injury, feelings of emptiness and increased mood swings for the past seven years. Her self-harm behaviour was reported to have begun at the age of fifteen, and she had been evaluated by a psychiatrist and prescribed medications. Irregular adherence to the prescribed medication regimen was observed. Additionally, despite recommendations for hospital admission from the physician, the patient declined to pursue this option. She was treated in the OP where the irregular adherence was noted. Later during the completion of her postgraduate, she visited the psychiatrist and used medications for a brief period (three weeks). She returned to the psychiatrist two years back, in 2021 due to difficulties dealing with her social situations and interpersonal communication.\u003c/p\u003e\u003cp\u003eThe familial report indicated that she was an adamant child with increased temper tantrums that would extend to hitting herself and banging on the wall. Extreme behaviour was indicated with her hitting her mother with sharp objects and pinching in inappropriate places and she often expressed being content by exerting pain on others. Invalidating of other\u0026rsquo;s emotions and distress, and at times exhibiting defiant intransigent behaviours involving dropping food, eating from the floor and threatening to harm herself to get desired objects or actions from family members. She reported a close relationship with her grandmother and had a falling out with her believing that she was given less importance compared to her siblings. She often reported to indulge in behaviours that distressed her grandmother and also refused to extend her help when she was in her deathbed. Lack of emotion was reported after her grandmother\u0026rsquo;s death.\u003c/p\u003e\u003cp\u003eIn 2020, she was reported attempted suicide on consumption of sleeping tablets (20 Zolfresh) with a suicide note expressing hatred towards her father and blaming him for her actions. Though no adverse effects occurred, she was precautionary taken to the hospital when she reported this to her parents the next morning.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eCurrent history indicated the presence of multiple relationships that would last only for a brief period, with very poor interpersonal connection and extreme emotional dysregulation resulting in social avoidance. She also reports of crying spells and used extremely foul language when situations would not go her way. Furthermore, she had difficulties with her peers about academics due to poor communication and aggressive social demeanor resulting in loneliness/emptiness. She would compensate by indulging in smoking and non-suicidal self-injury. Difficulties in her interpersonal romantic relationships were also reported, where she is not able to accept her partners leaving her, and would lie about taking birth control medicines so that she can make them stay with her by getting pregnant.\u003c/p\u003e\u003cp\u003eOn performing the mental status examination, she appeared tense and fidgety with a low tone and slow tempo of speech. Further clinical evaluation reported hypnogogic hallucinations on rare occasions, with intact cognition and judgement. Importantly, she is aware that her illness is caused by something unknown in her.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Case Formulation\u003c/h2\u003e\u003cp\u003e\u003cb\u003eDiagnosis Impression and Assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBased on the patient and family history, a provisional diagnosis indicates that she falls into cluster B personality- borderline type with added comorbidities of substance use and historical behavioural. Given the clinical presentation further evaluation was conducted to confirm the pathology and indicators. She was evaluated for organicity, cognition, psychopathology, and projective tests, and the severity of her symptoms was rated on a scale. The assessment was completed with the Bender Gestalt Test, Weschler\u0026rsquo;s Adult Intelligence Test IV, Millon Clinical Multiaxial Inventory, Sentence Completion Test, Thematic Apperception Test, and Rorschach Inkblot Test.\u003c/p\u003e\u003cp\u003eThe assessments indicated higher visuospatial ability with the absence of organicity. Her intelligence was evaluated as 111 with the performance quotient being higher than the verbal quotient. Pathological evaluation indicated a depressive personality pattern, masochistic personality pattern in the clinical personality pattern; borderline in the severe personality pathology; dysthymia and anxiety as clinical syndromes. Conflicts were identified with the family, especially with the father. Needs identified were affiliation, deference, sex, succorance, abasement, blame avoidance and retention. The presses identified were lack, uncongenial environment, coercion, imposed task duty, rejection and dominance; further indicating emotional conflicts and constant fear of abandonment. RIBT indicated disturbed thinking patterns, and exaggerated self-involvement with an inflated sense of personal worth dominating her perceptions of the world. Interpretation also revealed antisocial acts with less adaptive interpersonal behaviours and highly impulsive behaviour with a heightened perception of aggressiveness, dramatic behaviour, and low empathy indicative of a Cluster B personality disorder.