“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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Are you sick of seeing the same Psychopath posting all over the web when researching Narcissistic Personality Disorder? Did you get sucked into his boards, forums, books, speeches?

Or are you one of the victims who adore Sam Vaknin, Look up to him and hold him up on a pedestal as your life saver?

if so let’s take a closer look at the supposed “Dr Sam Vaknin PhD”

In one of his repetitively & compulsively posted online articles, Vaknin reveals in his own words the reason he really runs the Narcissism ‘Support’ Groups all over the net and so on….

‘There is nothing to be learned from the answers to these questions because each individual has her own threshold. No, I simply enjoy the momentary ability to inflict traumatic pain (emotional pain – I am not the physical type and will never harm a woman physically). It is as close as I can get to omnipotence. It is the perfect gender revenge.’…

‘As a Jew I would have done the same to Nazis. As a victim of a woman, I celebrate with unrestrained glee my ability to degrade women, to humiliate them, to frustrate them, to make them beg for life itself, for they see their (often imagined) relationship with me as life itself. This is why I abstain from sex. This is why I dazzle them with my intellect and charm and wit and knowledge, with unprecedented intrusive interest in their petty, boring, housewivish lives – and then I let go abruptly. At this stage, they are so brittle, so vulnerable that they crash to a million shreds with the crystalline sound of agony.’

Is this really a man you want to give you advice and support on Narcissism, Psychopathy or on your relationships? . Imagine for a moment, you have left your Narcissistic partner/spouse/family and have finally seen the light. You stumble across Sam Vaknin and drink in everything he has written on the subject.

You have just walked out on one Narcissist into the world of another.

Imagine, as an abuse survivor of someone with malignant narcissism or narcissistic personality disorder, giving your life over to a psychopath, and doing it with trust and a firm belief in his authority. What if said psychopathic conman, was advising victims? It seems absurd, that an abuser would advise the abused. It seems even more absurd, that the abused would take the advice to heart.

Vaknin is now a DIAGNOSED PSYCHOPATH – not a Narcissist!

Read the entire article at the original site.

No related posts.

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Clinicians have long been aware that patients with certain types of psychiatric illnesses — including mood, anxiety and personality disorders — are more likely to become addicts. According to the National Institute of Mental Health’s Epidemiologic Catchment Area Study, patients with mental health problems are nearly three times as likely to have an addictive disorder as those without.

Conversely, 60 percent of people with a substance abuse disorder also suffer from another form of mental illness. Still, it’s unclear whether addiction predisposes someone to mental illness, or vice versa.

Scientists do know that having a mental illness doesn’t just increase the chance of intermittent drug abuse; it also significantly raises the risk of outright dependence and addiction. The conventional wisdom is the link represents a form of “self-medication” — that is, people are using drugs long-term to medicate their own misery.

And of course, I can’t overlook this one:

Certain personality disorders also raise the odds of drug abuse and alcohol abuse. Narcissistic patients, who constantly battle feelings of inadequacy, are frequently drawn to stimulants, like cocaine, that provide a fleeting sense of power and self-confidence. People with borderline personality disorder, who struggle to control their impulses and anger, often resort to drugs and alcohol to soften their intolerable moods.

Maybe that is an interesting factor for understanding the difference between NPD and BPD. In my experience, those with BPD are usually drawn to benzos, alcohol, and opiates. In my poll about substance abuse over 75% of respondents said they have had problems with substance abuse. Because of the u-opioid study by Stanley and Siever (and others), it seem natural for borderlines to seek pain-squelching medications, illicit or not.

Related posts:

1. Amy Winehouse and Husband Battle it out
2. Media Reports the Amy Winehouse may have had Borderline Personality Disorder
3. Amy Winehouse found dead at 27

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Two of the potential issues Anthony could suffer from are border personality disorder and psychopathology, the experts said. The main thing these issues have in common is a total lack of empathy, according to LeslieBeth Wish, a psychologist and licensed social worker in Sarasota, Fla.

