“SUICIDAL BEHAVIOR IS A BROAD term that includes death bysuicide and intentional, nonfatal, self-injurious acts committed with or without intent to die. It is associated with severalmental disorders, including depression, substance dependence, and schizophrenia. Borderline personality disorder (BPD) is 1 of only 2 DSM-IV diagnoses for which suicidal behavior is a criterion.“

The emphasis is mine. I thought “what’s the other disorder that suicidal behavior is a criterion?” The answer: Major Depressive Disorder. So, today I am posting the DSM criteria for Major Depressive Disorder. It’s fairly long and I’ve included the “Major Depressive Episode” to clarify. If you’d like to get the full criteria, follow the “continue reading” link.

Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Major Depressive Disorder

Single Episode

A. Presence of a single Major Depressive Episode

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Recurrent

A. Presence of two or more Major Depressive Episodes.

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects or a general medical condition.

Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
Chronic
With Catatonic Features
With Atypical Features
With Postpartum Onset

Specify
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern

Major Depressive Disorder

Single Episode

A. Presence of a single Major Depressive Episode

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Recurrent

A. Presence of two or more Major Depressive Episodes.

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects or a general medical condition.

Specify (for current or most recent episode):
Severity/Psychotic/Remission Specifiers
Chronic
With Catatonic Features
With Atypical Features
With Postpartum Onset

Specify
Longitudinal Course Specifiers (With and Without Interepisode Recovery)
With Seasonal Pattern

Related posts:

1. A Classic Case of BPD
2. BPD: What’s the Cost?
3. Understanding Major Depression With Borderline Personality Disorder?

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Bon: I found an interview with Dr. Leland Heller about Borderline Personality Disorder. He does a good job explaining the pain associated with the disorder… Here are some excerpts. The entire interview can be read here.

Diagnosing Borderline Personality Disorder And Finding Treatment That Works

Dr Heller: Good evening, It’s great to be here. I have a way of explaining the Borderline Personality Disorder in layman’s terms that might be useful. It’s how I explain it to patients and their families.

Imagine you had a pet dog and it runs into the street and by accident it’s hit by a car. The dog’s leg is broken and it limps off into an alley to lick it’s wounds. A friend of yours sees the dog and comes over to help. The dog is now feeling trapped and cornered – a “wounded animal” – and misinterprets the friend’s attempts to help. The dog snaps at the friend’s hand who is trying to help. The BPD (Borderline Personality Disorder) is a malfunction in the brain’s trapped or “cornered” animal area. Under stress, a seizure develops in that area. That’s why under stress, while raging, a borderline will say to him or herself: “Why am I doing this” – yet be unable to stop it. It’s a seizure – nerve cells firing inappropriately and out of control.

David: And the cause of Borderline Personality Disorder?

Dr Heller: The BPD has many causes including head trauma and brain infections, but it appears that emotional hurts literally damage the brain. Most likely the brain’s support cells – the 90% of brain cells called “glial cells” – are damaged by traumas, causing the person to overreact to stress once puberty strikes. During puberty the brain’s limbic system goes into “overdrive” and adolescents are at their highest risk of seizures in their lifetime. “Sticks and stones may break my bones…but names cause brain damage.” So does incest, abuse, severe trauma, head injuries, attention deficit disorder, and other causes.

David: From my understanding, one of the biggest difficulties facing individuals who have BPD is maintaining stable relationships. This is a great cause of consternation for those people who are on the other side of the relationship. What causes this?

Dr Heller: There are a number of problems. The three most significant are 1) inappropriate mood swings; 2) misinterpretation of motives; and 3) remembering those misinterpreted motives as real. Oftentimes self-fulfilling prophecies occur, and self-hate eventually leads to a significant other coming to the same conclusion – that the individual isn’t worth being with.
…
janet: Would you please tell us more about the self-hate characteristic and how that damages the BPD or his/her relationships?

Dr Heller: Much of it comes from self-destructive behaviors that are used to stop the horrible pain of dysphoria; anxiety, rage, depression and despair. When an individual behaves out-of-control, in a manner that’s inconsistent with their beliefs or normal choices, terrible self-hate develops. Additionally many individuals had low self-esteem and related problems since childhood and are in an environment that causes self-hate to flourish.

crazy32810: How is self-injury related to BPD?

Dr Heller: We all injure ourselves to stop noxious neurological sensations. Interestingly we do it in a linear manner, ripping the skin. A common noxious neurological sensation is the toxins released with an insect bite. BPD dysphoria is about as bad as it gets. The pain is horrible. Many individuals have broken major bones and declared the pain of the fracture was nowhere as severe as dysphoria. When an individual with the BPD discovers that self-mutilation, or other techniques of self injury, work to temporarily stop the pain of dysphoria – they’ll do what it takes to stop it. This is no different than the individual with a fracture wants pain medication. I broke my shoulder last December and I tried to deal with it without taking narcotics. I was foolish and wrong. The pain was so bad it needed to be treated medically. Once individuals with the BPD have their chronic symptoms stabilized, and have safe medication options that work for dysphoria, the self-destructive patterns are no longer needed to stop their pain.

Related posts:

1. Interesting Article from Time Magazine on BPD
2. Tough Love is not an effective approach to BPD
3. A Must-Read Interview with a recovered Borderline

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You can purchase a copy of his latest book at Amazon below.

See larger image The Believing Brain: From Ghosts and Gods to Politics and Conspiracies---How We Construct Beliefs and Reinforce Them as Truths (Hardcover) By (author) Michael Shermer List Price: $28.00 USD New From: $14.23 In Stock Used from: $14.23 In Stock Release date May 24, 2011.

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Borderline patients unfairly labelled violent

January 20, 2012 By Mary Anne Kenny

Most people with borderline personality disorder (BPD) are not violent, contrary to the overwhelming body of research, which has unduly focused on those already in the justice system, a systematic review has found.

“Although this may be the case in some patients, they are likely the minority of individuals with BPD,” the researchers from the University of Toronto wrote in Current Psychiatry Reports. “The diagnosis of BPD may be less useful in predicting violence than one might suspect, and violence in BPD may not be as strongly determined by impulsivity as is commonly held.”

Most research had been conducted in unrepresentative samples including prisoners, people undergoing mandated psychiatric treatment, psychiatric patients, substance abusers and delinquent youths, the report noted.

“Clinical lore holds that patients are at risk of committing violence, especially in the context of perceived or feared loss or abandonment in interpersonal relationships,” the researchers said. However, this and other contextual factors needed to be examined more closely.

It was important to look beyond the diagnosis of BPD and individually assess the issue in light of interpersonal relationships and other risk factors for violence, the researchers said.

The diagnostic criteria for the condition included unstable and intense interpersonal relationships, impulsivity, affective instability, and difficulties with controlling intense or inappropriate anger.

These features suggested that aggression might be a common result, but it was important to avoid over-generalising and adding to the heavy burden of stigma that BPD patients already faced, the authors wrote.

Current Psychiatry Reports 2011 doi 10.1007/s11920-011-0244-9

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2. Emotion-Regulating Circuit Weakened In Borderline Personality Disorder
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There is also currently a category of illness that has to do with coping skills and temperament called the “personality disorders.” It’s not a particularly good term, and I wish they had thought of another — “I’m sorry, your diagnosis is a disordered personality” is not a particularly useful approach to helping people.

For the longest time, it was thought that psychotic illnesses were more genetic/organic, and neurotic illnesses (such as depressive illness, or post-traumatic stress disorder) were reactions to stress and more amenable to treatment by psychotherapy. A type of personality disorder called “borderline personality disorder” was an exception to the neurotic rule – those afflicted tended to unravel and even appear to be psychotic while receiving the old-fashioned on the couch free association type of therapy called psychoanalysis. That’s where the name “borderline” came from in the first place – it was thought to be on the “borderline” between psychosis and neurosis.

What is borderline personality disorder? It describes a type of temperament and coping, usually in women but found in men also, where someone is highly sensitive, prone to dramatic relationships, depression, anxiety, addiction, eating disorders, and self-injurious behavior such as cutting. It is very common, with nearly 6% of the population affected. Unlike depression which tends to come and go over the years, personality disorder symptoms are more stable and chronic, though for most people, borderline symptoms do tend to get better over the decades as we live and learn.

Borderline personality disorder most often develops in someone who was abused as a child, but people can have it without ever being abused. Usually it happens in those cases when there is a mismatch of temperament between parent and child. More modern types of therapy can be helpful for the symptoms, but you can only imagine what it must have been like to have borderline personality disorder and to feel unsure and anxious, free associating on the couch while your therapist said very little back in the psychoanalytic days. That kind of therapy would be like re-experiencing the neglect and abuse of childhood in its own way, and that is why psychoanalysis could make borderline personality disorder worse. Ultimately, borderline and some of the other personality disorders can get better as people learn to feel worthy and loved.

But, like everything else, we’ve discovered that even the personality disorders have biological underpinnings. I’m not sure why people continue to be surprised by these findings – it all happens in our bodies, and is thus mediated by biochemistry. In the case of borderline personality disorder, a paper and editorial in the American Journal of Psychiatry explore a link between borderline symptoms and opiate receptors.

We all have opiate receptors. They are activated by our natural endorphins, and can help with pain relief and relaxation. Opiate receptors are also activated by opiates derived from the opium poppy — morphine, oxycodone, heroin, vicodin, percocet, etc. etc. etc. There are opiate activators found in certain varieties of food, most notably wheat (the exorphins) and milk (beta casein A1). We can increase our own endorphin activity through several behaviors – exercise, binging, binging and purging, and self-injury. (While self-injury is a risk factor for eventual suicide, in general people do not engage in cutting as a suicide attempt, but rather the painful act relieves anxiety and focuses psychic pain on a physical level). The placebo effect is also thought to be mediated through activation of the endorphin system (1).
In the paper, scientists measured how an opiate binder called [11C]carfentanil showed up in the brain of living borderline patients with a history of self-injury and in normal controls. They found pretty significant differences within the two groups, suggesting that the patients with borderline personality disorder who self-injure have differences in their opiate systems. Other studies have shown that people who engage in self-injurious behavior such as cutting have lower levels of endoprhins in the blood at baseline and differences in their endorphin genes compared to non-injurers.

Our endorphins regulate many of our social interactions, and almost anything we do to self-soothe, from childhood on, will activate our endorphin system. A certain subset of people, self-injurers in particular, will have less ability to self-soothe that seems to be genetically mediated, so they may go to more desperate measures (binging, addiction, self-injury) in an attempt to feel better. The same endorphin system deficit can explain some of the social problems that people with borderline personality disorder experience.

There are many levels of speculation to engage in at this point. The deficits run in families, and anyone can see how anxious, addiction-prone families can lead to less than optimal conditions for a growing child trying to find his or her way. Epigenetics may well play a role. Add chronic stress and inflammation, poor health, and poor diet – there’s a whole recipe for generation after generation of biologically mediated mental distress. Fortunately, as we develop more understanding of the underpinnings of these conditions, we can start helping people with specific and sensible treatments. Overall, developing strengths in healthy self-care and self-soothing is the key to success in getitng past problematic behaviors such as self-injury.

Copyright Emily Deans, MD

Source URL: http://www.psychologytoday.com/node/84991

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A therapy that helps to rebuild broken lives

SHEILA WAYMAN

Tue, Dec 27, 2011

ANNE* ALWAYS felt she was different from everybody else and, having had a difficult early childhood, by the time she was a teenager she did not think she belonged in this world.

“I believed I was invisible – I didn’t think people saw me,” she says. “I was insecure and very mixed up about my own identity; I did not know who I was, or how to fit in to life.”

From her mid-teens on, she attended a succession of psychiatrists and counsellors and was prescribed various medications for her “mood”. However, becoming a wife and mother gave her a new, positive feeling of belonging, and she moved on to become a mature student, followed by short-term work placements and voluntary work.

But when, in her 40s, life threw up challenges over which she had no control, her thoughts and emotions began to change rapidly.

Old fears of being abandoned returned; she became angry and impulsive. She started to self-harm and contemplate suicide; she misused alcohol and became dependent on prescribed medication.

It was only then that she was diagnosed with borderline personality disorder (BPD) and she began to understand the impact it had on her.

BPD is a broad category of mental health problems, often defined by “really powerful emotional distress and sometimes a lot of problems in relationships”, says Jim Lyng, a counselling psychologist with Cluain Mhuire, a community-based adult mental health service in the southeast of Dublin.

Affecting an estimated 1-2 per cent of the population, the disorder is characterised by impulsive and often life-threatening, self-destructive behaviour. Problems tend to start to show before a person reaches adulthood, as they begin to cope with their emotions in extreme ways.

“In a heightened state, people start to make desperate choices,” he explains. Talking of deliberate self-harm or attempts at suicide as “cries for help” misses the point, he suggests. “They are desperate attempts to cope.”

Luckily for Anne, she is living in one of the few areas of Ireland where the successful, evidence-based treatment programme of dialectical behaviour therapy (DBT) is available. Within weeks of diagnosis, she started DBT at Cluain Mhuire.

DBT was developed by Dr Marsha Linehan from the University of Washington to help people with a history of repeated self-harm and suicidal behaviour, many of whom would be classified as having borderline personality disorder.

And it was only this year Linehan disclosed that she has struggled with the disorder herself – so first-hand experience informs the therapy.

It involves a minimum of one year of treatment, with both a weekly one-to-one session of psychotherapy and a weekly group session for learning new skills in managing emotions.

Participants keep a daily diary of their feelings and responses to them. Telephone support is also provided for difficulties that may arise in between sessions.

“Fifty per cent of DBT is learning to accept and 50 per cent is learning to change,” says Lyng. “It sounds simple, but it is very difficult to put into practice.”

For people struggling with extreme emotions, DBT can be “the difference between complete chaos and not being understood, to having some framework to cope with what’s going on and to start building a life worth living”.

When DBT was piloted in Cluain Mhuire more than 10 years ago, the benefits were so overwhelming – a dramatic reduction in the use of inpatient psychiatric beds and in attendance at hospital emergency departments by participants in the two-year follow-up period – it quickly became a “serious option for many of our clients”, he says.

Now a special DBT group for people aged 18-25 who are self-harming has been started on a pilot basis at Cluain Mhuire and it is thought that they will benefit faster as the behaviour they are trying to change is less entrenched.

Self-harm is on the rise in Ireland. The 2010 annual report of the National Registry of Deliberate Self-Harm showed hospital attendance for self-harm was up for the fourth year in a row.

A total of 11,966 presentations to hospitals in 2010 were due to self-harm and these involved 9,630 individuals.

With a 4 per cent rise in the rate of self-harm overall, the most notable increase in 2010 was among 20-24 year olds.

There is a strong link between self-harm and suicide; it is estimated that between a quarter and a half of those who take their own lives have previously carried out a non-fatal act.

DBT is not for everybody, says Lyng, but it is the treatment with the most international research supporting its effectiveness.

And he is frustrated and concerned at its limited availability across the State in a mental health system that is effectively a “post code lottery”.

To be able to avail of DBT, people have to live in the catchment area of the approximately 10 teams of mental health professionals that are offering it, in the east of the State and across Co Cork.

Private services offer elements of DBT, he says, but not “comprehensive” DBT programmes.

There are between 20 and 25 participants in the two DBT programmes currently running at Cluain Mhuire and it has had people moving into its catchment area to try to access the treatment.

Although DBT requires a lot of resources initially, it is, in the long term, a much better use of the health services, Lyng argues, rather than leaving people to turn up at emergency departments with the physical consequences of their disturbed emotions or admitting them for very costly inpatient psychiatric care, which has not proven to be effective.