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eImportantly, the patient showed symptoms from all four subtypes of Cluster B personality disorder. From a narcissistic perspective, grandiose thoughts that \u0026lsquo;she will be liked by the men around her no matter what\u0026rsquo;, \u0026lsquo;she is more beautiful than her elder sister\u0026rsquo; as well as anger outbursts when told otherwise are present. From a histrionic perspective, mental status examination indicated inappropriate clothing in the hospital with more importance given to her physical looks along with self-dramatization. From a borderline perspective, her self-harm and suicidal gestures are hallmark symptoms along with emotional dysregulation, chronic feelings of emptiness, and inability to have stable relationships. From an antisocial perspective, a lack of remorse and empathy was noted from her childhood, which continued till the present age and manipulative behaviour was also present. As noted, the patient has traits from all four types and hence was diagnosed as having a Cluster B Personality Disorder- Borderline type with supportive evidence from the psychometric assessments. Further, her cognitive assessments show an imbalanced IQ profile with her performance part of the test being greater than the verbal part in WAIS, and this is a rough indicator of a sociopath.\u003c/p\u003e\u003cp\u003eHer lack of guilt, empathy, and any emotions with heightened narcissism, further shows the individual does not feel \u0026lsquo;fear\u0026rsquo; and the dysregulated emotions, making it easier for her to act on her impulses. Adverse environmental factors such as Adverse or neglected parenting, abuse and trauma have poorly regulated emotional processing and self-control. A key indicator identified was cognitive assessments that demonstrate an imbalanced IQ profile where the individual\u0026rsquo;s performance part of the test (associated with the right brain) is greater than the verbal part (associated with the left brain) in WAIS. (Duara et al.,1984). This imbalance suggests a right hemisphere superiority in comparison with the left hemisphere, and is noted in abused and neglected children due to the constant fear. The tendency is termed as \u0026lsquo;frozen watchfulness\u0026rsquo; and is a right hemisphere motor skill, which develops earlier than the left hemisphere\u0026rsquo;s language skills. Experience of abuse or neglect during the organizational period of brain development leads to more emphasis on the right brain functioning throughout life. Further, increased dependence on the right hemisphere occurs due to a significant left hemisphere dysfunction.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Results","content":"\u003cp\u003eThe treatment protocol is based on eclectic psychotherapy of DBT, and REBT with behaviour techniques that inculcate strategies aimed at understanding the cognitive conceptualization, addressing emotional regulation, irrational thoughts in belief systems in interpersonal relationships and distress tolerance, as well as improving interpersonal effectiveness and mindfulness. Contemporary behaviour techniques were also adopted to address her addictive behaviours.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe first stage of the treatment process was aimed at reducing life-threatening behaviours such as suicidal gestures and other self-harm habits (cutting wrists and medicine overdose). This was specifically identified as NSSI (Non-Suicidal Self-Injury) based on history and psychometric evaluation and further confirmed during therapeutic formulation. This behaviour re-surfaced during the initial stages of therapy, and she reported that this behaviour gives her the feeling of control in any relationship that she pursues. This particular behaviour was addressed by using chain analysis, followed by challenging maladaptive thoughts that led to the development of emotional regulation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure 5.2: \u003cem\u003eIllustrates the chain analyses taken into account adapted from\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.helpwithdbt.com/behaviour-chain-analysis\" target=\"_blank\"\u003ewww.helpwithdbt.com/behaviour-chain-analysis\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.helpwithdbt.com/behaviour-chain-analysis\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e \u003cem\u003eand modified for the current patient\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe identification of risk behaviour indicated that there is a learned response to abandonment in the patient and self-harm habit is reinforced by a significant person. Chain analysis indicated the presence of difficulty in relationships, and the tendency for self-harm, which was highlighted by self-destructive behaviours- based on this a verbal agreement was made. Following this the patient expressed intention during therapy but never indulged in it. A thought diary was followed, consisting of situations, thoughts, emotions and the consequent behaviour. This prompted further discussion regarding her relationships. Techniques such as Socratic questioning and self-monitoring identified negative automatic thoughts. She was taught to cope with her automatic thoughts through the process of distraction techniques. With repeated questioning, it was identified that she was impulsive, and also her core belief was that she was not lovable and she had a fear of being alone. Socratic dialogue was used to challenge this, where she was able to attain insight on her thoughts. Following the above exercise, she showed progress in her attempt to work on self-recognition and adapt abilities to self-sustain.