“They can turn a person into a non-person,” Wish said. “Borderline personalities have more emotional regulation problem and often use lying to get away from something and not ever feeling like they’re responsible.”

Those two potential issues were the ones that I identified and opined on the other day. The second paragraph above is why I believe that Casey Anthony probably doesn’t have BPD. The reasons for the lies are not impulsive and reactive, as they seem to be most often in BPD. People with BPD are much more likely to “bullshit” (as a term of art not vulgarity) than to actually lie with proactive intent. They can make up some elaborate stories about themselves, typically to make their world a safer and more livable place when others think better of them. Still, most often BPD lies are to get through a painful moment. Very often as the lies collapse, they will admit everything and ask forgiveness. Casey did NOT do this. She maintained her lies even after the police were aware they were lies. In fact, she started lying to her parents LONG BEFORE Caylee went missing.  She lied (by omission) about her pregnancy. She lied about having a job at Universal Studios BEFORE the cops got involved.

As for psychopathy…. I presented the guidelines of Hare’s PCL-R on the other page. Let’s look at them again and see which of these seem to match Casey Anthony, based on what we know from the press:

PCL-R items

The following findings are for research purposes only, and are not used in clinical diagnosis. These items cover the affective, interpersonal, and behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person’s psychopathy.

Factor 1

Aggressive narcissism – Hard to say for Casey Anthony. We don’t really know enough. We do know that, when in jail, she got angry about what this situation was doing to HER!

Glibness/superficial charm – Yes.

Grandiose sense of self-worth – Again hard to say. This is one factor that really separates BPD from the narcissism spectrum. People with BPD have a lot of shame and generally hate themselves.

Pathological lying – YES, YES, YES.

Cunning/manipulative – I’d have to say yes.

Lack of remorse or guilt – Again, I think we need to say yes here.

Emotionally shallow – Hard to say.

Callous/lack of empathy – Could be. Hard to say.

Failure to accept responsibility for own actions – Yes. It’s never her fault.

Factor 2

Socially deviant lifestyle – Party girl. One night stands.

Need for stimulation/proneness to boredom – Probably, but who knows.

Parasitic lifestyle – Yes. She was living off her parents and then off friends while pretending to have a job. Actually, it is interesting to note that she was telling her mother she had a job long before Caylee disappeared.

Poor behavioral control – Probably. Again, one night stands.

Promiscuous sexual behavior – Yes.

Lack of realistic, long-term goals – Yes.

Impulsiveness – Yes.

Irresponsibility – Yes.

Juvenile delinquency – well, some form of delinquency. She stole checks from her friend and passed them.

Early behavioral problems – unknown.

Revocation of conditional release – we’ll see.

Traits not correlated with either factor

Many short-term marital relationships – no, but many short-term boyfriends

Criminal versatility – it depends. She stole and possibly caused the death of her daughter. They couldn’t prove it in court to the satisfaction of the jury, but we may never know.

Ok, onto the article:

‘Dr. Judy’ Doubts Casey Anthony’s Penchant for Lying Can Be Cured

By CHRISTINA NG
July 19, 2011

Casey Anthony’s lawyers have said that Anthony has suffered “trauma” and will need counseling now that she is a free woman, but experts aren’t sure Anthony can be helped.

“It would be exceptionally difficult for anybody to treat her. There is no magic pill that’s a truth serum for a person who’s a pathological liar,” said Dr. Judy Kuriansky a psychologist from Columbia University, but better known from her radio show as Dr. Judy.

Kuriansky believes that Anthony likely feels that she has been rewarded for her lying with her acquittal and release from jail.

“Why would she want to go to therapy when she basically got what she wanted? There’s no motivation for her to seek help,” Kuriansky said. “If she had been sent to jail, maybe she would want to see somebody because her style didn’t work, but it did.”

Anthony, 25, is in hiding after being released from a Florida jail following her acquittal on murder charges for the death of her 2-year-old daughter Caylee. She has received death threats and as she left jail protesters changed “Caylee, Caylee.”