There is a good chance that people completing the programme can be discharged completely from the mental health services.

Anne has not reached that stage yet, but DBT has “given me hope”, she says.

“It is a new way of living.” If she is having a bad day, she can now draw on coping skills to manage her emotions.

“I know what to do when I become overwhelmed. I am beginning to know who I am and I am not struggling so much with identity issues. It allows me to function in the real world,” adds Anne, who believes it is a “massive injustice” to people like her who can’t have this treatment.

*Name has been changed
© 2011 The Irish Times

Related posts:

1. Mentalization Based Therapy Shows Promise with BPD
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I found validation isn’t as effective until the underlying agenda tilts more towards acceptance rather than change.  This may sound strange, but after we accept that the situation may not change (and behave accordingly), it then grows room to change.

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In Dialectical Behavior Therapy, the ability to accept life, the reality of circumstances in which we find ourselves and the painful events that each of us must endure is taught as a skill.

These skills can be difficult to teach and learn because the ability to respond to the world as it is, is an underlying attitude towards life. These skills, taught in the Distress Tolerance Module of the skills training group, include strategies to get both our bodies and our minds into more accepting attitudes.

Below are a few exercises on acceptance:

Body Awareness

To cultivate a more accepting state of mind, increase awareness of your body. Start by simply bringing your awareness to the position of your body. This can be done any time and any place. Whether you are walking, standing or sitting, notice your position. Become aware of the purpose of your position. For example, are you folding your arms across your chest in a defensive stance or are you tapping your foot in anxiety. If you notice that your mind has drifted, bring your attention back to your breath. It can be helpful to practice breathing exercises, such as counting each breath or saying “in” with each inhale and “out” with each exhale.

Turn Your Mind

Acceptance requires a choice. You have to turn your mind towards accepting reality, rather than rejecting and judging reality. You must commit to accepting the current situation and reality over and over. Each time your mind tells you it’s unfair or shouldn’t be as it is, you must turn your mind towards acceptance.

Be Willing

When the world seems unfair and you’re feeling stuck, depressed or frantic, it’s natural to want to give up, try to fix what can’t be fixed, or simply refuse to tolerate the situation. Instead of trying to impose your will on reality, focus on doing what works. Do just what is needed in each situation. Your job is to simply do your best, whatever the world throws at you.

Accepting reality can become a habit. If done regularly, it can reduce stress and anxiety and improve your ability to identify and solve the problems in your life. What helps you accept life as it is?

By CHRISTY MATTA, MA

From PsychCentral’s DBT Blog

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WILLINGNESS

• Cultivate a WILLING response to each situation
• Willingness is doing just what is effective in each situation, in an unpretentious way.
• Willingness is listening very carefully to your WISE MIND, acting from your inner self and your deepest core values.
• Willingness is becoming aware of your connection to the universe and to the person you are interacting with.
• Willingness engenders listening and mentalizing.
• Ask yourself, in 5 years from now, will the situation that causes the distress matter?

WILLFULNESS

• Willfulness is like sitting on your hands when action is needed, refusing to make changes that are needed.
• Willfulness is about the desire to be right in a situation, regardless of what is needed to get through effectively.
• Willfulness causes you to fight any suggestions that will improve the distress and thus make it more tolerable.
• Willfulness is being rigid and inflexible.
• It is the opposite of doing what works, of being effective. Willfulness is trying to fix every situation or refusing to tolerate the distressful moment.

That last example in willfulness is particularly important to read and consider. Often, I find the loved ones of borderlines to be “fixers” and try to solve each problem for the borderline. Being willing to listen, and really hear what the other person is feeling and going through is usually more effective, despite the distress it may cause, than telling the other person what to do or giving advice.

Adapted from dbtselfhelp.com, with edits and additions by Bon

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DBT iPhone App

Are you in DBT? Do you want to know more about it? The creator of the new DBT iPhone application has graciously provided me with a coupon code for a free version of the app. If you’d like to receive this coupon code and want to download the app to your iPhone for free, please send me a direct message on twitter @bondobbs. I only have one, so I expect it to go fast.

UPDATE: You can also claim this code by commenting on this post and providing your email address (which is not shared). I will email you the code and instructions if you have problems redeeming it.

UPDATE 2: Code is gone! Sorry. However, if you’re still interested in the app go to www.diarycard.net

UPDATE 3: I got another code. The last one went fast. If you want it comment on this post.

UPDATE 4: Sorry the second code is gone. Yet, if you want the app for free, comment here. I will not post the comment, I’ll just ask for more codes and email them if I can get them. The codes are limited. Act fast!

UPDATE 5: OK, I’ve given away several codes. I have one more… the final one for me. If you want the final code, please comment on this thread. I will not post the comment, but will send you the code.

FINAL UPDATE: All codes are now gone. Thanks to Sammy for providing them to my readers!

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The Holidays can be a time of stress

The holidays are often thought of as a time of warmth and happiness, family gathered around the table creating wonderful family memories. But for many of us, it can also be a time of angst and anxiety. (link to the article)

There are many reasons you may feel stress. Perhaps you are a student struggling with school and are afraid of criticism from your family. You may be unemployed and don’t want to face questions about your job search or finances. Maybe you’ve put on or lost “too much” weight this year and are feeling self conscious. If you have been struggling with depression, mood swings or anxiety, you may be more emotionally vulnerable. This time of year could remind you of someone who has become ill, passed away or moved.

There are as many reasons for holiday stress as there are individuals. All of them are what we at Silver Hill call “triggers” – they can bring about or literally “trigger” feelings of anxiety, loss and frustration.

The holiday season and family events can be enjoyable and help build meaningful connections with the people in your life, but if triggers set you off, you may instead find yourself caught in a riptide of emotion.

In the Silver Hill Dialectical Behavior Therapy (DBT) Program, we teach our patients strategies to deal with triggers like these. Three of the strategies are Radical Acceptance, Coping Ahead and Wise Mind.

Radical Acceptance

People usually do not change much from year to year. Personality traits you find irksome will still be there. Your snarky nephew will continue to be snarky. The self-obsessed sister will still be self-obsessed. Your mother-in-law will continue to make comments about your appearance or weight.

Expecting them to be kinder and gentler will only lead you to disappointment. Remember, unrealistic expectations are disappointments waiting to happen. Making matters more interesting, people tend to regress when they are around family. You may too. So if your brother really was a “brat,” don’t be shocked if he becomes a grown-up version of his former self. Accepting this fact, and dealing with the people as they are, will reduce your stress.

But Radical Acceptance works to your advantage because the flip side is also true: People who were good will most likely still be good. Your ever warm and wonderful grandmother will continue to be that way. The cousin with the infectious laugh will not let you down, and your always helpful brother-in-law will be his old self too.

Find a way to accept your own personal cast of characters, the good and the bad. It will help you with the next strategy called “Cope Ahead.” 

Cope Ahead

Coping ahead is an extremely useful strategy in every aspect of our lives. Its core tenet is exactly as it sounds: Plan ways to cope ahead of the situation.

Think about the day, location and people in advance. Imagine what you might feel, what thoughts might go through your mind, and what urges you might have. Then come up with a strategy for dealing with those difficult moments.

One of these six may work:

• Identify your allies. Talk with one of your supportive people and agree to be each other’s ally. Discuss strategies you can use if either of you is feeling overwhelmed.
• Take a breather. Fresh air is always good. Being stuck inside only makes us feel enclosed and suffocated. Walk outside for a twenty minute breather. Physical activity gets our endorphins pumping too, which is also a mood enhancer.
• Change the conversation. Someone just can’t stop needling you about your unemployed child? Change the topic. Get them talking about something they care about – something positive. Maybe they ski or paint or got a new puppy. Ask them how it is going.
• Go to another room. If everyone is watching the game and you just can’t stand it, find a quiet room if possible. Family events can begin to feel very crowded. We all need some space.
• Call a friend. Yes, family times are “no phone zones” and we certainly don’t encourage you to keep your phone out as an excuse not to deal with everyone around you. But if it really gets overwhelming, step away, call a trusted friend and quietly vent. Once you’ve regained your composure, you can walk back in and fully participate.
• Ask a lot of questions. Find someone you’d like to know more about, think of questions to ask them and when you get there, make sure you do. Maybe your niece has just started art school or your mother-in-law knits. Just knowing you have a plan to talk with someone will ease your anxiety going in – and they’ll love the attention.

Use Your Wise Mind

Our last strategy is about perspective: Don’t get overwhelmed by events. Be aware of what is going on, and stay true to yourself. Remember, you are your center. If you eat too much, you may be sorry later. Drink too much and you may say things you regret. Enjoy, but be in the present moment. Practice the mindfulness exercise we discussed in an earlier blog: Pause if you need to, breathe in and out to help regain composure.

Using your Wise Mind also means developing something of a “Teflon Mind.” In other words, let things roll off your back. Yes, your aunt said something annoying. But it’s her problem, not yours.

Remember, the purpose of the holidays is to bring family together, not push them further apart.

DBT teaches people to have meaningful connections with each other, because after all, connections make life meaningful. Using DBT skills this holiday can help you gather around the table, build positive memories and have a good time.

– Bradley W. Bloom, LCSW
Silver Hill Hospital

Silver Hill Hospital’s blog is intended only to provide information; it is not intended to provide diagnosis or treatment. If this is an emergency, please call 911.

Note: I modified this story to apply to the the holidays, rather than to Thanksgiving only.

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Personality Type Might Help Identify Teens at Suicide Risk

Leslie Sinclair

Q-factor analysis of adolescents who have attempted suicide may shed light on personality subtypes of attempters.

Studies of adolescents who have attempted suicide usually focus on identifying how they differ from their nonsuicidal peers. Researchers at Emory University, however, have begun to identify how adolescents who attempt suicide differ from one another.

Their work adds to previous studies that have reported personality subtypes within samples of adult suicide attempters and completers. “Overall, assessing adolescents’ risk of suicide attempt should include not only a list of risk factors but also a deeper understanding and consideration of personality,” wrote lead author Dorthie Cross, a doctoral student in the Department of Psychology at emory University, and her colleagues in the October Journal of Nervous and Mental Disease.

The researchers used a Q-factor analysis to identify subtypes based on the Shedler-Westen Assessment Procedure-II for Adolescents (SWAP-II-A), a 200-item measure of personality pathology administered by clinicians that was codeveloped by Drew Westen, one of the authors of the new study.

“Q-factor analysis is also called inverted factor analysis because it aggregates patients rather than variables, identifying people with similar profiles across a set of items instead of items with similar content across cases,” the researchers noted. “the goal of Q-factor analysis in this study is to identify groups of adolescent attempters with shared personality characteristics that distinguish them from other adolescents who have attempted suicide,” they explained.

The researchers recruited 950 psychiatrists and psychologists with at least three years’ postlicensure experience from membership rosters of the American Academy of Child and Adolescent Psychiatry and the American Psychological Association. Participating clinicians were asked to provide data on a single randomly selected adolescent patient currently in treatment of “enduring maladaptive patterns of thought, feeling, motivation, or behavior—that is, personality.” they were asked to select a patient without a particular diagnosis, yielding 267 patients with a history of suicide attempt. Publications detailing the sampling procedure and the rationale for using clinicians as informants in basic science research, also coauthored by westen and published in the American Journal of Psychiatry, were referenced.

Q-factor analysis of the 267 patients with a history of suicide attempt resulted in six subtypes: externalizing, internalizing, emotionally dysregulated, high functioning, narcissistic, and immature.

• The externalizing subtype comprised the largest group of adolescents, characterized by substance abuse, attachment disruption, and being the victim of childhood physical abuse. It included a higher proportion of males and was a significantly younger age group. “We found that this subtype was related to less-lethal suicide attempts, which may be partially explained by the younger age of this group,” the researchers said.
• The internalizing subtype “reflects a substantial body of literature, showing the risk of suicide associated with mood disorders, independent of other factors like substance abuse,” and was characterized by depression, avoidance, and hopelessness; the group was predominantly female.
• The emotionally dysregulated subtype was characterized by childhood sexual abuse, school problems, borderline personality pathology, and substance abuse, as well as increased risk of comorbid mood and substance use disorders. Adolescents fitting this description were considered to be of highest risk.
• The high-functioning subtype “seems healthy and does not experience most of the risk factors associated with suicide,” wrote Cross and colleagues. They may be perfectionistic, experiencing guilt and anxiety, and their attempts tend to be less lethal. “It is possible … (they) may have less access to lethal means of suicide, or they may have a diminished desire to actually die relative to other suicidal adolescents whose functioning may be more impaired.”
• The narcissistic subtype showed high adaptive functioning and school performance and low levels of substance use disorders and conduct disorder.

The immature subtype displayed marked social isolation and anxiety, as well as significant association with schizoid personality disorder. “although immature adolescents seem similar to socially phobic adolescents who are at an increased risk of suicide attempt, they may represent adolescents at risk for the development of psychotic disorders,” wrote Cross and colleagues.

To validate each subtype, the researchers compared the study subjects across relevant Axis I and Axis II pathology, adaptive functioning, and etiology. “Depression, substance abuse, physical and sexual abuse, attachment disruption, and particular personality characteristics (e.g., impulsivity or neuroticism) are all markers for risk; however, these markers do not apply, nor can they apply, to all suicidal adolescents,” they explained.

In discussing the limitations of their study, Cross and colleagues noted that only adolescents who attempted, rather than completed, suicide were able to be evaluated, potentially omitting meaningful subtypes, though they cited increasing evidence that suicide attempt and completion constitute a single spectrum of risk.
“Despite its limitations, this study shows that the path to suicide may be quite different depending on what type of person is making the decision,” concluded Cross and her colleagues. “Understanding those differences is vital to the prediction and prevention of future suicide attempts.”

The research was funded by a grant from the National Institute of Mental Health.

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TRAGIC AMY WINEHOUSE HAD ‘MENTAL ILLNESS’

TROUBLED Amy Winehouse suffered from an undiagnosed mental illness, a relative has revealed.

The talented soul singer could have been struck down by the little-known Borderline Personality Disorder.

Sufferers have feelings of anger, emptiness, shame and guilt and become emotionally volatile.

And it can also push them into substance abuse and eating disorders, both of which Amy succumbed to.

Yesterday a member of the Back To Black star’s family said: “It was never diagnosed, because unfortunately she would never agree to a proper diagnosis.

“I’m not an expert, but from what I’ve read on Borderline Personality Disorder it kind of fitted with her.”

Meanwhile Amy’s dad Mitch, 61, said he wished his daughter, who died in July aged 27, had sought counselling.

He said: “She never stopped trying.

“She hated the way she was when she was drunk and when she was ill.

“And you know, the way I look at it, she died trying.

“She didn’t give up. She died trying to make her- self better.”

This article, although short, points out several interesting things about people with BPD. Since there’s no guarantee she had it, I’m going to generalize a bit. First of all, it is tragic that BPD is “little known” because it is much more prevalent than bipolar disorder. The article says: “Sufferers have feelings of anger, emptiness, shame and guilt and become emotionally volatile. And it can also push them into substance abuse and eating disorders, both of which Amy succumbed to.” This is very true. A person in extreme emotional pain will do anything to stop the pain. The article ends with “She died trying to make her- self better.” I’d like to amend that statement to “She died trying to make feel her-self better.” That’s the nature of the disorder and that’s what many non-BPDs do not understand. It’s all about his/her feelings (IAAHF) and not about controlling, manipulating or calling for attention.