\u003c/p\u003e\u003cp\u003eGiven her self-comfort, the next phase of treatment involved addressing emotion regulation and building distress tolerance. This particular step was initiated based on her beliefs that were built from past childhood experiences that were reported by her to be traumatic (Specific to her paternal grandmother and relation with her sibling). Addressing her emotions, and distress relating to her family members where she felt that they are not comprehensive of her needs and expressions. Thus, we initiated the use of the safe place visualization exercise that would help her distress. She was further followed up with the use of a radical acceptance process involving the identification of distress situation and building new coping thoughts as described below in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eShows the distressing situation and its corresponding new coping thought\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS. No\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistressing Situation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNew Coping Thought\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMy roommate has a stable boyfriend who is kind to her\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eI am still young and I can find a partner who will be kind to me\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMy father yelled at me this morning for something that was not my fault\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThat is how he is, he has always been criticizing everyone, it is not my mistake\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhen watching a romantic movie, I feel sad I do not have someone like that\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIt is just a movie; it is not reality and this feeling will soon pass\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFurther steps involved \u0026lsquo;Thought and Emotion Defusion\u0026rsquo;, the process of detaching from overwhelming thoughts and emotions by indulging in mindfulness exercises that help to overcome and control emotions. This process was enforced by a course of five to six weeks. She was then started with cognitive techniques from REBT to restructure her cognition belief with the existence of an irrational belief system in interpersonal relationships; where it was identified as her having an irrational thought that she needs to be in control in her interpersonal relationships to feel safe.\u003c/p\u003e\u003cp\u003eRational analysis was used when instances were provided to dispute her irrational beliefs, changing language to avoid giving absolutes such as always, never, should, reframing was done to help her re-evaluate the choices of disappointment, concern, distress and shedding light on the positives in a negative situation; alarming her to realize that things can be a lot worse but it\u0026rsquo;s not; emotive technique of shame attacking - Helping her talk to herself like she would if she was a child, helping her understand that certain things are beyond control and also implementing self-image - by saying nice things about her in the mirror, dressing up and clicking pictures of herself - to celebrate her self.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBehavioural management strategies were used simultaneously for managing smoking behaviour because she was having ten cigarettes per day on average, specifically in the mornings, afternoons and before bedtime. The smoking behaviour was also habituated to a place and situation and the displacement techniques were employed in her case. (Miltenberger et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). The patient was educated about this technique and was asked to use her balcony for other stimulating activities except smoking for two weeks using a carefully monitored routine chart.\u003c/p\u003e\u003cp\u003eAfter two weeks, the client reported that she started using her balcony for other activities such as taking a walk during the first smoke of the day (7 AM), eating a snack during the second smoke of the day (5 PM) and finally playing her guitar during the third smoke of the day (8 PM). Gradually, she reported that after engaging in these other activities and conditioning herself, she did not have the urge to smoke whenever she was on her balcony. However, it should be noted that her frequency of smoking per day did not come down but only the association between smoking and balcony reduced.