Casey Anthony Therapy Will Be ‘Challenge’

Anthony’s criminal lawyer Jose Baez has said, “It is my hope that Casey Anthony can receive the counselling and treatment she needs to move forward with the rest of her life.”

Her civil attorney Charles Greene was quoted as saying Anthony was “emotionally unstable” following the trauma of her daughter’s death and the grueling trial.

Psychologists interviewed by ABCNews.com agree that the desire to change is the key to successful treatment for pathological liars, which some believe Anthony may be.

While acquitted of murder, she was convicted on four counts of lying to police. One of her lies was that Caylee was kidnapped by a fictional nanny named Zanny. Zanny was one of a dozen bogus characters that Casey had created. She also lied about working at Universal Studios.

None of the psychologists who spoke with ABCNews.com have treated Casey Anthony, but spoke from observations and personal experience.

Two of the potential issues Anthony could suffer from are border personality disorder and psychopathology, the experts said. The main thing these issues have in common is a total lack of empathy, according to LeslieBeth Wish, a psychologist and licensed social worker in Sarasota, Fla.

“They can turn a person into a non-person,” Wish said. “Borderline personalities have more emotional regulation problem and often use lying to get away from something and not ever feeling like they’re responsible.”

Wish explains that for people who suffer from these problems, separate lies can quickly become entire narratives that the teller can even come to believe as true.

“A lie begets a lie and it’s easy to get trapped in telling lies to protect other lies,” Wish said. “Does she believe her lies? She might, but more than likely she believes that she’s good enough to make you believe her lies.”

While Kuriansky emphasizes that she cannot make a diagnosis on a patient she has not seen, she does believe that Anthony has a personality disorder. Her personality disorder could have “narcissistic features with particular attention to pathological lying.”

The symptoms of this problem include volatile moods, extremely manipulative personalities, a lack of empathy of others and a strongly defensive nature, she said.

“I believe there is something that can be done for people like this,” said Tony Ferretti, a psychologist in Melbourne, Fla. “The behavior has been learned and can be unlearned. A person is not born a liar.”

The problem with Anthony, Ferretti believes, is that she does not appear to have the motivation or desire to change her behavior.

“It’s kind of like an addict, until they acknowledge that they have a problem or desire or motivation to change, nothing is going to chnge,” Ferretti said.

Casey Anthony Therapy Will Be ‘Formidable Challenge’ to a Therapist

Wish said the problem generally develops in early childhood and can come from a lack nurturing and stability, especially from parents.

Casey Anthony’s murder trial tore apart the Anthony family with lurid accusations that her father and brother molested her and that her father had a mistress. George Anthony denied those accusations. Casey Anthony’s relationship with her mother was also portrayed as strained, with several witnesses saying that the two argued a lot and were often at odds.

Psychologists agree that all of this could contribute to Casey Anthony’s penchant for lying.

Kuriansky believes that Anthony might be able to benefit from supportive counseling, but this would be a formidable challenge for a counselor or therapist who would need to be on guard about believing anything Anthony said.

“It’s really hard to treat,” Wish said. “You can’t say it’s impossible, but it’s very difficult.”

“These are people that cannot withstand very much self-examination, but you can work on emotional regulation and helping them understand and see [things] differently,” Wish said. “It’s a very small rope of balancing emotions and thinking.”

All three psychologists agree that it mainly comes down to what the person in question wants. If they want help, they can be successful, but if they do not, it is virtually impossible to help them.

Casey Anthony is a free woman and her next step is up to her, and perhaps her lawyers, but Wish believes, “She still needs something. She can’t just be tossed out there.”

Related posts:

1. Amy Winehouse is back in the news again
2. ABC News Reports: Ignored Psych Patient Dies on Hospital Floor
3. Experts Argue that BPD should be an Axis I disorder

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latimes.com

BOOSTER SHOTS: Oddities, musings and news from the health world

Personality disorders category is likely to be dramatically revised for next psychiatry textbook

By Shari Roan, Los Angeles Times / For the Booster Shots blog

12:05 PM PDT, July 7, 2011

Several types of personality disorders will be dropped from the next edition of the Diagnostic and Statistical Manual of Mental Disorders. But one disorder previously proposed for elimination — narcissistic personality disorder — will likely remain in the text.