See larger image Lioness: Hidden Treasures (Audio CD) List Price: $13.98 USD New From: $8.84 In Stock Used from: $11.02 In Stock Release date December 6, 2011.

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Amy Winehouse May Have Had a Mental Illness
Posted by Roberta Seldon on December 5, 2011 4:23 AM

Amy Winehouse may have been suffering from an obscure mental illness that ultimately led to her untimely demise, according to a report from the Daily Star.

According to the Star, Winehouse may have been suffering from Borderline Personality Disorder — a condition that leaves the individual emotionally volatile, with feelings of anger, guilt, shame and emptiness, thereby pushing him or her into eating disorders and substance abuse.

According to the Star, a family member said that the Grammy award-winning singer may have suffered from Borderline Personality Disorder. “It was never diagnosed, because unfortunately she would never agree to a proper diagnosis,” the Daily Star quoted a family member as saying. “I’m not an expert, but from what I’ve read on Borderline Personality Disorder it kind of fitted with her.”

Meanwhile, Winehouse’s father, 61-year-old Mitch Winehouse, told the Star he wished Amy would have sought counseling. “She never stopped trying. She hated the way she was when she was drunk and when she was ill,” the Daily Star quoted Mitch as saying.

“And you know, the way I look at it, she died trying.”

“She didn’t give up. She died trying to make herself better,” he added.

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This app was developed by Dr. Sammy Banawan in Durham, NC. Dr. Banawan maintains a full-time private practice in Durham where he also did his internship and post-doctoral fellowship at the Duke University Medical Center. During his post-doctoral fellowship, he worked directly with Dr. Marsha Linehan and her colleagues in continuing to adapt DBT for a variety of psychological conditions.

While this app was developed by a mental health professional, it is not intended to replace a therapist. You will get the most from the app with the aid of a DBT-trained psychotherapist. Remember that if you are actively suicidal or engaging in self-injurious behaviors, you need to be working with a therapist.

This application was created in an effort to bring psychotherapy practices up to 21st century standards. As more and more people carry around mini-computers in the form of smartphones, having to use sheets of paper to record something like behaviors or emotions seems a little ridiculous. It was also designed with the utmost in customizability in mind since no two people are working on the same sets of issues or with the same sets of treatment targets.

Over years of experience treating patients using Dialectical Behavior Therapy, we started to get a sense of what most people need to track and what types of coaching is useful and that’s where the app starts. As you use it and add more of your own information into it, the app will start to be even more helpful to you.

 

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F60.3 Emotionally Unstable (Borderline) Personality Disorder

A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.

Impulsive type:
The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.

Includes:

• explosive and aggressive personality (disorder)

Excludes:

• dissocial personality disorder

Borderline type:
Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).

Includes:

• borderline personality (disorder)

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In one part of the book “Lost In The Mirror”, Dr. Richard A. Moskovitz, M.D. writes, “Elton John’s characterization of Marilyn Monroe as a candle in the wind captures the essence of the borderline personality. She is an elusive character lacking in identity, overwhelmed by a barrage of painful emotions, consumed by hunger for love and acceptance, and careening from relationship to relationship and impulse to impulse in a desperate attempt to control these feelings.”

See larger image Lost in the Mirror: An Inside Look at Borderline Personality Disorder (Paperback) By (author) Richard Moskovitz List Price: $13.95 USD New From: $6.91 In Stock Used from: $2.48 In Stock

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Tragic Vikki’s mum can’t forget court recording of girl’s last call

Published on Monday 28 November 2011 07:13

PROUD mum Pamela Bowmaker remembers how her daughter loved singing Spice Girls songs on her karaoke set. She once adored her Barbies, lived to play practical jokes and dreamt of becoming a children’s nurse.

But her final memory is a haunting one. On a night in September 2008, Vikki McGovern made a desperate call to NHS 24, screaming that she was going to kill herself. She repeated the words over and over again until a fire alarm went off in the NHS building. The worker on the other end of the line gave Vikki a telephone number and said she could phone again in ten minutes, before ending the call.

Vikki, 19, never rang back.

The next morning she was found dead in her hostel bedroom. She had taken a fatal dose of methadone. That dose had been given to her by a criminal who knew she wanted to kill herself.

“They played that tape in court three times,” says Pamela. “Vikki kept saying the call better not be traced or she’d run away and hide. She said she wanted to kill herself over and over. I think she was hinting at them to find her, it was a cry for help. Then the fire alarm went off and she was told to call back.

“That’s the last time anyone spoke to her.

“To hear that recording over and over again,” she says, before trailing off.

“It was unlucky what happened, but I think the NHS could have called back. I felt they had enough time to trace the call. Vikki phoned from the hostel’s office phone – from a place for people struggling with mental health. Vikki never got what she needed.”

Heartbroken Pamela visited her daughter’s grave last Wednesday to lay flowers – and let her know the “nasty piece of work” who gave her methadone during her desperate hours had finally been caged.

In Dundee High Court last Tuesday, with Pamela watching, James Whitson was convicted of culpable homicide after giving Vikki the lethal dose of the class A heroin substitute just days before her death in September 2008.

“In court, that lad smirked at us, although his smirk started to drop as the trial went on. It’s the second time he’s gone to court over this. He got off on appeal [in 2009]. When he was sentenced back then he got ten years. I hope he gets longer this time,” she says.

For Pamela, his imprisonment offers some comfort. She says his conviction will give her an opportunity to grieve.

A picture of Vikki as a baby takes centre stage on the living room wall in her Piersfield Place home, surrounded by pictures of her four happy, healthy siblings: Douglas, 19, Dionne, 16, Robert, 14, and Dale, 11.

Vikki, she says, was a girl who had “snapped” after the death of a close family friend – a grandfather figure – when she was 16.

“When she was growing up she was a typical wee girl. She grew up around a big family and she was a lovely girl. Her siblings adored her, they wouldn’t leave her alone.

“But when she was 16 our neighbour died. Vikki had been so close to him, she would tell him everything and she would visit every single day.

“The day he passed away, something snapped in her. She didn’t really react to the death, she just went into herself. She refused to go to the funeral, which I thought was strange.

“She said she wanted to remember him how he was before he died.”

Soon after his death, Vikki started self-harming. The increasingly nervous teen would wear long tops, which she’d pull over her knuckles to hide cuts to her wrists and hands. Vikki’s brother, Douglas, was the first to guess what was going on when he noticed bits of paper covered in blood scattered around his sister’s room.

“After that I’d regularly ask Vikki if I could see her arms,” Pamela says sadly. “But she got good at hiding the marks. She’d cut her legs instead.”

Frustratingly for Pamela, Vikki would try to hide as much as possible from her mother. “When she turned 16, that was it,” she says. “Vikki wanted to be independent and everything was confidential, the doctors would tell me nothing. When we heard in court that she’d tried to kill herself 13 times, I had no idea.

“Vikki was so quiet. She didn’t drink, she didn’t smoke, she didn’t do drugs. It was so hard to get her to accept help. I told her ,‘Shout, Vikki, shout when you get angry’, but she whispered back that she couldn’t.”

Soon afterwards, Vikki moved out of her home to a supported flat in the Meadows. Next, she moved to Cranston Hostel, then to St John’s Hill Hostel, where Pamela says “the problems really started”.

“One night when she was staying in Cranston, Vikki phoned me from the ERI. She’d been cutting herself too much. She told me she had to leave Cranston for her own safety.”

In a rare moment, Vikki confided in her mother that doctors had diagnosed her with borderline personality disorder.

“It made sense when she said it,” says Pamela. “Vikki could switch from telling everyone she wanted to die and was going to kill herself, then a minute later would be talking about her favourite music and what to get her brother for his birthday. I read that people feel very alone even when they’re not, and that makes me so sad.

“My concerns for Vikki got worse when she went to St John’s. Vikki was isolated there and it was full of people addicted to drugs and alcohol. I don’t believe it was the right place for her.”

Pamela also believes that a lot of the fellow residents used to bully her daughter, marching her to the bank so she could withdraw cash they would then spend and taking items of clothing. On the day Vikki died, the tearful mother claims that Vikki’s bag containing her mobile and belongings – things she would “never be without” – was stolen from her room.

“We’ve still never found it to this day,” she reveals. “My last visit to the hostel, about four days before Vikki was found, I remember my exact words to her support worker were: ‘I don’t feel my daughter is safe living here’.”

It was on September 20 that Pamela got the final knock on the door. “CID were standing there and straight away I knew. I remember I wouldn’t sit down because I didn’t want them to tell me Vikki had passed away.

“We later found out in court that the nasty piece of work at the hostel had been wanting to sell methadone. He’d asked Vikki if she wanted to buy it. I don’t know if he gave it to Vikki or she was too scared to say no, so she bought it. She kept saying she wanted to kill herself. Other people were laughing at her, saying she couldn’t even do that properly.”

Her bullies were referring to a previous attempt to kill herself with methadone the month before. In August she ended up in the ERI, where she sent her mother a text message saying she was sorry and that she wouldn’t do it again.

Tragically, Vikki did do it again. But Pamela doesn’t believe her daughter meant to do it. She is furious that methadone got anywhere near her tormented child’s hands.

“Vikki had been having a hard time before she died, but one of the support workers, Shirley, told Vikki on the Friday night that they were going to have a girly day the next day. Shirley found her dead at 9.30am.”

Vikki was buried on October 7 in Piershall Cemetery, just around the corner from where her heartbroken mother lives.

“The main thing is, I don’t feel like I’ve ever had a proper chance to grieve for Vikki. I just hope that now he’ll accept his sentence and let us move on as a family,” she says quietly.

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New guidance for management of self-harm issued

23 Nov 2011

The healthcare guidance body NICE has today published a new clinical guideline on the longer-term care of adults, children and young people who self-harm. The guideline development group was chaired by Professor Navneet Kapur in The University of Manchester’s Centre for Suicide Prevention.

This new guideline follows on from the NICE guideline on the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (NICE clinical guideline 16). The new recommendations focus on the longer-term psychological treatment and management of self-harm.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: “Self-harm is a very broad term for a behaviour that can be expressed by those affected in very individual ways, which is why it is so important that each person receives the right care plan for them. The previous NICE guideline on the short-term treatment of self-harm focused on the first 48 hours of an episode and the care they received in the Emergency Department. This new guideline aims to help healthcare professionals support, in the longer term, people who are known to self-harm in reducing and then stopping the behaviour.”

Professor Kapur, Professor of Psychiatry and Population Health in the University’s School of Community-Based Medicine, said: “People may keep self-harm a secret which means it is difficult to know how widespread it is. Many cases are unreported unless medical treatment is required. However, it is thought to be common, especially amongst young people, with one UK study finding that 1 in 10 girls aged 15-16 had self-harmed in the previous year. This new guideline is an important step in improving health professionals’ understanding of self-harm and thereby helping to ensure people receive the treatment and support they need.”

You can listen to a podcast about self-harm by Professor Kapur here (link takes you to the NICE website).

Key recommendations include:

• Working with people who self-harm: Health and social care professionals working with people who self-harm should aim to develop a trusting, supportive and engaging relationship with them, be aware of the stigma and discrimination sometimes associated with self-harm and ensure that people are fully involved in decision-making about their treatment and care.
• Risk assessment: When assessing the risks of repetition of self-harm or suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:

1. methods and patterns of current and past self-harm
2. specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm
3. coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other antecedents

• Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.
• Care plans: Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others. The care plan should identify realistic and optimistic long-term goals, including employment and occupation and identify short-term treatment goals (linked to the long-term goals) and steps to achieve them
• Interventions for self-harm: Consider offering 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self-harm. The intervention should be tailored to individual need and could include cognitive-behavioural, psychodynamic or problem-solving elements. Therapists should be trained and supervised in the therapy they are offering to people who self-harm. Therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm.
• Treating associated mental health conditions: Provide psychological, pharmacological and psychosocial interventions for any associated conditions as described in the relevant NICE guidelines, for example, borderline personality disorder (NICE clinical guideline 78), depression (NICE clinical guideline 90), bipolar disorder (NICE clinical guideline 38).

Professor Tim Kendall, Consultant Adult Psychiatrist, Director of the National Collaborating Centre for Mental Health (NCCMH) and Medical Director at Sheffield Health and Social Care Trust, said: “Self-harm is very common and involves a wide range of methods, the most common being self-poisoning with prescribed or over the counter medicines, or by cutting. People self-harm for numerous reasons, and although self harm is not usually an attempt at committing suicide, it is a way of expressing deeper emotional feelings, such as low self-esteem, the emotional results of previous abuse and hurts. However, people who self harm are much more likely to die by suicide, and many suffer from long term physical effects of self injury and self poisoning, as well as psychiatric problems such as depression. It is very important that we help identify people who self harm sooner and to help them come to terms with the underlying problems and access treatment when they need it. This guideline is a really important step to achieving this”.

Dr Suzanne Kearney, GP in Aylesbury and guideline developer, said: “Although most people who self-harm do not wish to end their lives, it does increase the likelihood that the person will eventually die by suicide by between 50- and 100-fold. NICE has already published guidance on what services should be offered to people immediately after an episode of self-harm; with this new guideline on the longer term management, we hope to provide healthcare professionals with clear recommendations on how to work with people who self-harm and enable them to choose the right treatment for their individual needs.”

Mr Gareth Allen, guideline developer representing service user and carer interests, added: “Every person who self-harms is different; they do it for individual reasons and have their own individual needs. It is hoped the recommendations made in this new guideline will help healthcare professionals identify the needs and risks that should be considered when assessing a person who has self-harmed and the types of treatment available.”

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• Psychic Equivalence – when the world is equivalent to the person’s mind. This is the “feelings = facts” mode. “If I feel sad, there must be someone/something that made me sad.”
• Pretend – mental states are not anchored in reality. Pretending “as if” something is true, when external evidence shows the contrary. This is “bullshitting” mode.
• Teleological – mental states can only be expressed in action. “If you loved me, you’d buy me a car.” Only tangible actions count, not words or thoughts.

In addition, there are other ways of thinking that inhibit mentalization such as:

Concrete thinking – “But he said he hated me!” Taking something as gospel and ignoring the underlying mental states and their malleability.

Pseudo-mentalizing – seemingly understanding of mental states, but used in a self-serving fashion.

What do you do when the failure to mentalize happens? When a break in mentalization occurs, you must intervene immediately. You cannot let the break go unnoticed or simply “let it go.” You have to be attentive to the level of mentalization in the conversation and stop the flow of the conversation right away.

Bateman has 3 basic ways of dealing with the break in mentalization, each used for a different intensity of the break. They are:

1. Stop, Listen, Look (for minor cuts, bumps or abrasions).
2. Stop, Rewind, Explore (for breaks, burns and internal injuries).
3. Stop and Stand (for life-and-death struggles and near-fatal injuries)

Huh? What’s up with those?You will notice that “Stop” begins each of these methods. Bateman suggests actually holding up your hand, palm forward in a traffic cop sort of way and saying, “Stop…” (or some variant). This “mentalizing hand” is the “shock to the system” that indicates a hold on further progress to a conversation. It is an indication that you can’t continue the conversation without some sort of clarification of what just happened.

Stop, Listen, Look

This puts the conversation in “pause mode.” It is to remedy a small break in mentalization. It is a reaction to the reaction of the other person. If the person is triggered into an emotion by something that you said, you must stop, listen and look. Some of the ways to do this are:

• “Wait. I’m confused. What I said seemed to have upset you. That wasn’t what I intended. Can you clarify how you feel?”
• “Stop for a minute. You said I was being mean. I didn’t intend for that to be mean, but I guess I was. What do you feel that’s about?”
• “Hold it. You appear to be angry at that. Is that right?”
• “Hang on. I think what I said upset you. Can you help me out here and explain why?”