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe technique of contingency management (Notley et al.,2019, Ainscough et al.,2017, McPherson et al.,2018) was used in the present case. It is based on the assumption that the consequence of a particular behaviour will reinforce the probability of whether the behaviour occurs again or not, thereby increasing adaptive behaviours and reducing maladaptive behaviours. Firstly, she was psycho-educated on the harmful and long-term effects of smoking regularly. She reported fear of the consequences, expressed her want to put a stop to it and her difficulty in stopping it. She was asked to cut down on three cigarettes per day and instead engage in other distracting activities such as chewing gum, drinking cold water and engaging in physical activity whenever she craves a cigarette.\u003c/p\u003e\u003cp\u003eDespite trying to do so, during the next session, she reported that she was not able to stop the craving and ended up smoking the same amount per day. Thus, the principle of contingency management was used where the therapist showed a subtle withdrawal of warmth from the client by sitting back on the chair, looking at the notes, speaking in a more serious tone and discussing the harmful effects of smoking again. The decreased attention from the therapist was noted by the client who reported that she wanted to try the technique again in the next session. The following week, she reported that she was able to cut down two of her daily cigarettes and the therapist expressed pleasure and showed increased attention to the client in terms of their body language. Therefore, by using the techniques of adaptive systematic desensitization and contingency management, the client\u0026rsquo;s smoking was reduced. With these techniques, she was able to bring down her nicotine usage to two cigarettes per day from ten cigarettes before\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Progress\u003c/h2\u003e\u003cp\u003eThe patient\u0026rsquo;s current status post ten months has indicated progress both in her behaviour and habits. She stopped indulging in self-harm behaviour and has become more communicative and expressive. She was able to identify triggers in her emotions and progressively used mindfulness training. Her smoking has been reduced to once or twice a day. She has become more compliant in understanding situations from other\u0026rsquo;s perspectives and can utilize adaptive learning to adjust to stressful situations. Follow-up targets and goals will largely focus on intimate partner relationships, forming bonds and working more on her impulsive behaviour that is often triggered by family. Patient adherence and maintenance throughout the therapeutic process were monitored by her regularity to sessions. Rescheduling was only present in case of examinations and public holidays.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThe illustrated case study highlights the process of eclectic psychotherapy used with DBT and REBT in combination with contemporary behaviour techniques for a patient diagnosed a Cluster B personality disorder- borderline type along with sociopathic tendencies that were noted. In the present case, DBT was used in attaining emotional regulation, while REBT was used in restructuring the irrational cognitive belief system in interpersonal relationships and behaviour techniques of displacement and contingency management were used for her nicotine dependency. The given study was taken with an eclectic therapeutic plan as it is needed to embrace the multidimensional understanding of the disorder, acknowledging its various causal pathways. (Livesley, 2008).\u003c/p\u003e\u003cp\u003eBehaviours such as hitting self on the wall, hitting the mother showing callous unemotional traits with lack of remorse or guilt and impulsive eating of food from the ground as noted in the present case, can be categorized as deviant behaviours which are known to start before the age of two. Reinforcement of these disruptive behaviours is done by adverse environmental conditions such as abuse and neglect (Rutter M et al.,2008).\u003c/p\u003e\u003cp\u003eA lack of awareness of the emotions expressed by others can further contribute to the detached behaviour exhibited by the patient. Such children further learn to cope with the aversive environment, making them vulnerable and inadequate in monitoring social cues thereby increasing the use of coercive solutions (Rutter M et al.,2008). This can be considered as a type of threatening behaviour as the patient is aware of the consequence of this self-harm from the previous attempt of similar self-harm. In the current case, the non-suicidal self-injury and the chronic emotional dysregulation were targeted with chain analysis of the NSSI, and emotional regulation techniques where she was able to manage and identify her emotions better.\u003c/p\u003e\u003cp\u003eNon-suicidal self-harm in the form of cutting her wrist and taking an overdose of sleeping tablets in the current case can be explained by Bowlby\u0026rsquo;s Attachment theory, according to which, a mentally healthy individual should be raised in a warm, intimate and continuous relationship with the mother or any substitute caregiver, such that both the child and the caregiver are satisfied and pleasured (Bowlby,1951). Adult attachments are further shaped by the internal working model that is formed during the early child-mother relationship, which was present with difficulties with the current patient. Such insecurities in attachment can interfere with the latter emotional regulation and in the general mental health.