The American Psychiatric Assn. announced Thursday that the framework for personality disorders in DSM-5 will be a “hybrid” model that is substantially different from how personality disorders are diagnosed currently. Under the new system, personality disorders will be aligned with particular personality traits and levels of impairment.

The committee working on the personality disorders chapter of the DSM-5, which is due to be published in 2013, has proposed six types of disorders: antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal. They have proposed dropping paranoid, histrionic, schizoid and dependent personality disorders.

However, to qualify for a diagnosis, a patient would have to have a high level of impairment in two areas of personality functioning — self and interpersonal. Patients would be assessed for how they view themselves and how they pursue their goals in life, for example, as well as how they get along with other people and whether they think about the consequences of their actions. The new model is less rigid than the existing diagnostic model. It is designed to reflect that behavior can change over time while personality traits tend to remain stable.

“In the past, we viewed personality disorders as binary. You either had one or you didn’t,” said Dr. Andrew Skodol, chairman of the DSM work group on personality disorders, in a news release. “But now we understand that personality pathology is a matter of degree.”

The American Psychiatric Assn. also announced that a public comment period on DSM-5 proposals has been extended through July 15.

 

Related posts:

1. A New Name for Borderline Personality Disorder (BPD)?
2. It’s time to reject the notion that people with personality disorders are beyond help
3. Proposed Changes in the DSM-V for Borderline Personality Disorder

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Casey Anthony Acquitted

A few weeks ago I posted an article entitled Casey Anthony: Borderline Personality Disorder, a Psychopath or What? This “analysis” garnered a lot of attention (or at least a lot of traffic) for me. I found that yesterday was the busiest day on my blog ever with over 400 views of that article alone (usually I get about 600 daily views of my blog so this was unusual). Of course anyone that has followed the Casey Anthony trial knows why – she was acquitted of first degree murder and aggravated child abuse, but was convicted of four misdemeanor charges of making false statements to the police.

I watched about half of the trial. I followed it as closely as possible and read about Ms. Anthony’s lies, watched the jail videos, read about her partying, watched her interviews, etc. The issue I see here is two-fold. Firstly, it is not a crime to lie (except to officials, which she did and was convicted of; or to the court, which she did not, since she didn’t testify), nor is it a crime to party with your friends. While the behavior is odd and curious (why would one do that if your child is missing?), it is not criminal. What the state was attempting to prove in this case was first-degree capital murder, without physical evidence, DNA, witnesses or a cause of death. A very high standard and hard hill to climb. Not too surprising that she was acquitted. I think (as do many others) that the state of Florida should have charged her with lesser crimes (homicide or manslaughter for example). It seemed to me from the beginning that Caylee’s death was probably a horrible accident or an impulsive action (like doping the child too much) that Casey thought she could distance herself from by lying and avoiding. Unfortunately, she has now learned that lies (even if she didn’t do it or it was an accident, we’ll probably never know unless someone with knowledge of what happens starts to talk) have paid off. In fact, if it WAS an accident and she had come forward at the beginning and said “I messed up, I’m sorry” she would have probably received a more severe punishment than she will now receive. (Of course I have trouble believing the George Anthony angle because Casey has a history of telling lies to get herself off the hook.) She is not a felon at this point. All that being said, I believe that this case is one in which our justice system was shown to work, but justice was not done for the child.

Which brings me to my second point about this case… It is not a crime to be mentally ill, no matter if you have Borderline Personality Disorder, PTSD from abuse or you’re a psychopath. You can’t be thrown in jail or executed just because you’re sick in the head. You can only be thrown in jail or executed based on what you do and what evidence shows you’ve done and what a jury of your peers (or a judge in some cases) believes, beyond a reasonable doubt, you have done. Criminal behavior and mental illness are not synonymous. Actions and feelings are not the same. Someone who has aggressive feelings towards others and never acts upon them, they’re innocent of any crime. As for Casey Anthony, even her defense team said that her lies were an indication that she needed help. Those lies were reflective of a deeper psychological disturbance. What it may be, we’ll probably never know, nor should we.