I know all of this seems rather clunky; however, the purpose of this is two-fold: 1) to get the other person thinking about their thinking (a re-engagement of mentalizing) and 2) to communicate that you are really engaged in the conversation and interested in how the other person is feeling.

Stop, Rewind, Explore

This process is a bit arduous. It requires you to step back through the last few moments of the conversation and explore each, “frame by frame.”

• “Let’s go back and explore what happened just then. It seemed to me we were relating well and then something happened. What do you feel happened?”
• “Something happened just now. Let’s try and rewind a bit to see where the conversation went astray, alright?”
• “Hang on a second. I feel like my intention and the way you felt about what I said are not in synch. Let’s go back and see what happened.”
• “Wait. There appears to have been a misunderstanding a moment or so ago. What do you feel about what I said?”Then, you have to go forward, step-by-step, statement-by-statement and explore each one and see how those made the other person feel.
• “So, I said, ‘maybe he was just tired’ and you felt I was being dismissive of your feelings? Is that right?”
• “You said that you didn’t want to talk about it and I continued. You felt badgered, correct?”
• “When I started talking about our daughter, you felt I wasn’t being attentive to your feelings. Do I have that right?”

Stop and Stand

This process is for the big problems. It is the way that you apply your own personal boundaries to a situation. When the other person is way down the path of emotional dysregulation, stop and stand can be the only option. It is basically your way of either ending the conversation or trying to re-frame it completely.

• “As far as I can tell, we are going around in circles about this. I don’t see any point and continuing to talk about it.”
• “I feel we have reached an impasse. You have your view and I have mine. I don’t think going back and forth will do either of us any good.”
• “I can’t really discuss this anymore right now. Maybe we could discuss it again in the morning.”
• “I can’t listen to you when you’re drunk. Let’s talk about this later.”

Remember: like any application of boundaries, this one is likely to cause an immediate strong reaction, but the “stand” part is that you have to stand your ground.

This content is based solely on my interpretation of mentalization skills.

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I’m gonna jump (link)

THE DOCTOR SAYS
By Dr MILTON LUM

The are several factors that increase the risk of a person commiting sucide.

EVERYONE’S life has its ups and downs, with feelings and emotions accompanying many of these situations. Most people adapt and cope with the downs. However, there are some who are so overcome with these emotions that they take their own life.

Suicide is an individual’s intentional act of ending his or her life.

Many suicide attempts are preceded by a history of self-harm, in which there is deliberate injury that a person inflicts on his or her body. This does not mean that the person who self-harms wants to commit suicide, but is an effort by the person to cope with intense emotions.

However, self-harm is an indication that the person needs immediate assistance.

Suicide is a common cause of death in young people worldwide. According to the National Health and Morbidity Survey 2006, there was a 6.3% rate of acute suicidal ideation, and 25.8% of chronic suicidal ideation. The highest prevalence rate of suicidal ideation of 11% was found in those aged between 16 and 24 years.

The National Suicide Registry Malaysia (NSRM) 2008 report stated there were 290 suicides in that year, of which 219 were men and 71 women, with Chinese comprising 53.5%, Indians 27.3%, and Malays 13.9%.

The youngest suicide victim was 12 years, while the oldest was 83 years. The NSRM estimated that there were 425 suicides between January and August 2010, averaging 60 per month, ie two daily.

It is estimated that the suicide rate is similar to that of the United States.

Although women are more likely to attempt suicide and other self-harm behaviour, it is the men who are more likely to succeed in suicide. The suicide rate in men in many countries is about three times that of women.

Risk factors

The reasons why some people commit suicide while others in similar situations do not, have not been determined. However, there are some factors that increase the risk of suicide.

Genetics is believed to be a risk factor as suicide has been found to be more common in certain families. There are several genetic mutations reported that may alter the chemicals in the brain, increasing the vulnerability to suicidal thoughts and behaviour. However, no specific gene for suicide has been identified.

Mental health conditions are the most significant risk factor, particularly serious and chronic mental health conditions. It has been estimated that about 90% of people who commit or attempt suicide have a mental health condition.

Severe depression is associated with misery and hopelessness – there is a 20-fold increase in the likelihood of attempted suicide than the general population.

Sufferers of bipolar disorder alternate between extreme joy to severe depression. About a third of these sufferers attempt suicide, and about 10% commit suicide.

Patients with schizophrenia are unable to think logically, and have difficulty differentiating between real and unreal experiences, with about 5% committing suicide. The risk is greatest when the diagnosis is made, but with the passage of time, they are better able to cope with their situation.

Anorexia nervosa is a condition in which anxiety about body weight leads to extreme efforts at limiting food consumption. About a fifth of anorexics will attempt suicide.

Patients with borderline personality disorder have altered thinking, unstable emotions, impulsive behaviour and unstable relationships. About half of these sufferers will attempt suicide, with an increased risk in those who were sexually abused in childhood.

It is believed that a combination of other factors increases the risk of suicide. These factors may or may not be significant, depending on the person’s vulnerability at the point in time. They include:

• History of a recent traumatic experience, eg end of a relationship, bullying, loss of job, bereavement.
• History of a traumatic experience in childhood, eg sexual or physical abuse, bereavement, parental neglect.
• A parent with a serious mental health condition, eg severe depression, bipolar disorder, schizophrenia, or who committed suicide.
• A previous attempt at suicide.
• Social isolation, with few family members or friends.
• Misuse or abuse of drugs and alcohol .
• Unemployment or poor job satisfaction or security.
• Debt.
• Occupations which permit access to the means to attempt suicide, eg doctor, nurse, pharmacist, planter.

Danger signs

There are warning signs that indicate that a person is suicidal. They include talking or writing about death or suicide threats to injure or kill himself or herself, and actively seeking methods of committing suicide, eg stockpiling medicines, particularly sleeping pills, and/or pills used to treat serious mental conditions.

Other warning signs include:

• Complaints, talk or behaviour that indicate hopelessness or a meaningless life.
• Loss of interest in personal appearance, eg poor dressing, cessation of use of make-up.
• Reckless or risky behaviour without concern for the consequences.
• Sudden mood changes, anxiety, agitation.
• Increased withdrawal from interactions with family members and friends.
• Insomnia or sleeping all the time.
• Abuse or misuse of drugs or alcohol.
• Putting their affairs in order.

When warning signs are noticed, it would be useful to encourage the affected person to talk about it and to listen attentively. One should listen to what the person has to say to let them know that there is someone who cares about them.

A non-judgemental manner and empathy are essential. One should not influence what is said, but rather, facilitate honest and frank conversation.

Any questions raised by the listener have to be open-ended, and not end the conversation.

At the same time, the person’s doctor or nurse should be contacted. If it is not possible to do so, the accident and emergency department of the nearest hospital should be contacted as to how to get professional help for the affected person. If one assesses that the affected person has a high risk of dying by suicide before the arrival of professional help, one should contact the nearest ambulance service.

At the same time, any possible means of suicide should be removed from the immediate environment of the affected person. This would include medicines, household chemicals, sharp objects, etc.

Providing care to a suicidal person is stressful and distressing, and it can impact upon the carer’s mental health. Professional help may be required to address the carer’s emotions after the event.

Preventing suicide

Mental health is no different from physical health. Measures can be taken to improve mental health so that one is stronger emotionally and better able to cope with the downside of life, thereby reducing the risk of developing mental health conditions like depression.

Exercise is effective in the management of depression. Physical activity reduces stress and anxiety, improves mood, and promotes the release of brain chemicals called endorphins, which makes one “feel good”.

A healthy diet not only provides protection against physical health problems, but may also be vital in maintaining mental health.

Avoidance of social isolation is an important measure as it is a risk factor for suicide. Having friends is beneficial for mental health. If there is individual difficulty in making friends, you should consider joining a local activity group or support group. There is evidence that people involved in providing assistance to others through voluntary or charity organisations are mentally healthier than the general population.

Having a positive attitude is vital as persistent negative thoughts increase the risk of isolation. Cognitive behaviour therapy (CBT) is a type of talking treatment that assists in the management of problems by changing the thoughts and actions of the affected person.

Many people use drugs to help them cope with life’s problems. Their misuse or abuse may lead to more problems and increases the risk of developing serious mental conditions like depression.

Even recreational drugs like marijuana, which is perceived to be less harmful, increase the risk of depression and schizophrenia in some people.

Many people use alcohol to help them cope with life’s problems. Its misuse or abuse may lead to more problems and increases the risk of depression. It would be prudent to avoid exceeding the recommended daily alcohol consumption limits – ie three to four units for men and two to three units for women. A unit is the equivalent of about half a pint of normal strength lager, a small glass of wine, or 25ml of spirits.

A consultation with your regular doctor would be helpful if there are problems with drug usage or alcohol consumption.

However, the evidence is that an effective preventive strategy is to educate doctors on how to recognise and treat depression, and restricting access to lethal methods of suicide. Another promising strategy is to train particular groups of people on how to identify those at risk and refer them for treatment.

Support groups provide counselling and practical advice to people who are depressed, or have suicidal thoughts. The local support group are the Befrienders and their contact details are 95, Jalan Templer, Petaling Jaya 46990 (Telephone: 03 7956 8144 or 03 7956 8145; email: sam@befrienders.org.my)

If you do not like the idea of talking to someone on a helpline, you can talk to a family member, trusted friend, doctor or religious leader. You should also consult your doctor, who can prescribe treatment for mental health conditions.

> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

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The medical borderline: personality characteristics that promote increased risk of opioid misuse

Geralyn Datz, Melissa Bonnell, Toni Merkey, Todd Sitzman
Forrest General Hospital, Hattiesburg, MS, USA,
University of Southern Mississippi, Hattiesburg, MS, USA, Advanced Pain Therapy, PLLC, Hattiesburg, MS, USA

Purpose

Opiate Abuse

Undiagnosed or untreated psychiatric comorbidities may contribute to medication misuse. In particular, personality disorders may place patients at risk for medical nonadherence, via negative coping styles. Patients with Borderline Personality Disorder (BPD) utilize medical services more frequently than those without BPD and are less likely to adhere to medical regimens. Patients with borderline traits have greater incidences of risky behavior, including abuse of prescription medications. We examined a large outpatient sample of chronic pain patients being screened for appropriateness of long-term opioid therapy in order to determine correlations between high-risk behaviors and personality type.

Method

Participants were 96 patients who were assessed in an outpatient pain management program. Participants were administered the Millon Behavioral Medicine Diagnostic (MBMD), which measures psychosocial assets and liabilities that affect treatment response, and the Screener and Opioid Assessment for Patients with Pain – Revised (SOAPP-R), which is a measure designed to predict aberrant medication-related behavior. Hierarchical regression analysis was used to evaluate which psychiatric indicators of the MBMD would predict total SOAPP-R score. Each analysis adjusted for age, gender, duration of pain, and number of pain sites.

Results

Hierarchical regression analysis was used to evaluate which psychiatric indicators of the MBMD would predict total SOAPP-R score. Each analysis adjusted for age, gender, duration of pain, and number of pain sites. Model 1 included demographic variables, duration of pain, and number of pain sites, F(5,91)=5.81, P<.001. Overall, the model explained 24.2% of the variance in SOAPP-R scores. Results indicated that age and number of pain sites significantly predicted SOAPP-R score. Model 2 added the psychiatric indicators of the MBMD. Overall, Model 2 explained 42.7% of the variance in SOAPP-R scores, F(5,91)=6.42, P<.001. Number of pain sites and emotional lability significantly predicted SOAPP-R score over other psychiatric indicators.

Conclusions

Identifying “at-risk” patients for opioid misuse has significant importance in today’s climate of increased scrutiny towards pain medications. These findings suggest personality assessment serves as an effective adjunct to risk stratification. Personality factors such as emotional lability and traits of borderline personality may increase opioid misuse potential. Clinical interview, history taking, and psychological assessment are valid ways pain specialists can assess personality. Prescribing strategies such as prescreening, close monitoring, limit setting, inclusion of psychological support can mitigate risk. Personality traits are key factors that may contribute to aberrant behavior and are of importance to prescribers of opioid regimens.

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I would imagine that for people with BPD this physical pain would be even more painful…

Study Illuminates the ‘Pain’ of Social Rejection

Rejection and Pain

ScienceDaily (Mar. 28, 2011) — Physical pain and intense feelings of social rejection “hurt” in the same way, a new study shows.

The study demonstrates that the same regions of the brain that become active in response to painful sensory experiences are activated during intense experiences of social rejection.

“These results give new meaning to the idea that social rejection ‘hurts’,” said University of Michigan social psychologist Ethan Kross, lead author of the article published in the Proceedings of the National Academy of Sciences. “On the surface, spilling a hot cup of coffee on yourself and thinking about how rejected you feel when you look at the picture of a person that you recently experienced an unwanted break-up with may seem to elicit very different types of pain.

“But this research shows that they may be even more similar than initially thought.”

Kross, an assistant professor at the U-M Department of Psychology and faculty associate at the U-M Institute for Social Research (ISR), conducted the study with U-M colleague Marc Berman, Columbia University’s Walter Mischel and Edward Smith, also affiliated with the New York State Psychiatric Institute, and with Tor Wager of the University of Colorado, Boulder.

While earlier research has shown that the same brain regions support the emotionally distressing feelings that accompany the experience of both physical pain and social rejection, the current study is the first known to establish that there is neural overlap between both of these experiences in brain regions that become active when people experience painful sensations in their body.

These regions are the secondary somatosensory cortex and the dorsal posterior insula.

For the study, the researchers recruited 40 people who experienced an unwanted romantic break-up within the past six months, and who indicated that thinking about their break-up experience led them to feel intensely rejected. Each participant completed two tasks in the study — one related to their feelings of rejection and the other to sensations of physical pain.

During the rejection task, participants viewed either a photo of their ex-partner and thought about how they felt during their break-up experience or they viewed a photo of a friend and thought about a recent positive experience they had with that person. During the physical pain task, a thermal stimulation device was attached to participants left forearm. On some trials the probe delivered a painful but tolerable stimulation akin to holding a very hot cup of coffee. On other trials it delivered non-painful, warm stimulation.

Participants performed all tasks while undergoing functional magnetic resonance imaging (fMRI) scans. The researchers conducted a series of analyses of the fMRI scans, focusing on the whole brain and on various regions of interest identified in earlier studies of physical pain. They also compared the study’s results to a database of more than 500 previous fMRI studies of brain responses to physical pain, emotion, working memory, attention switching, long-term memory and interference resolution.

“We found that powerfully inducing feelings of social rejection activate regions of the brain that are involved in physical pain sensation, which are rarely activated in neuroimaging studies of emotion,” Kross said. “These findings are consistent with the idea that the experience of social rejection, or social loss more generally, may represent a distinct emotional experience that is uniquely associated with physical pain.”

The team that performed the research hopes that the findings will offer new insight into how the experience of intense social loss may lead to various physical pain symptoms and disorders. And they point out that the findings affirm the wisdom of cultures around the world that use the same language — words like “hurt” and “pain” — to describe the experience of both physical pain and social rejection.

The study was funded by the National Institute of Mental Health and by the National Institute on Drug Abuse and performed at Columbia University.