\u003c/p\u003e\u003cp\u003eFurther, insecure attachment has two discrete dimensions including attachment anxiety and attachment avoidance, and the increase in the former is related to self-injuries. The non-suicidal self-injuries are a type of avoidance of negative emotions. These attachments also help individuals to modify and control their emotional experiences, which may help in regulating their emotions during periods of heightened stress. Thus, a higher prevalence of insecure attachment can be considered a risk factor for an individual to develop non-suicidal self-injury when it appears as a result of negative emotions and emotional distress (Paris 2005, Braga,2014). In the present study, behavioural chain analysis was used to reduce her non-suicidal self-injury. Our major aims were to understand her vulnerabilities, triggers and the chain of events leading to her non-suicidal self-injuries and then address them by helping the patient cope better with her triggers. By doing so, awareness of the consequences of such acts was understood by the patient followed by the establishment of a no suicide contract. Here, the patient\u0026rsquo;s knowledge and education level were the positive factors as the contract could be established and understood by her without much difficulty. She was able to reprocess her emotional experiences and work on emotional regulation and distress tolerance leading to adaptive behaviours.\u003c/p\u003e\u003cp\u003eThe patient felt intolerance when she perceived that she was alone. Moreover, the incidence or perception of losing someone significant triggers the individual\u0026rsquo;s \u0026lsquo;hyperbolic\u0026rsquo; habit and exaggerates their feelings and emotions. The exaggerated feelings can explicitly convey suicidal gestures and self-harm to get a response from the significant or loved one. The habit thus gets reinforced when the individual receives the attention or the \u0026lsquo;help\u0026rsquo; from the significant person (Gunderson,2001). These irrational beliefs contribute to emotional distress, hence REBT was introduced to help in the restructuring of irrational beliefs with rational beliefs that are more flexible, realistic and constructive. Rational beliefs promote emotional resilience and effective coping strategies (Ellis A, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). Here, an irrational belief of needing to be controlled to not feel abandoned which was compensated with manipulative thoughts was identified and was targeted with REBT techniques.\u003c/p\u003e\u003cp\u003eWhile considering the developmental perspective, the birth order of the patient is taken into consideration. The patient is a middle child having one elder sister and one younger brother. From an Alderian view, a middle child mostly feels left out and hence, attention-seeking qualities are present in them. Studies have shown that middle-born children are more rebellious, less religious and conscientious when compared to their first-born siblings. Further, a perception that circumstances are not in their control and feelings of not belonging are present. (McGowan, 2009). Apart from having a pre-disposing factor of being a middle child, a traumatic event, as reported by the patient\u0026rsquo;s sister also occurred, during the age of fifteen she felt abandoned by her family when she was admitted to the hospital for indulging in self-harm behaviour of cutting her wrists. The feeling of not fitting in with her family which started due to this event, has been continuing till now. Further, from a social point of view, it should also be noted that the continuous verbal abuse she receives from her father can act as a maintaining factor. This is assumed to be the start of her irrational cognition belief system.\u003c/p\u003e\u003cp\u003eThe use of dependence-producing substances in an attempt to mitigate emotions perceived as overwhelmingly negative or to replace these with a pleasant state (self-medication hypothesis) is also seen in these patients. The use of addictive substances is also triggered by factors related to the social environment, such as peer pressure. Substances are frequently taken to produce a state of dissociation and hence there are often episodes that follow this kind of substance use. However, the pattern of use shows the same diversity as in the general population. Contemporary behavioural therapy of contingency management and displacement techniques (Petry,2006) for smoking cessation showed improved outcomes by reducing her addictive behaviour. However, further work is needed for complete smoking cessation. DBT proved effective when aided by contemporary behaviour therapy techniques to address these additional factors.