Still, I believe that Casey Anthony will be unable to stay on the right side of the law for long. She’ll not likely kill anyone but, based on her pattern of behavior, she is impulsive and believes that she can talk her way out of just about anything. Unfortunately, this time she was able to talk her way out of any involvement in her daughter’s death – murder or accident.

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

Without Conscience: The Disturbing World of the Psychopaths Among Us

The Psychopath Test: A Journey Through the Madness Industry

The Psychopath: Emotion and the Brain

Handbook of Psychopathy

The Mask of Sanity (Mosby medical library)

Related posts:

1. Mentalization and BPD
2. Anti-social Personality Disorder mistaken for BPD – when people get it wrong
3. Ok, Bon, what’s wrong with boundaries?

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10 Signs That You’re An HSP (Highly Sensitive Person)

By Zoë Kessler, BA, B.Ed.

Many people with ADHD (myself included) identify with being an HSP (Highly Sensitive Person), so I thought I’d revisit this topic in today’s blog post.

I’m not saying that non-HSP’s don’t experience these traits, but it’s much more common amongst the 15 to 20% of the population who carry the gene for sensitivity (yes, research backs up its genetic origin).

Sensitivities can manifest as physical characteristics, in social situations, and at work.

I’ve created the Chick A-D-D P.O.S. System to categorize these common 10 HSP characteristics.

P= Physical sensitivities
O = Occupational sensitivities
S = Social sensitivities

See if you can find your POSition through these 10 Signs That You’re An HSP.

1 ) Loud Movie Soundtracks (P)

non-HSP: Wow!
HSP: Ow!

I remember seeing Star Wars when it first came out (yes, I’m that old). I think I actually put my hands over my ears (which, come to think of it, did make me feel like a little old lady although I was only 18 at the time). The entire soundtrack was like having the Imperial Stormtroopers’ E-11 blaster rifles shooting directly into my ears.

2 ) Big, Excited Crowds (S)

non-HSP: Fun!
HSP: Run!

I’ve had the heebie-jeebies in crowds since a young age. I can get downright claustrophobic shoulder-to-shoulder at a large fireworks display, parade, or crowded bar (at least in a bar I can anesthetize myself with a few vodka coolers).

3 ) Delicate Or Subtle Smells, Art, Flavours (P/S)

non-HSP: Miss
HSP: Bliss

Two examples of this from my life are 1) I’ve been known to sit, mesmerized, in front of a painting for over three hours at a stretch and 2) the subtleties of East Indian cuisine intrigue and delight me, with delicate nuances and undercurrents of sauteed-’til-popping-mustard-seeds, cumin and cardamom.

4 ) Crude Sexual Innuendo (S)

non-HSP: Bad-ass
HSP: Simply Crass

An example of this can be found in what I refer to as the X-rated section of a card shop:

Cover of the card – “ You know you’re getting older when your underwear creeps up on you …”

Inside of card: “… and you kinda enjoy it.”

Actually, wedgies can also fall under the P (Physical) category. Ew.

5 ) Brassiere (P)

non-HSP: Wearable
HSP: Unbearable

In about 3 nanoseconds of wearing a brassiere, I want to rip the damn thing off and run screaming back to my closet for a top that will disguise that I’m no longer wearing it. I only wear one under duress (i.e. when décorum demands it. At work, for example). Straps, underwire, the whole contraption smacks to me of bondage (I know, I know; this feature is actually an attraction to some of you, but this post isn’t the place to discuss that).

For you male HSPs, I wonder if the jockstrap is the bra-torture equivalent? Fortunately, it’s highly unlikely that a male HSP would be a jock, so it’s probably not an issue.