Link

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I do not think that lying and manipulation are part of this diagnosis. If they seem to be present, look either to another PD or to shame and anxiety as the cause, along with a long history of learning to never overtly state what you needed to be okay, or to express how rotten you felt, as the consequences always seemed to be much worse…

Sometimes it seems as if people hate those that are dx BPD precisely because they haven’t quite gone off the deep end for good. It’s bewildering how many professionals seem to resent them for this too.
They may curl up in a fetal position for hours, but then they will struggle out of bed and go on. They smile at us, while their inner world self-destructs. They might seem as alive as anyone, but -in the best of times- they feel dead inside; and as intelligent and gifted as many of them are, they never realize their full potential. But they would rather die than admit this to the outside world.

Who would today be dx’d BPD? Vincent Van Gogh, Kafka, Proust, Nathanial West, Sylvia Plath, Anne Sexton, Janis Joplin, Jim Morrison…

It’s ironic that they are so often seen as “emotional” when what they lack is a full nuanced range of emotions. Inner tension keeps anxiety coiled, emotionally stressful situations release it, and before they have a chance to think through what they feel, they are overwhelmed by fear and anger and despair. They get mired in their negativity. Studies have shown that those with BPD do not get angry more often than anyone else, but they have trouble leaving it behind when they do. And afterwards they drown in remorse, because these reactions are NOT felt to be syntonic. No one seems to pay much attention to this, but all other “personality disorders” are understood to be PD’s because they are syntonic with the personality. This is radically different in BPD.

That right there should raise lots of doubts about what this dx is. Is it part of the affective disorder spectrum? Is a akin to partial seizures in frontal lobe epilepsy? Is it a developmental disorder akin to autism? This is all possible, and perhaps BPD is a dx given to many different people who do not share underlying causes. This should at least stop us from quickly claiming that they CHOSE to feel the way they do. As if they were hell bent on living in hell…

When they do awkwardly, fearfully, try to communicate this pain, when they do reach out for help, they generally do so when their psyche is at it’s most shattered. They will quickly learn that their behavior is not acceptable to anyone. So they’ll go through DBT or through some other behavioral therapy, and sink into so much shame and guilt that lo and behold they will no longer qualify on the DSM for BPD; they will have learned to suffer in silence and to isolate (if they haven’t before – many of those with BPD will never consult a therapist in their lifetime and go through life pretty much invisible), learned to not bother anyone, but the dysthymia, the insomnia, and the dysphoria will still be there, eroding their lives, their aliveness. And as hard as they try, fear will still strike them out of the blue when they least expect it. As hard as they try, they will still plummet down into misery with the least negative emotion. Skinless creatures, they can not tune out human suffering, they can do nothing about the heightened sensitivity that they were born with. Only now no one will know. And so hopefully, thankfully, no one will ever call them “Borderline” again.

 

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Being blamed for everything is tiring to say the least. Coupled with the BP’s inability to take responsibility (and blame) for his/her own actions, this aspect of BPD is maddening. It is impossible for one person to shoulder all the blame for everything in a relationship. One of my therapist friends once told me, “If you are responsible for everything, you are responsible for nothing.” I truly believe that it is impossible for anyone to take all the responsibility and blame in a relationship.

Why does a person with BPD seem so fixated on blame-finding? (Which I like to call “blame-storming” in a nod to “brain-storming”). Why does he/she go to great lengths to assign blame to anyone else (including God, the world, everyone, etc.) other than his/herself? The reason seems to be similar to that of the inability to take responsibility for his/her actions. He/She does not want to be seen as the “cause” of problems or of pain. This would again make him/her “all-bad” and in being “all-bad” he/she deserves nothing less than death. It is easier to find someone else (or something else, like karma or life itself) that is a more acceptable cause of his/her pain and problems. Some books call this “projection,” but I don’t think it is projection per se. It is more the fear of rejection, ridicule and emotional pain if he/she is at fault. It confirms his/her shame and that he/she can do nothing right. Through black-and-white thinking, if he/she is a bit at fault, he/she is doomed.

Sometimes I will hear my wife say that she “hates everyone” or that she feels “everyone is out to get her.” Clearly, these statements can be seen as paranoid or misanthropic, but ultimately she is expressing her belief that forces outside herself are to be blamed for how she feels.

Adapted from When Hope is Not Enough

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Depression and grief can be a trying experience for anyone. You feel pain in every area of your body and mind. Sometimes you will just want to retreat to your bedroom and go to sleep for hours, just to get some relief from the physical and mental anguish you feel. The sleep represents a distraction of both the mind and the body from the experience of complete pain. You might also use alcohol to relieve the pain by “turning off your mind.” Many people “drink themselves into a stupor” and, in doing so, extinguish the pain for a short period. Pain-killers, whether over-the-counter or prescription, can also remove pain by working on the pain at its source (in the brain where pain is actually felt). Once, when I was asked by one of my daughters about how the Tylenol knew to go to her foot (which was in pain), rather than to her head (because she’d taken it for headaches before), I explained that it acts in the brain where she feels the pain, not where the pain actually “is.” In the case of emotional pain, the pain seems to be both in the body and in the mind, but the pain-feeling area of the brain is where these drugs act. See below about substance abuse.

People with BPD are likely to feel emotional pain many times a day every day. Since these emotions are basic (like fear, sadness and anger) the reactions to them are both physical and mental. These emotional pain-states are powerful and have the ability to overpower rational thinking. When you are in pain, regardless of the source, the main reaction of the body and mind is to get out of or to relieve the pain as soon as possible and by whatever means necessary.  I used the example of someone who is literally on fire. This person will try to douse the flames in any way, without thinking about the people around her and what harm may come to others if the flames spread. This situation is analogous to a person in deep emotional pain. The person will do anything to stop the pain, which is why my Internet site and Internet list are called “anything to stop the pain” (ATSTP). This “anything” includes self-destructive and relationship-damaging behaviors.

Self-injury

Self-injury can come in many forms and includes cutting oneself with razors or knives, burning oneself with cigarettes or matches, pulling out clumps of hair and picking at oneself (especially the nails and/or cheek) until blood is produced. Self-injury is one of the most difficult behaviors for the loved one to understand. In the case of BPD, self-injury is done for the purpose of pain relief, not to “get attention” or to manipulate the loved one. Most self-injury is done in private and done without the knowledge of the loved one. Occasionally, the self-injury cannot be covered-up (i.e. the blood and/or scars are apparent or the hair is missing in large area of the head) and others notice the activities. The actions themselves are fraught with shame and may lead to even more shame for the person.

In the hospital, ER doctors take a dim view of those who injure themselves and a person who engages in self-injury often avoid hospitals to avoid the inevitable judgment and lack of compassion these doctors (and nurses) will exhibit toward her. What is important for a loved one to understand is that self-injury has a purpose and that purpose is usually pain relief, not self-punishment or attention-getting. The person who engages in this behavior may feel and describe a deep “itch” inside her body that she has to rid herself of immediately.

While self-injury can provide relief from pain (through the release of endorphins, or natural, pain-killing substances within the brain), it can have risks and negative consequences. These include embarrassment, scars, infection and, in some cases, death.

Substance Abuse

As stated above, many people use alcohol and/or drugs to dampen the effects of emotional pain. With BPD, it is likely that alcohol and/or drugs will be used for this purpose. Drugs and alcohol CAN function to reduce pain. However, this pain reduction is temporary. What I have noticed from the ATSTP group is that people with severe BPD are likely to use large quantities of alcohol and/or drugs to deaden their pain. Some estimates of substance abuse by people with BPD are as high as 75%.

Many people with BPD use and abuse alcohol and drugs. Often, they will ingest large quantities (more than someone without BPD could handle) and not overdose or even pass out. They may take both prescription drugs with anti-anxiety medication, such as Xanax, Ativan and Klonopin (and others); painkillers, such as Oxycotin, Vicodin or Codeine (and others); or they may take illicit drugs, such as Marijuana, Cocaine, Heroin, or Methamphetamine (and others). The purpose, again, is to remove emotional pain. Unfortunately, these substances, especially in the quantities consumed, can have several negative effects and consequences, including overdose, driving violations and an increase in impulsivity or dyscontrol.  These periods of impulsivity and dyscontrol and the behaviors that result (such as “risk-taking behavior” below) may cause more shame and self-punishment when the BP sobers up.

Risk-taking Behavior

People with BPD also engage in risk-taking behaviors of various forms. These behaviors include risky sexual behaviors, reckless driving and thrill-seeking behaviors. Many of these activities could be considered life-threatening either in the short term (by having a car accident) or in the long term (by contracting HIV or another fatal sexually transmitted disease). The people with BPD will, at the time of the risk-taking behavior, most likely not consider the consequences to life and limb – either physical or legal. Again, the purpose is to halt and/or deaden the emotional pain. In other words: “it seemed like a good idea at the time.” Sexual activities can provide pleasure, dangerous driving can provide a thrill and other risky behaviors, like hanging out of windows or jumping off cliffs into lakes, can provide a rush of adrenaline that temporarily removes the emotional pain. The point is for you, the loved one, to understand that the motivation of these behaviors, however short-sighted and ill-conceived you think they are, is to remove pain.

One member of the ATSTP group reported that her husband had totaled four cars in a period of eight years. These behaviors are impulsive and therefore not “thought through.” They are another method to “put out the fire” within the person. Certainly, these behaviors can have significant consequences, physical, legal, financial and otherwise.

Eating Disorders

Another behavior that many people with BPD engage in (particularly females) is eating disorders. Whether it is starving oneself or binging-and-purging or overeating (especially secret overeating), the eating disorder is another tool someone with BPD can use to alleviate emotional pain.

Again, eating disorders can have negative consequences including starvation, ill-health, poor self-image and obesity.

Other Binge Behavior

Other binge behaviors (or indulgent/irresponsible behaviors) are binge shopping, obsessive plastic surgery and “running away” through binge travel. These behaviors provide temporary relief from emotional pain as well. And again, they can have negative consequences by damaging a relationship or financial consequences.

On a final note on dangerous behaviors: it is important to prioritize when you are trying to help the BP halt or alter their behavior. You will want to start with the most dangerous first. If your daughter with BPD is having unprotected sex and smoking marijuana, regardless of your feelings about drugs, the unprotected sex will have to come first. Also, you need to be practical about it. Giving her condoms and saying, “I can see how buying these or asking your boyfriend to wear one might be embarrassing to you” rather than insisting she no longer see the boy is probably more effective, again regardless of your feelings about premarital sex. Once the genie is out of the bottle, it is difficult to stuff it back in. You can, however, help make it safer and you do so by being effective. Of course, you also have to be brave in this situation. It can be very difficult for a parent to talk to a child about sex.

Adapted from When Hope is Not Enough

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• Sending someone to therapy is not like having your car repaired. It involves a lot of hard work on the part of the patient/client and on the part of their loved ones and supporters.
• Therapy as usual (referred to as TAU in the studies) can actually make BPD worse in some individuals. There are several BPD-specific therapies, such as DBT, Schema-focused therapy and Mentalization-based therapy.
• Therapy requires the buy-in of the patient/client. If he/she doesn’t want to admit he/she has a problem or doesn’t trust the therapist with his/her feelings, therapy will likely not have a lasting effect.

Unfortunately, you can’t force someone to go to therapy if she doesn’t want to go (except through a court order). What I suggest is that you use the tools I offer for a while. After you do that for some time, the borderline might begin to gather some self-awareness or to share her inner thoughts and feelings with you. It is likely that these thoughts and feelings will be filled with shame, self-hatred and worry. At that point, you can say something like, “Boy, it must feel awful to feel that way about yourself. What do you think you can do to feel better?” or “That’s so painful to feel that way. Maybe therapy can help?”

My wife has resisted going to DBT because it identifies her as a borderline and she “doesn’t want to be that person.” She also resists because DBT seems like a therapy of last resort to her and, if she fails at it, she feels that she will have to be committed to a mental institution. I occasionally do reinforce to her that there are people who are trained to help her feel better and encourage her to look into it. She is in therapy, but not in DBT. My daughter does see a DBT therapist. She decided to go because she was so angry all the time, and she felt terrible. She wanted to learn how to feel better. At some point, her emotional pain reached an intolerable level.

I have tried to model these skills in my life and, by doing so, shown my wife that I can more adequately cope with emotional situations, both personal and interpersonal. This modeling encourages my wife to consider DBT (or another emotional training program) to help her feel better. My suggestion is that you practice effective tools, master them and use your mastery over emotional situations as a beacon for your borderline’s healing.

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1. Mentalization Based Therapy Shows Promise with BPD
2. Can therapy actually hurt borderlines?
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latimes.com/health/la-he-child-temper-20111010,0,3234089.story

latimes.com

Child mental disorders: New diagnosis or another dilemma?

A proposed new diagnosis for outbursts and tantrums sparks debate in the psychiatric community. Would it help parents desperate for answers, or just add to the confusion?

By Shari Roan, Los Angeles Times

October 10, 2011

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The final straw for Carolyn Alves came last fall when she tried to help her daughter Cecelia dress for kindergarten.

The volatile 6-year-old had worked herself into a frenzy as she tried on outfit after outfit, rejecting each as unacceptable. The tantrum at full bore, she scooped up a pile of clothes and hurled them at the front door of the family’s Spanish-style bungalow in Glendale.

The clock ticked past the school’s 8 a.m. bell. Alves pulled her wailing child into her arms and held her on the couch. After several minutes, Cecelia stopped, took a breath and announced that she was ready to go to school.

“It was like watching someone who was having a mental breakdown,” Alves said. Then “a switch went off and she went back to being normal.”

Alves and her husband, Marcos, have consulted five doctors and therapists in the last four years. Cecelia has been diagnosed with a smorgasbord of psychiatric disorders — including the controversial diagnosis of child bipolar disorder — in addition to being called a normal kid.

Experts in pediatric mental health readily acknowledge that their failure to pinpoint the problem with children like Cecelia makes a difficult situation worse. And some of them are pressing for an unconventional solution: a new diagnostic category called disruptive mood dysregulation disorder, or DMDD.

Creating a diagnosis is considered a radical step in mental health circles, and the proposal has sparked much debate. The controversy underscores the fact that therapists simply don’t know what to make of the estimated 3% of children in the U.S. who suffer from severe irritability and emotional outbursts.

“Everyone wishes we could have a genetic test or a blood test” to determine which disorder a child has, said Erik Parens, senior research scholar at the Hastings Center, a bioethics think tank in Garrison, N.Y. “Unfortunately, nature doesn’t work the way we wish.”

As a result, parents may be told their children have conduct disorder, oppositional defiant disorder, attention deficit hyperactive disorder, depression or bipolar disorder — if they get a diagnosis at all.

Adding disruptive mood dysregulation disorder to the list of ailments doctors may consider would reduce the number of children misdiagnosed with bipolar disorder and treated with powerful psychiatric medications, proponents say. And, they add, improving treatment for children who have problems with mood and temper would reduce the number of children at risk of falling through the cracks in school and society.

But critics counter there is no scientific evidence to warrant recognition of a new mental disorder.

As doctors quarrel, parents like Alves struggle with the lack of medical options.

“I feel in limbo right now,” Alves said one afternoon, cuddling her painfully shy daughter. “Having a diagnosis would help me know what direction to take.”

Psychiatrists sharpened their interest in child mood problems several years ago in response to criticism over the number of children diagnosed with bipolar disorder — a debilitating condition in which periods of depression alternate with euphoria or elevated moods. It is considered incurable, although symptoms may be treated with drugs that carry serious side effects.

The idea that bipolar illness can begin in childhood caught hold in the last decade. The number of outpatient visits for children diagnosed with bipolar disorder mushroomed from fewer than 200,000 a year in 1995 to 800,000 in 2003, according to a 2007 study in Archives of General Psychiatry.