\u003c/p\u003e\u003cp\u003eHer major challenge was attaining stability with family and an intimate partner relationship. Her impulsiveness and need for immediate gratification played a major role here. (Bender et al., 2005). The therapeutic process for these two key aspects is still being continued because even though she has shown progress, complete and independent control over her nature and behaviour is yet to be attained.\u003c/p\u003e"},{"header":"6. Patient Perspective","content":"\u003cp\u003eThe patient was asked to provide feedback about the management plan for which she reported that she was able to better manage her emotions and act in accordance. Further, she was able to engage in other adaptive coping mechanisms during periods of high stress instead of engaging in self-harming behaviours and was able to bring out a reduction in her smoking behaviour. Overall, the patient reported that the therapeutic management was paced out with a mixture of psychotherapy and techniques and further felt she was able to sense a change in her behaviour pattern after the treatment process.\u003c/p\u003e"},{"header":"7. Conclusion","content":"\u003cp\u003eThe current case study highlights the diagnostic and therapeutic process of using eclectic psychotherapy comprising dialectical behaviour therapy, and rational emotive behaviour therapy in combination with contemporary behaviour therapy techniques for a patient with cluster b personality disorder. The focus of the case discussion is on highlighting the effectiveness of eclectic psychotherapy and further the utility of additional behavioural techniques that can provide a successful outcome in the therapeutic process.\u003c/p\u003e\u003cp\u003eFurther assertions in therapy will be progressively attempted based on patient needs and the occurrence of target behaviour\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe patient consented to participate in the study and in the publication of their case study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBateman A, Fonagy P Psychotherapy for borderline personality disorder: Mentalization-based treatment. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/med:psych/9780198527664.001.0001\u003c/span\u003e\u003cspan address=\"10.1093/med:psych/9780198527664.001.0001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBehaviour Chain Analysis [Internet] Help with DBT. 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Psychiatry Psychol Law 20(3):329\u0026ndash;343. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13218719.2012.674716\u003c/span\u003e\u003cspan address=\"10.1080/13218719.2012.674716\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"SRM Institute of Science and Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Borderline Personality Disorder, Non-Suicidal Self Injury, Dialectical Behaviour Therapy, Behaviour Therapy, Rational Emotive Behaviour Therapy","lastPublishedDoi":"10.21203/rs.3.rs-8038272/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8038272/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCluster B personality disorders are characterized as having dramatic, emotional, and erratic personality traits with a general lack of empathy for others and poor impulse control. Dialectical behaviour therapy is a known treatment for addressing adaptive behaviours and regulating the patient\u0026rsquo;s emotions in cluster B personality disorders. The present case study has encountered pathological and psychosocial distress in borderline personality disorder, throughout therapy an eclectic approach was formulated by the use of Dialectical Behaviour Therapy, Rational Emotive Behavior Therapy and contemporary behavioral techniques. The case presents with a complaint of talking to self, alongside dissociative tendencies with depression, and a feeling of distress with increased tendencies of Non-Suicidal Self Injury in addition to difficulties in social life and nicotine dependency. Further, a clinical interview with the family revealed childhood aggressive behaviour with a lack of remorse and difficulty in expressing appropriate emotions. It was indicated that the integration of these techniques showed improvement from the distress caused by maladaptive personality traits and aided in addressing behavioural habituation further enabling social adaptiveness. Weekly sessions were conducted and tracked by maintaining target goals and homework assignments (involving behavioural exploration and conditioning with social languages and interactions). This case report aims to provide a practical approach to the treatment process that can be used when addressing individuals with similar symptoms and presentation.\u003c/p\u003e","manuscriptTitle":"Eclectic Structured Psychotherapy for Cluster B Personality Disorder- Borderline Type: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 05:42:41","doi":"10.21203/rs.3.rs-8038272/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"704c9c8d-694a-4a64-940b-34b7876a0e33","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57622303,"name":"Psychology"}],"tags":[],"updatedAt":"2025-11-10T05:42:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 05:42:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8038272","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8038272","identity":"rs-8038272","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}