6 ) Unkind Remarks at Work (O)

non-HSP: no big issue
HSP: get out the tissues

HSPs are known to be highly emotionally reactive. Ok, we’re drama queens (aka “emotionally labile” in psychology-speak). The same insensitive remark would affect an HSP and non-HSP very differently. I’ve been known to break into tears at work for careless and uncalled-for remarks on more than one occasion (especially when off my ADHD meds).

7 ) Violent Films (S)

non-HSP: bring on the action!
HSP: emotional reaction

Although I love film, I have to be very selective about what I watch. I’ve missed some excellent films because of this. I just can’t expose myself to graphic violence, or even to movies where someone dies at the end. (Whatever possessed me to go to the film Titanic, I’ll never know. I think I was secretly hoping that everyone would be rescued at the end. Duh! Failure to foresee consequences is a frequent ADHD symptom, so I might have an out for that little oversight…)

8 ) Circus In Town (S)

non-HSP: fun and magnificent
HSP: torture of the innocent

Just hearing the radio ad, “the horses and elephants will entertain you,” makes me physically ill and bawl my eyes out.

9 ) Tags In Clothes (P)

non-HSP: laundering navigation
HSP: endless irritation

Ever heard of, The Princess and the Pea? – that’s me.

10 ) Being Evaluated (Watched) at Work (O)

non-HSP: doing my best
HSP: make a big mess

If you want to see me walk into furniture; develop a sudden case of Parkinson’s, dropping things randomly on the floor; giggle maniacally for no reason while cracking nonsensical and non-humorous jokes, tell me I’m being scrutinized at work. The mere concept of a “Probation Period” sends me into near-panic.

How about you? HSP too?

So – how’d you do? If you found out that you’re an HSP, no worries. Just like ADHD, there are ways to cope, and even – yes – ways to turn your challenges into strengths.

Want to find out more? Read Elaine N. Aron’s excellent book, The Highly Sensitive Person.

 

Related posts:

1. Why you should NEVER let a person with BPD have access to a gun
2. British Personality Survey shows 77% show signs of PD
3. BPD: What’s in a Name and How does it feel to be that person?

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Casey Anthony BPD or Psychopath or What?

A few days ago I got an email from a member of the ATSTP list asking me what I thought about the possibility of Casey Anthony, who is currently on trial for the murder of her 2 year old daughter (Caylee Anthony), having Borderline Personality Disorder (BPD). In 2008, I was following the case with interest. I have followed it a bit during the trial. I am not a doctor or a mental health professional, yet I have met a LOT of people with BPD (both men and women) and members of their families. I’ve looked at Casey Anthony’s behavior and compared it with the behavior of people that I know with BPD. I pretty much come to the conclusion that Casey Anthony doesn’t have borderline personality disorder. It seems to be more likely that she’s a psychopath. It seems that some criminal profilers agree…

http://today.msnbc.msn.com/id/36551199/ns/today-today_people/t/do-letters-show-casey-anthony-psychopath/

Pat Brown, a criminal profiler, told TODAY’s Meredith Vieira that in her opinion, Anthony is a psychopath who is trying to get potential jurors to feel sorry for her. The letters are the way she does it, Brown said.

“This will prove she’s a new woman. After all, she’s found God,” Brown said, adding that juries will frequently sympathize with a woman who claims she was abused and mistreated but now has found the light.

“A lot of time women go to court, juries start feeling sorry for them,” Brown said. “It’s manipulation.”

Brown called the letters “a wonderful window into how a psychopath thinks.”

Here is some information about psychopathy:

In his 1941 book, Mask of Sanity, Hervey M. Cleckley introduced 16 behavioral characteristics of a psychopath:

• Superficial charm and good “intelligence”
• Absence of delusions and other signs of irrational thinking
• Absence of nervousness or psychoneurotic manifestations
• Unreliability
• Untruthfulness and insincerity
• Lack of remorse and shame
• Inadequately motivated antisocial behavior
• Poor judgment and failure to learn by experience
• Pathologic egocentricity and incapacity for love
• General poverty in major affective reactions
• Specific loss of insight
• Unresponsiveness in general interpersonal relations
• Fantastic and uninviting behavior with drink and sometimes without
• Suicide threats rarely carried out
• Sex life impersonal, trivial, and poorly integrated
• Failure to follow any life plan.