The study reinforced the notion that childhood bipolar disorder had become a fad diagnosis.

“The diagnosis means exposure to pretty potent medications,” said Dr. Jan Fawcett, a psychiatrist at the University of New Mexico School of Medicine in Albuquerque. “And, if the diagnosis holds, it means lifetime exposure to these medications.”

Such children often receive drugs like lithium or Depakote, which can cause severe weight gain, sedation and involuntary muscle contractions. They aren’t prescribed antidepressants or stimulants, which could worsen the condition in children who are truly bipolar. If the diagnosis is incorrect, however, children are deprived of drugs that could alleviate their anxiety or depression.

“We had to do something about it,” said Dr. David Shaffer, a child psychiatrist at Columbia University in New York and member of an American Psychiatric Assn. work group that proposed adding disruptive mood dysregulation disorder to the Diagnostic and Statistical Manual of Mental Disorders, the book that forms the bedrock of psychiatry. That would allow doctors to reclassify a significant portion of children who are considered bipolar, he said.

According to the definition under consideration, DMDD would be characterized by severe, recurrent temper outbursts in response to common stressors that are not developmentally appropriate and are out of proportion to the situation. Between tantrums, the child’s mood is nearly always negative, irritable, angry or sad. Such children are not like 3-year-olds who have fits if they don’t get cookies before dinner.

Symptoms would be apparent not just to parents but to teachers and others, and they would be present for at least 12 months before a diagnosis was made in a child under 10. It’s unclear how the condition would be treated, although proponents of the diagnosis say they are trying to reduce the use of antipsychotic medications.

But some of the symptoms can also be found in children with bipolar disorder or other conditions, said Dr. David A. Axelson, who argued against the proposed diagnosis this year in the Journal of Clinical Psychiatry. He and other experts say there is insufficient evidence that a distinct disorder exists.

“The scientific backing for it is quite lacking,” he said. “It doesn’t mean this shouldn’t be a diagnosis in the future, but we need solid scientific studies.”

David Miklowitz, a professor of psychology at UCLA, said he feared that many doctors who were reluctant to label children as having bipolar illness or conduct disorder would adopt DMDD as a default diagnosis.

“I think they are actually solving one problem but creating another,” he said. “The risk, with a diagnosis like this, is that clinicians who are strapped for time will slap on this diagnosis and say, ‘I’ve got it figured out.’ ”

The debate has been polarizing and uncharacteristically bitter for the mental health community. In his recent paper, Axelson and his colleagues charged that the proposal was “a step backward for the progression of psychiatry as a rational scientific discipline.”

And a past editor of the Diagnostic and Statistical Manual of Mental Disorders, Dr. Allen Frances, has written several critiques of the proposal, including one last summer that accused the scientific review group that endorsed DMDD of running a “sham review process.”

“New diagnoses are as potentially dangerous as new drugs, and we need a much tighter regulatory mechanism to ensure that they are both necessary and safe,” Frances said in an interview.

Fawcett acknowledged that more scientific evidence was typically needed to justify a move like this.

“Creating a new disorder should require much more evidence than we have,” he said. “But, on the other hand, there is a much bigger problem here.”

Alves doesn’t care what doctors decide to call her daughter’s condition, but she wants them to come up with a firm diagnosis. She wants strategic help for the child who, at 9 months, was having long bouts of screaming and uncontrollable crying and who, at age 3, would bang her head against the floor if something upset her.

Alves remembers the sunny day in June when the family attended Cecelia’s kindergarten performance at school. Cecelia didn’t want to go on stage and erupted in a 20-minute meltdown before reluctantly joining her classmates.

“It’s more apparent all the time that this is not just a tantrum,” Alves said.

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Judgment Hurts those with BPD

A person with BPD fears judgment almost to the point of being allergic to it. She is extremely sensitive to judgment from other people, even if that judgment is merely perceived. Because of the shame (the belief that she is a bad person and deserves to be deemed as such) and the rejection sensitivity, a person with BPD avoids situations in which her actions can be judged by others. When I say “judged” here and “judgment,” what I am referring to is not “using one’s better judgment” in a situation, but rather it is the sense that a person’s actions or the person herself can be judged as “right or wrong” in a given context.

Interestingly, even with a strong fear of judgment of herself and her own behavior and self, she also tends to judge other’s behavior and character harshly. How many times has your loved one with BPD told you that you were doing something “wrong” or that you are a “mean” or “bad” person?

Fear of judgment and emotional reactions to judgment (real or perceived) is a major issue for a person with BPD. Judgment of her actions causes emotional pain and to avoid judgment, she might lie or avoid social situations in which she feels she will be judged. If she is consistently concerned with doing something “the right way” or she feels that you think she “does everything wrong,” it is likely that she suffers from a fear of judgment.

Additionally, there is a stigma associated with being “crazy” when a person has BPD. A person with BPD might feel “not normal” inside and might have felt that way most of her life. However, if the outside world labels as “crazy” or “not normal” or “mentally ill,” it becomes an external validation for what she might already feel. The fact that others “know” about her can make her feel exposed. It is a form of judgment and fear of it that reduces the likelihood that the person will “admit” she has a problem.

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Tears of freedom, now the bidding war begins

Karen Kissane October 05, 2011

THE family of the murdered girl was bereft; the family of the alleged murderer jubilant.

Amanda Knox

After judges in the Italian hill town of Perugia declared convicted murderer Amanda Knox not guilty on appeal, her sister Deanna said outside court: “We’re thankful that Amanda’s nightmare is over. She has suffered four years for a crime she didn’t commit.”

Ms Knox, 24, was flying home to Seattle last night, where she is expected to receive offers for multimillion-dollar book and movie deals about her ordeal.

TV networks are already bidding for her first interview.

Ms Knox’s mother and other relatives were seen at Rome’s Leonardo da Vinci Airport, where Ms Knox joined them on a flight to London before boarding a connection to the United States.

But for the family of the woman she was accused of murdering, 21-year-old Meredith Kercher, there was no joy in the legal decision that overturned Ms Knox’s conviction and 26-year jail sentence.

They said in a statement: “We respect the decision of the judges but we do not understand how the decision of the first trial could be so radically overturned. We still trust the Italian justice system and hope that the truth will eventually emerge.”
The prosecutor Giuliano Mignini vowed an appeal to Italy’s highest criminal court.

“Let’s wait and we will see who was right. The first court or the appeal court,” Mr Mignini said.

“This trial was done under unacceptable media pressure. The decision was almost already announced; this is not normal.” If the highest court overturns the acquittal, prosecutors could request Ms Knox’s extradition to finish her sentence.

At an earlier media conference Ms Kercher’s sister Stephanie said the “brutal murder” was being overlooked: “Meredith has been hugely forgotten.” Her brother Lyle said: “It is very hard to find forgiveness at this time. Four years is a very long time but on the other hand it is still raw.”

Judges also acquitted Ms Knox’s alleged partner in crime, her Italian former boyfriend, Raffaele Sollecito. The two had been convicted of raping and murdering Ms Kercher, an English exchange student, in the bedroom of a cottage the two women shared in Perugia in 2007.

The case sparked lurid language and an almost lascivious fascination inside and outside Italy’s justice system.

Judges have yet to give their reasoning but it is thought they relied on experts who testified the original investigation had been botched, with more than 50 errors in the handling of DNA evidence. The two judges, sitting with a six-person jury, were not swayed by the venomous language of the lawyer who had painted Ms Knox as a she-devil for initially falsely blaming her employer, bar owner Patrick Lumumba, for killing Ms Kercher. Mr Lumumba was arrested and jailed for two weeks after Ms Knox claimed she had heard him enter Ms Kercher’s room and then clapped her hands over her ears to muffle screams.

Mr Lumumba’s lawyer told the court: “The woman you see before you today is charming [and] angel faced … [but] she was a diabolical, demonic she-devil. She was muddy on the outside and dirty on the inside. She has two souls, the clean one you see before you, and the other.” He also claimed: “She is borderline. She likes alcohol, drugs and she likes wild, hot sex.”

Borderline personality is a serious psychiatric disorder involving severe mood swings, chaotic personal relationships and sometimes dissociation.

Police had become suspicious early on because of reportedly strange behaviour by Ms Knox, who had allegedly performed cartwheels and splits while waiting to be questioned and who had gone shopping for a g-string the day after the killing, where she was heard promising her boyfriend wild sex.

She was found to have lied about Mr Lumumba. Judges this week sentenced her to three years’ jail for slandering him. She was freed because she has already served four years jail, although she must also pay him €22,000 ($30,600) in damages.

Ms Knox said she lied only after being bullied and cuffed by police, who questioned her without a lawyer present. Ms Knox’s parents reportedly mortgaged their homes to pay her legal fees.

Mobile phone records suggested that she and her boyfriend had been near the scene at the time of the killing and turned off their phones for three hours around the time Ms Kercher is thought to have died.

Prosecutors at one point suggested the killing was the result of an attempted sex game and that Ms Kercher had been raped and killed for refusing to play. But this theory did not fit with the fact that the courts also convicted an Ivory Coast drifter, Rudy Guede, of the killing after DNA samples at the scene were matched to him. Ms Knox barely knew Mr Guede and Mr Sollecito had not met him.

Ms Knox’s father, Curt, said after her conviction “the attacks on Amanda’s character … overshadowed the lack of evidence in the case against her”.

Ms Knox thanked those “who shared my suffering and helped me survive with hope”, in a letter to a foundation that seeks to promote ties between Italy and the US and which has always championed her cause.

Her supporters in the US, where she is expected to take part in a $US1 million ($1.03 million) interview, greeted her acquittal with delight. In Seattle, supporters holding vigil hugged, wept and cheered.
They were not alone. Ms Knox, who had been rushed sobbing from the courtroom by guards, was returned to jail to be formally released. “There was a huge cheer … an ovation from every cell,” one of her supporters, the Italian MP Rocco Girlanda, told journalists. “Everyone was shouting ‘libera, libera!’ [free, free!] It was like being in a football stadium and was something I will never forget. Amanda saluted the other prisoners with a timid wave – she didn’t really know how to react.”

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Young student raising awareness

by Kevin Mertz

Published: Wednesday, September 28, 2011 8:21 AM CDT

MILTON — Seven-year-old Kiflyn Hockenbrock sat quietly by her mother Dawn Hockenbrock’s side, grinning from ear-to-ear, as Dawn spoke on the pride she has for her daughter, who has launched a fundraising effort to support a worthwhile cause.

Kiflyn, a second-grade student at Baugher Elementary School, will be participating in the Out of the Darkness Community Walk, to benefit the American Foundation for Suicide Prevention, Sunday, Oct. 16, at Lycoming College in Williamsport. She will be joined at the walk by a team of friends and family.

To raise funds for the walk, Kiflyn is spearheading a Chinese auction, to be held starting at 11 a.m. Saturday, Oct. 8, at the New Columbia Civic Center, located on Third Street in New Columbia.

Prevention of suicide is a cause close to Kiflyn’s heart. Her father, Cody Lahr, passed away as the result of a suicide in November 2009.

Dawn said her daughter has been traveling with her to a number of local businesses seeking donations for the auction.

“(I’m) very proud,” Dawn said of Kiflyn. “She’s shy. For her to go out to do this is amazing.”

Dawn said Kiflyn is also growing as a person by heading up the fundraiser.

“She’s learning there’s a lot of people who have the same issues, people who lost people to this issue,” Dawn said. “She’s not alone.”

She said Lahr had been diagnosed with a borderline personality disorder. In the days leading up to his suicide, a number of bad things had happened in his life, including a death in the family.

“It was too much (for him),” Dawn said.

She said Kiflyn is learning that it’s OK to talk about suicide and she hopes others realize that as well.

“(Suicide) is not something that’s really talked about,” Dawn continued. “It’s hush hush sometimes when something like this happens. It’s OK to talk about it. It’s OK to miss her dad or whomever it happened to.”

She said one of the goals of the American Foundation for Suicide Prevention is to get the word out that help is available for those who may be considering suicide and need support in their life.

Dawn said her daughter has had a strong support system since her father’s death.

Anonymous community members made a blanket for Kiflyn using fabric from T-shirts which had been worn by Lahr. A similar blanket was also crafted for Kiflyn’s younger sister, Laney Lahr.

Dawn said the blanket “means a lot” to Kiflyn.

“She slept with it the first couple of nights,” Dawn said. “It’s nice to have that constant reminder.”

She’s thankful for the community members who made the blanket. Members of the United Methodist Church in New Columbia also made pillows made out of Lahr’s jackets for his children, Dawn said.

She and Kiflyn are thankful for the various community members who are assisting in Kiflyn’s efforts to raise funds for the American Foundation for Suicide Prevention.

The family recently received notification that the Local 38 Union will be donating $500 to the cause.

“When we got the call about the $500, we about fell over,” Dawn said. “It is amazing. When I’ll go out and ask people for donation, people will say ‘I knew someone’ (who was a suicide victim).”

Items that will be a part of the Chinese auction include Vera Bradley items, a night’s stay at the Comfort Inn in New Columbia, a lottery tree and at least 50 gift certificates to local businesses.

Team members participating in the walk with Kiflyn and Dawn include: Stephanie Kreps, Jose Castro, Kristy Dreisbach, Kristy Foster, Courtney Haas, Millie Hockenbrock, Michelle Kashuba, Amanda Kiessling, Laney Lahr, Teresa Lahr, Jessica Reich, Donna Schaffer, Becca Stevenson and Genie Ficks.

For more information on the walk or the American Foundation for Suicide Prevention, visit http://afsp.donordrive.com.

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An article from psychcentral about a study indicating that social problems in teens can lead to personality disorders:

Social Problems in Teens Can Lead to Personality Disorders

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on September 29, 2011

A new research study looks at how adolescents think, how disordered thinking can take root, and how this thought pattern can ultimately lead to an adult personality disorder.

The study examines the relationship between borderline personality disorder (BPD) traits and “hypermentalizing” in adolescents. Mentalizing is the social intelligence that refers to the ability to infer and attribute thoughts and feelings to understand and predict another person’s behavior.

Dr. Carla Sharp, psychologist at the University of Houston (UH) and lead researcher, believes the results of the data can be used for early intervention, treatment, and identification, of borderline personality disorder (BPD) in adolescents.

This includes improved treatment strategies — such as putting the brakes on “hypermentalizing” — and encouraging a BPD patient to stick to the facts.

“Why does someone with borderline personality disorder key a car, if doing so will not lead to good consequences? What compels her to make that decision?” Sharp said.

“I am trying to understand the development of the disorder and what happens in the brain, and what happens in the minds of these children as they develop to put them on a different trajectory compared to their peers.

“Borderline personality disorder is a condition in which people have long-term patterns of unstable or turbulent emotions about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships.

“The criteria for BPD includes: excessive anger, affective instability, a clear pattern of self-harm over two years – burning, cutting, suicide attempts, abandonment fears, relationship problems, significant impulsivity – drinking alcohol, drug abuse, eating, anorexia, overeating and illegal activities.

“Clinicians have been reluctant to diagnose BPD in adolescence because there is the notion that personality is not fully developed in childhood and adolescence. We know that the brain is only fully developed by age 25, so how can we diagnose a personality disorder in someone if they don’t have a fully developed brain yet?” said Sharp.

“On the one hand, we are finding in our research that kids do have a stable pattern of interaction with others. Parents will describe their kids to you in terms that remain stable over time.

“Therefore, personality researchers have highlighted the point that teens do not wake up at 19 and have a personality disorder on the first day of their 19th year, so there must be some precursors to the disorders. There’s been a group of people, including myself, advocating that we not necessarily diagnose borderline personality disorder in adolescence, but that we assess for it to make sure that we don’t miss these children.”

The study spanned a two-year period and included 111 adolescent inpatients between the ages of 12 to 17.

A key component was the use of a new tool to assess social cognition in children. The tool is called the Movie for the Assessment of Cognition (MASC) and is used alongside self-report measures of emotion regulation and psychopathology.

In the study, research subjects were presented with actual movie scenes. They were introduced to the characters in the movie: Sandra, Michael, Betty and Cliff, by showing a photo of each. They were instructed to watch the 15-minute film carefully to understand what the characters are feeling and thinking.

They are then asked what the character in the movie might be feeling or thinking, with four options to choose from, forcing a single response prompt for one of the following categories: no mentalizing, less mentalizing, hypermentalizing or accurate mentalization.

Researchers found that 23 percent of the adolescents in the inpatient setting met the criteria for BPD. The young adults who met criteria for BPD had a higher frequency of these overmentalizing responses.

The study also found hypermentalizing interacted with emotional regulation. The individuals with BPD misread people’s thoughts, upsetting the adolescent and disrupting emotional regulation which can lead to an increase in borderline personality disorder symptoms.

“This research study is groundbreaking in that it’s the first to provide empirical evidence of the link between BPD and mentalizing in adolescents. By identifying precursors and treating BPD early in adolescence, we can use validated treatments to help these children,” Sharp said.

“The danger of not recognizing precursors of BPD in adolescents is that it can lead to years of confusion and pain for family members and the individual with misdiagnosis and lack of appropriate treatment. These families often go through years of assessment, and people might think it’s bipolar disorder, depression, conduct disorder or comorbidity.”

They are often relieved when they get to their mid-’20s and get to the right treatment facility that can actually diagnosis them and give a name to the cluster of symptoms they’ve been experiencing for so long, Sharp said.

“The next step is to try to do this work while neuroimaging the teen’s brain, so that we can look at the biological correlates of this. Such research could potentially lead to pharmacological intervention in addition to the talk therapy,” she said.

Source: University of Houston

APA Reference
Nauert PhD, R. (2011). Social Problems in Teens Can Lead to Personality Disorders. Psych Central. Retrieved on October 4, 2011, from http://psychcentral.com/news/2011/09/29/social-problems-in-teens-can-lead-to-personality-disorders/29893.html

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Rage burns and burns

In the support groups, rage is one of the most talked about aspects of BPD. Why? Because it is one of the most difficult for the Non-BPD to endure. Many people ask themselves, why is this person so angry (with me)? It seems to make no sense. A person with BPD will fly into a rage about seemingly nothing. The smallest thing that is out of place or not done the way that this person expects causes sometimes hours of anger and raging, yelling and screaming and sometimes physical violence. Again, many Nons ask: “what’s up with that?”

Anger and rage are usually secondary emotions to other primary ones. Sensitivity to judgment plays a major role in the triggering of rage. The symptoms and feelings associated with BPD interact and, at times, feed each other. In the case of rage, I believe that it is fed by two other symptoms: shame and sensitivity to judgment (which is also fed by shame).

When someone with BPD feels shameful and when you (as a “Non”) criticize or judge her behavior as “bad” or “negative,” the trigger for rage is pulled within the person with BPD. Why? Because your judgment reflects her shameful feelings and resonates deeply into her core beliefs about herself. She panics that you are “finding out” that she is a bad person. She has to (at all costs) defend her “goodness.” What I have found with my own borderline is that this is the point at which she will rage and introduce the “what about you?” argument. The “what about you?” argument is a way to rage at the Non and release anxiety about the Non finding out about her shameful “badness.” Some people in the support community like to call this “projection” or “denial.” I personally don’t believe it is actually projection or denial (although there are times in which projection is clearly there). It is a form of misdirection to try to take the focus off their inner shame and refocus the discussion on you and your faults.

Nobody is perfect, not even you. When a person with BPD rages against you, you often feel very imperfect – especially if she uses the “what about you?” attack. When someone with BPD uses the “what about you?” technique she is usually deflecting blame and judgment on you. However, you experience the rage as hurtful to your very self. You find that the rage “forces” you to defend yourself against her. That is what the “what about you?” attack/rage does best. That is its intention; it puts you on the defensive and shifts focus away from her and her behavior. As I said, it is form of redirection away from the person with BPD’s shame.

One interesting thing about raging is that once the anger and raging is done, it is usually over. Sometimes the person with BPD will be exhausted after the rage and will just collapse and go to sleep. The same is the case with tired children. Sometimes a tired child will have a temper tantrum (which is a form of rage) and then, once the emotions are released, she will either go to sleep or sit placidly in your arms. The inner agitation has been released and she is done.

Adapted from the FAQ from When Hope is Not Enough

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Performance artist Bobby Baker’s diary of the drawings she created during the 11 years she struggled with mental illness has been chosen as the Mind Book of the Year.

Authors and judges of the prize Fay Weldon, Blake Morrison and Michele Roberts found Baker’s Diary Drawings: Mental Illness and Me to be the book which had provided the greatest literary contribution to increasing understanding of mental health issues over the last year. A collection of 158 drawings and watercolours from the hundreds Baker drew daily between 1997 and 2008, it is an “astonishing insight” into the artist’s journey to recovery after she was diagnosed with borderline personality disorder in 1996, said Mind, and “a graphic, often darkly comic insight into the life of an artist grappling with huge internal upheavals”.

Author Emma Henderson was named runner-up for her debut novel Grace Williams Says It Loud, a “passionate and honest portrayal” of 11-year-old Grace’s life in a mental hospital which was also shortlisted for the Orange prize for fiction. From memoir to fiction, the other authors in the running for the Mind award were Joanne Limburg for The Woman Who Thought Too Much, John Marzillier for The Gossamer Thread, Candia McWilliam for What to Look for in Winter, Tim Parks for Teach Us to Sit Still, Wendy Perriam for Broken Places and Rupert Thomson for The Party’s Got to Stop.

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A link to a gallery of the photos.

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Why discuss emotions when we are talking about a personality disorder? Well, most researchers agree that the main component of BPD is emotional dysregulation. If you understand the function of emotions and how they play a part in BPD, you can understand the relationship better and interact more effectively with someone with BPD.

A threat or not?

Emotions involve both the body and the mind. Each emotion has a physical and mental configuration. [Dr. Paul Ekman has shown that for “universal emotions” (he cites seven of them: anger, sadness, joy, disgust, contempt, surprise and fear) the person feeling the emotion also will display the emotion on their face. It is impossible to suppress this emotional display inside of 1/25th of a second. Ekman calls those expressions that are quickly suppressed (but not completely suppressed) “micro-expressions” and has developed a tool for recognizing those within other people. I highly recommend Ekman’s tools for learning to read emotions as displayed on other people’s faces.] What we see is that, once the emotional system becomes engaged, the body reacts automatically and reacts in a way that is “hard-wired” in our brains and bodies. We may feel a knot in the stomach, sweaty palms, a loss of blood to the extremities, a rise in blood pressure or other automatic physical reactions.

The emotions triggered are in line with the interpretation of the event. Sometimes the interpretation is “misaligned” with reality, yet the emotions are real and felt nonetheless. An example I use in When Hope is Not Enough, is that of an ancient Hindu parable. In this parable, a person sees a rope as a snake and jumps away with fear. The fear is real to the person seeing the “snake.” The fear only dissipates when the person realizes that it is a rope and not a snake, and perhaps the person will feel foolish that they jumped away in fear from something that was harmless. Still, the person feels the fear and has the natural physical and emotional feelings run through their body and mind. Also, this person behaves in the natural way as a reaction to fear: they jump away from the “threat.”

What I realized about this story after I published that book was that humans get more utility from a “false positive” (thinking a rope is a snake) than a “false negative” (thinking a snake is a rope). It allows us to better survive in a threatening world. Considering the “false alarms” (positives) that a person with BPD experiences, this threat-awareness, for whatever reason, seems to be on a hair trigger for someone with BPD.

Emotions play a huge role in our lives and in our decision-making. Many people believe that a person can’t make sound decisions if they are “too emotional.” Most people place value in being rational (as opposed to rash). However, studies have shown that every decision – from buying ice cream to hiring an employee − has an emotional component. We just don’t notice the emotional component often because it is so built-in that it just seems natural, unless the emotions are expressed for everyone to see. We usually only notice the emotions of people that “wear their heart on their sleeve.” Yet, everyone has emotions. When something just doesn’t “feel right,” that is your emotional system contributing to a decision.

Typically, people do the natural thing when responding to their emotions. This natural thing is built-in. In Emotions Revealed, Dr. Paul Ekman tells us that there are seven universal, built-in emotions.

So, when your loved one reacts in the “reflex” way to the  emotions, he/she is reacting naturally. Whether the “trigger” is appropriate for the situation remains to be determined, but the reaction is typically the normal one.

These emotions are “reflexive” emotions and can save a person’s life. However, if the reflexive emotion is not aligned with reality, it can cause problems. One skill  is how to turn reflexive emotions into “reflective” emotions. Reflective emotions can encourage wise choices.

Adapted from “Beyond Boundaries” by Bon Dobbs

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Lemonsky had to wait until her late twenties even to be given a name for the condition that left every aspect of her life in disarray. Then, after one of her suicide attempts came perilously close to succeeding, a concerned doctor got her an appointment with Anthony Bateman at St Ann’s Hospital in London.

Bateman’s unit specialises in treating personality disorders, but Lemonsky didn’t realise that until, sitting in his office, she pleaded for an explanation of her problems. “He said: ‘It’s borderline personality disorder.’ I said: ‘Is it treatable?’ He said: ‘Yes.’”

This simple yet optimistic exchange will surprise many people who have been given the same diagnosis. It may even surprise some psychiatrists. Personality disorders revolve around difficulties interacting with other people. They can be extremely debilitating to those with the condition and those around them, and have been thought to be lifelong afflictions. Borderline personality disorder, in particular, has a terrible reputation, summed up on a cover of Time magazine as “The disorder that doctors fear most.” Even the current edition of psychiatry’s handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), perpetuates the gloom by describing personality disorders as “stable and enduring”.

“It turns out that it’s not true,” says John Oldham, a specialist in personality disorders at Baylor College of Medicine in Houston, Texas, and president of the American Psychiatric Association, which publishes the DSM. For despairing families, the encouraging news is that the problems of people with borderline personality disorder subside with age. Recent clinical trials have also shown that specialised psychotherapy can significantly improve their lives. Still, a lingering “untreatable” stigma, combined with the difficulty of securing funding for therapy, means that relatively few people with the condition get the help they need.

The encouraging results for borderline personality have kindled hope that other forms of personality disorder? – which are collectively more common but poorly studied? – might also be less ingrained and more amenable to treatment than thought.

Psychiatrists currently recognise 10 personality disorders, classified into three “clusters”? – though the constellation of conditions is mired in diagnostic confusion (see “What’s in a name?”, page 48 ). The disorders manifest in diverse ways, from the callous disregard of others typical of those with antisocial personality disorder?- many of whom pursue a life of crime?- to the extreme social anxiety of people with avoidant personality disorder. Problems interacting with others are the common thread. “You can’t have a personality disorder on a desert island,” observes Conor Duggan, a forensic psychiatrist at the University of Nottingham in the UK.

Borderline personality disorder, which is characterised by extreme emotional instability, is the best studied because the people that have it are aware something is badly wrong and tend to seek help. Anyone familiar with the condition knows that “borderline” doesn’t mean that people with this diagnosis are close to the boundary between mental health and mental illness. Far from it: the disorder got its name because it seemed to combine the distress of neurosis with some of the delusions of psychosis.

At the core of the disorder lies an inability to form stable relationships. People with borderline personality have an almost paranoid fear of abandonment, which often becomes a self-fulfilling prophecy. Friends may be idolised one day only to be despised the next after a perceived slight. Angry outbursts are frequent, and people who try to help often bear the brunt.

“These are patients who don’t trust you. They are highly vigilant and quick to misinterpret things,” says Oldham. “A lot of healthcare workers don’t understand that it’s part of the pathology and take it personally.”

Road to recovery

The first study, led by Mary Zanarini of the McLean Hospital in Belmont, Massachusetts, reported last year that 86 per cent of 249 patients had improved to the point that they no longer met diagnostic criteria for borderline personality for at least four years within the 10 years of follow up (American Journal of Psychiatry, vol 167, p 663).

This result was no fluke: in April this year a second study, which set a higher bar for judging remission, reported that 85 per cent of 111 patients had remitted for at least a year over a 10-year period (Archives of General Psychiatry, vol 68, p 827).

“I’ve been immersed with these patients and I didn’t anticipate it,” says John Gunderson, also at the McLean Hospital and one of the leaders of the second study. He says that psychiatrists simply failed to realise that many people who stopped turning up for therapy were actually getting better.

Given the suffering of people with borderline personality and their families, finding ways to accelerate recovery is a top priority. Although some progress has been made in understanding the condition’s biological basis (see Inside the borderline mind, page 47), the pharmacological revolution that dominates modern psychiatry has stalled in the case of borderline personality. Antipsychotic drugs or mood stabilisers can help lessen some symptoms, but last year a systematic review of clinical trials concluded that such drugs make little difference to the disorder’s overall severity.

Another successful approach is mentalisation-based treatment, pioneered by Bateman and Peter Fonagy at University College London. MBT comes from the tradition of psychoanalysis, and concentrates on getting people with borderline personality to better understand their own and others’ mental states. It has been less widely studied, but seems to reduce suicide attempts and the use of psychiatric services, while increasing people’s ability to hold down a job.

For Lemonsky, who had found previous therapists dismissive of what seemed to them trivial issues, the last aspect was a revelation. “Whatever I said was treated with the utmost importance,” she says of her experience in Bateman’s clinic.

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Extended-Release Opioid Gets FDA OK

By Emily P. Walker, Washington Correspondent, MedPage Today

Reviewed by August 26, 2011   Review

WASHINGTON — The FDA has approved tapentadol (Nucynta), an extended-release oral opioid, to treat severe chronic pain.

The agency first approved the drug for relief of moderate to severe acute pain in 2008. Friday’s approval is for an extended-release pill that chronic pain patients can take twice daily.

The approval is based on a randomized, double-blind, controlled phase III study that tested tapentadol as a treatment for moderate to severe low-back pain and diabetic peripheral neuropathy.

Safety was evaluated in 1,100 patients with moderate to severe chronic pain over a one-year period. The drug was found to be safe and effective, according to the company that makes tapentadol, Janssen Pharmaceuticals, a unit of Johnson & Johnson.
Tapentadol was also well-tolerated, the company said. Opioids can cause a number of side effects, including constipation, that may cause patients to discontinue their use.

A 2010 phase III study comparing the drug to oxycodone in patients with painful knee osteoarthritis found that tapentadol provided effective pain relief with fewer of the gastrointestinal side effects seen with oxycodone.

“Chronic pain is difficult to manage, and even with the treatments available today, it can be a challenge to balance pain relief with a patient’s ability to tolerate the medicine,” Sunil Panchal, MD, president of National Institute of Pain, said in a press release from Janssen. “People with chronic pain will continue to need additional options, so an approval like this is welcome news for this community and the people who suffer from this often debilitating condition.”

The approval also comes with a Risk Evaluation and Mitigation Strategy (REMS), similar those approved for other opioids, meant to educate prescribers about the potential of abuse, misuse, overdose, and addiction with extended-release tapentadol.
The CDC estimates that 42 million Americans over the age of 20 suffer from chronic pain.

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“The difference is that in BP relationships, the closeness only comes back if the NON does something to make it so.”

I replied:
“I don’t necessarily agree or disagree with this. My feeling is that the nons and BPs are speaking different languages. It’s really hard to be close to someone who you feel doesn’t really understand you fully. If you want to get close, one of the parties has to learn the other’s language. I just feel that the nons have a greater capacity to learn emotional language than the borderline to learn practical language. The very natural of emotional dysregulation prevents the use of practical language/thinking. I mean, we have to accept what is before we can ask what can be.”

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Lewis: Like I remember one day I came in with white sticky tape wrapped all around my arm, and I told everyone that it was a cast and I had broken my arm.

Desperate for attention, she convinced her mother she couldn’t see, and got prescription glasses. By age 8 – her behaviors were self-destructive:

Lewis: I had a game, and I called it TP, and TP actually stood for taking pills. I would rummage in my parents’ medicine chest and I would take their pills.

This was only the beginning. Over the next years, Talya knocked her front teeth out with a hammer, started taking drugs, cutting herself, her behavior out of control in school. Her parents, whom she describes as distant socialites, didn’t seem to notice. But then came the wake up call.

Lewis: I overdosed on a bottle of sleeping pills in my high school, in the front lobby, and that was the beginning of what ended up years of long-term confinements in a private psychiatric hospital.

Talya was diagnosed with Borderline Personality Disorder, or BPD. Philadelphia therapist Edie Mannion describes it as a severe and complex mental illness with many symptoms:

Mannion: Difficulty regulating emotion, like a broken emotional thermostat, and difficulty controlling impulses, and what I see as mostly a profound amount of emotional pain.

For people with this disorder, small problems explode into catastrophes, friends become enemies, love turns to hate – often with breath-taking speed. Relationships crumble, jobs rarely last. And their families are along for the ride. Camille Myers describes life with her daughter, who is in her 30s and has BPD.

Myers: You know, at times, she doesn’t want to live, she hates me at times, her world falls apart, at times she’ll walk into a room with my friends and family, and havoc breaks loose.

Myers says relationship with her daughter is an exhausting roller-coaster.

Edie Mannion says the disorder has a bad rap among therapists, and many of the are reluctant to work with those who suffer from it:

Mannion: People were taught that people who have this are manipulative, and split people, and all of these kinds of stereotypes, that make people not want to work with people who have this

A very high suicide risk also scares therapists away. Paradoxically – that’s what attracted the field’s premier researcher to this disorder.  Marsha Linehan of the University of Washington set out to test treatments for highly suicidal patients – and found herself working with borderline patients:

Linehan: They have a ten percent suicide rate, so they are the highest rate of any group that I know, and really they are really incredibly interesting to work with.

Linehan has developed what many hail as the most successful treatment for this disorder.  It’s called Dialectical Behavioral Therapy, and is an intensive, long-term intervention that tries to end the destructive cycle of intense pain and strong reaction.

Linehan: The first thing you have to do is radically accept that you ARE hurt, and be mindful of that emotion, but also, you then have to move to trying to regulate the hurt and regulate actions related to hurt

Patients learn these skills in individual and group sessions, during phone coaching, and the therapists have a strong support system.

Part of the treatment is to teach family members how to de-escalate situations. Camille Meyers has taken the course and gives an example. Recently her daughter asked her for help with directions, but got very angry when Camille printed out maps for her:

Meyers: I don’t want to read maps, I don’t like maps, maps don’t help me!!!!!!!!

Camille remembered not to fan the flames:

Meyers: Previously my reaction would have been okay, I can’t believe you’re telling me this, you asked me to help you, I spent all of this time … if you think they are not going to be helpful to you, I understand, maybe maps don’t work for you

Her daughter has started Dialectical Behavior Therapy, and is doing well so far.

Talya Lewis, meanwhile, says she’s in recovery after many turbulent years. She works as a therapist, helping people understand Borderline:

Lewis: With this disorder I want people to have a wall of compassion, where you protect yourself, but at the same time, you can deal with the person in this kind of ongoing way, and empathetic manner.

She says her disorder didn’t go away, but she works constantly to manage the symptoms.  It is, she admits, exhausting to be her.

By: Maiken Scottmscott@whyy.org

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You can watch a clip of the series at NEA-BPD site.

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Q:  Why do you emphasize emotional validation so much?

A: Emotional Validation is a very powerful skill, or set of skills, for any relationship with an emotionally sensitive person (ESP), including those with BPD traits. There are a number of reasons that emotional validation is important for a family member of someone with Borderline Personality Disorder. Emotional Dysregulation is a core feature of BPD. Another core feature is shame. If you invalidate a BP’s feelings, you are likely to fuel more shame, because they actually feel those emotions, whether or not they seem right or appropriate to you.

Validation is a tool that verifies that the other person’s feelings are valid, but doesn’t necessarily condone or agree with their behavior. Remember, the behaviors come from feelings, beliefs and “action impulses” so they can be separated from behaviors. You are not “giving into” the BP if you learn to validate their feelings.

With validation, you are basically saying, “Your feelings matter. It is OK to feel that way. It is normal to feel that way.” The way in which you validate someone else’s feelings is important. Many people believe that saying “It’s OK. I love you” or “You are safe with me” is a form of validation, but it is not. Those statements are about your attitudes toward the other person, not about his/her feelings. Validation is always about the OTHER person’s feelings, not about our own feelings.

Validation is not giving advice. In fact, if you do give advice when the other person is emotional, they are likely to get angry with you. People don’t like to feel that they are being told what to do about an emotional situation – that is quite invalidating. It feels like you are telling them how they should feel and they can’t control the emotions.

The process of Emotional Validation can be summarized as follows:

I-AM-MAD

1. Identify the emotions.

It’s best to do this with “feeling” words, like “look”, “see”, or “sound”, rather than “know” or “understand”.

Examples:

• “I see that you are frustrated.”
• “You sound aggravated.”
• “You look really upset.”

2. Ask a validating question.

This encourages them to share their feelings about whatever triggered them.  Do not use “what’s wrong?”  If you use “what’s wrong?” they will hear “what’s wrong with YOU?”  Also, don’t assume you did anything wrong.  Remember, IAAHF (It’s All About His/Her Feelings).

Examples:

• “What happened?” (most effective because it is open-ended, requires more than yes/no answer)
• “Did something go wrong at work [school] today?”
• “Want to talk about it?”

3. Make a validating statement about their emotion.

Validate the feelings expressed in step 2.  This helps reinforce that it is natural and valid to feel what they are feeling in the situation.  Again, remember IAAHF.  Don’t defend against blaming or projecting.  And don’t apologize at this point, even if you are guilty.  (Apologies for things you are actually guilty of can come later… after they have returned to their emotional baseline.)

Examples:

• “Wow, it must have made you feel awful to have done poorly on that test.”
• “Yes, it is frustrating when it seems that someone is taking advantage of you.”
• “Yeah, that’s really disappointing.”

4. Make a normalizing statement about their emotion.

By relating the situation as common to all people or “normal” for them, this helps alleviate their stress about feeling judged or unaccepted.

Examples:

• “I think anyone would feel angry if they had to do that”
• “I would feel the same way if that happened to me.”
• “I can see why you feel that way.”

5. Analyze the consequences of their behavior.

By examining the consequences of both negative and positive behavior with the person, you help them to separate their emotional reaction from their behavior. The behavior may need to be changed, but the emotions are natural and should not be punished for.

Examples:

• “When you don’t ask questions about something that confuses you, I don’t realize that you are struggling, so I can’t help you. When you do ask questions though, I can either give you the information you need to solve the problem yourself or we can work together to figure out the best solution to the problem.
• “When you yell at me, I feel disrespected and become upset too.  However, when you speak calmly to me, I know you have respect for me, so I am able to listen to you better.”
• “When you refuse to talk to me, I don’t know what else to do except give you space.  When something is bothering you, it’s best to be open and honest with me so I know what’s going on and don’t make the wrong assumptions about what you need.

6. Don’t solve the problem for them.

Solving one’s own problems helps to build self-confidence.  Empower the person by getting them to come up with a solution themselves.  When given the opportunity in a non-judgmental setting, most people will find that they can come up with solutions to their problems.  You can guide them through this process by asking helpful questions to ascertain what they need or want.

Examples:

• “How would you like to handle this?”
• “What would help you make a better choice next time?”
• “Is there anything I can do to help?”

(Note:  Sometimes you have to go back and forth to help them find the most effective solution. They may say, “I don’t know” or “I don’t care.” This can be tough.  Go back to step one to deal with any additional emotions that become apparent.)

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Myth 1: BPD is untreatable

Borderline Personality Disorder is treatable and in the past 15 years numerous evidence-based treatments have been designed to treat the disorder. Dialectical Behavior Therapy (DBT), Mentalization-based therapy and Transference-focused therapy have all been shown to improve the behavior, cognitive abilities and functioning of people with BPD.

Myth 2: BPD only affects women

A recent study by the NIAAA showed that the lifetime incidence of BPD was essentially equal in men and women. It has been widely accepted for many years that the gender breakdown of BPD is 75% female. It seems that the only reason that the 75% figure exists is that women are more likely to seek help for the disorder. In the case of men, they are less likely to seek help and more likely to end up in jail.

Myth 3: BPD is just a case of bad behavior

BPD is an actual mental/emotional disorder. The behavior is fueled by dysregulated emotions. If the emotions are well-regulated, the behavior will not take place. Since emotional dysregulation is a core feature of BPD, it should be one of the primary focuses. The behavior is what upsets the family members and loved ones. Yet it’s the emotions that are the engine for the behavior.

Myth 4: BPD is extremely rare

The same NIAAA study indicated a lifetime incidence of BPD in 5.9% of almost 35,000 adults. Earlier studies have shown a 2% occurrence. If it’s 5%, that’s one adult in 20 who has BPD.

Myth 5: Poor Parenting causes BPD

Recent studies have shown brain anomalies in the u-poiod system (pain relief) in the brain. Like clinical depression, which shows serotonin differences, a person with BPD seems to have a deficit in u-poiods and over-active u-poiod receptors. This can explain why one child may develop BPD and another does not, even when each is in the same home environment. That being said, many borderlines do experience abuse and/or neglect as children. The trauma associated with that abuse (or invalidation) seems to reinforce the natural BPD-like tendencies and causes the BPD to be more marked.

Myth 6: People with BPD are incapable of empathy

A recent book by Dr. Simon Baron-Cohen has received a lot of notice because he indicated that a lack of empathy was the root of evil. He also listed three conditions in which empathy is lacking: BPD, some forms of autism and psychopathy. In my experience, a person with BPD might lack empathy, yet that is only when they are in emotional pain. You can’t feel for others when you’re burning inside. Once the emotional pain becomes manageable, I find people with BPD to be quite empathetic. They understand emotions very well and if they can understand that emotions apply to other people, they show deep empathy.

Myth 7: People with BPD use suicidal gestures just to get attention

Many family members believe that suicidal gestures are merely “calls for attention.” I would counter that in the moment that the suicidal gesture occurs, the borderline really wants to snuff the pain and death seems like the only alternative. It is an ineffective use of skills and pain-quelling behavior. Most borderline suicide attempts are unplanned and impulsive. They will access whatever is on-hand – all the pills in the cabinet, for example – and impulsively try to commit suicide. However, all suicide attempts are serious and should be treated seriously and with compassion. Few people are in so much pain that they want to die. Borderlines are tragically such people.

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… from an insightful blog post by Sonia Neale. Here is the text of the post:

Borderline Emotional Anaphylactic Reaction: Mindfulness and Acceptance

By SONIA NEALE

Sometimes, the smallest things in life can cause the greatest pain and physical reaction.  A bee’s sting is almost invisible to the naked eye and yet can easily kill someone when they have an allergic reaction.  A mere critical stinging comment can just as easily send a person suffering Borderline Personality Disorder into “emotional anaphylactic shock.”

When a person has a life-threatening reaction to the poison from a bee sting, an ambulance is called and the person is taken to hospital where they receive treatment for their illness as well as respect and dignity but when someone suffering an emotional reaction to life circumstances presents at emergency, they are sometimes treated with rejection, intolerance and disdain.  People can die from a bee sting and Borderlines can “die” from their own personal rage and self-hatred.  If you present at emergency with a swollen face and throat unable to breathe with all your body organs shutting down, is some doctor or nurse going to say, “OMG, it’s a tiny bee sting, how bad can that be, look at you, get over yourself,” like they sometimes do when Borderlines present at hospital with similar symptoms.

Yet both types of people are in much pain and danger.  One is considered entirely physical and the other is considered entirely emotional.  Or is it entirely emotional?  When a sensitive person with a history of trauma has an emotional “bee-sting” reaction to someone’s criticism there is a definite physical reaction.
Borderlines tend to be hypervigilant, which means they live with permanent muscle tension and a certain excess of adrenaline pumping round their system at any given time.  So when criticism hits, the body goes into an emotional anaphylactic state where cortisol floods the brain and body system and a type of blackout occurs where nothing anyone says or does registers.  Your body has gone into “shock.”  When I used to get into such a state someone could have cut my arm off and I would not have noticed.

Things are said during this time that are simply appalling.  I have used language I would not use in normal everyday life.  I have said things that are deeply hurtful and as my husband has said, “you can mend a vase but the cracks are always there for those to see.” My therapist says it is best to repair those cracks with gold. Her favourite quote, by Barbara Bloom is “When the Japanese mend broken objects they aggrandize the damage by filling the cracks with gold, because they believe that when something’s suffered damage and has a history it becomes more beautiful.”  I prefer her take on this matter.

Therapy has taught me that my perception of events and criticism is usually erroneous.  Even if people are critical and disrespectful, it is about them and not me.  If my ideas get criticized it is not because I am a loser and I deserve to die, it is because we both have a different belief system and ways of handling situations.  There is no right or wrong, just opinions.

I have criticized my therapist on many occasions including recently when she raised her colleagues’ fees in the light of almost certain public benefit cuts.  Her reply was that her practice survived before the benefits were given and hopefully will survive after the benefits are cut.  She raised her fees because she valued herself and her colleagues.  She did not feel the need to get upset or question herself or her actions because she believed that what she was doing was the right thing to do.

It is this sort of self-valuing that is empowering to people like myself who always feel others are more valuable and powerful than I will ever be.  When we assert ourselves and say, “No, I don’t like that because….” we can start to realize that it is ok not to people-please all the time.  I said no to unpaid overtime because I value myself as a worker otherwise I will feel undervalued and get resentful.  Like my therapist I am worth it.

Mindfulness and radical acceptance of people and situations as in Dialectical Behaviour Therapy is the key to, well, if not happiness, then a more content and peaceful self.  It is the road to what Abraham Maslow calls self-actualisation – autonomy, independence, few but deep friendships, a philosophical sense of humour, resistance to outside pressures and transcendence of the environment.  These are the things I strive for and have spent much time in therapy trying to get a good grasp of.

A great book, which promotes self-actualization that I am reading at the moment, is “The Art of Happiness” by the Dalai Lama.  While I may not quite reach the emotional plateaus that His Holiness is capable of, I can certainly learn how best to inoculate myself when swarms of emotionally stinging bees are trying to infiltrate my brain and body system.

See larger image The Art of Happiness, 10th Anniversary Edition: A Handbook for Living (Hardcover) By (author) Dalai Lama List Price: $25.95 USD New From: $13.08 In Stock Used from: $7.30 In Stock Release date October 1, 2009.

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