And here is some information from the Hare checklist:

PCL-R items

The following findings are for research purposes only, and are not used in clinical diagnosis. These items cover the affective, interpersonal, and behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person’s psychopathy.

Factor 1

Aggressive narcissism

Glibness/superficial charm

Grandiose sense of self-worth

Pathological lying

Cunning/manipulative

Lack of remorse or guilt

Emotionally shallow

Callous/lack of empathy

Failure to accept responsibility for own actions

Factor 2

Socially deviant lifestyle

Need for stimulation/proneness to boredom

Parasitic lifestyle

Poor behavioral control

Promiscuous sexual behavior

Lack of realistic, long-term goals

Impulsiveness

Irresponsibility

Juvenile delinquency

Early behavioral problems

Revocation of conditional release

Traits not correlated with either factor

Many short-term marital relationships

Criminal versatility

One thing we can say about Casey Anthony is that she is a compulsive liar. Here is one story about her continued insistence that she dropped her daughter off a the nanny’s even after the police were aware that it was a lie:

http://www.reuters.com/article/2011/06/02/us-crime-anthony-idUSTRE75162O20110602

Accused child killer Casey Anthony insisted that her daughter Caylee was kidnapped by a nanny, even after admitting to detectives that everything else she had told them was a lie, according to a taped interview played for jurors Thursday.

“I dropped her off at the (nanny’s) apartment,” Casey told detectives on July 16, 2008 in a tense exchange about her 2-year-old daughter.

“No you didn’t,” a detective responded.

“That’s exactly where I dropped her off,” Casey said.

“No you didn’t. And who did you drop her off with?” the detective asked.

“I dropped her off with Zenaida,” Casey said.

“No you didn’t,” the detective said.

By then, Detective Yuri Melich testified, he knew the apartment identified by Casey had been vacant for months and no one named Zenaida Fernandez-Gonzalez had ever lived in the apartment complex. Many other details provided by Casey about Caylee’s disappearance had not panned out, he said.

And here is some information from ABC News about Casey Anthony’s “top ten lies”:

http://abcnews.go.com/US/casey-anthony-top-ten-lies/story?id=13742643

• Casey Anthony told police that she spoke to her daughter Caylee on July 15, 2008, the day Caylee was reported missing. She told police Caylee said, “Hi, mommy” and told her a story about her shoes and a book she was reading. “She was excited to talk to me,” Casey Anthony told police. Caylee was already dead.
• She said she had a job as an event planner at Universal Studios. She even led police to a building on the Universal lot and down a hallway until she finally turned to them and admitted she didn’t work there.
• She claimed the babysitter was a former girlfriend of Jeffrey Hopkins, and that Hopkins was also a one time boyfriend of hers. She told her mother, Cindy Casey, that Hopkins had a toddler named Zachary. She had a picture of a man and a boy on her cell phone identified as Hopkins and filed under “boyfriend,” her mother told the court. Hopkins testified that he attended middle school with Anthony. Hopkins said he has no child and never met anyone named Zenaida Fernandez-Gonzalez.
• Casey Anthony described how Zenaida Fernandez-Gonzalez lived in one neighborhood for several months and then moved to another location. Her story of the babysitter’s move was complete with a description of the apartment’s interior.
• She claimed her friend and co-worker at Universal Studios was named Juliette Lewis. Casey and her mother, Cindy, went to help Lewis with a fundraiser, but after waiting for about 90 minutes, Lewis didn’t show up, Cindy Casey testified. Universal had said that no one named Juliette Lewis worked there.
• Casey Anthony told her mother that the father of Caylee was a man named Eric Baker. She later called home frantically to tell her mother that Eric Baker had been killed in a car crash. Anthony even told detectives she had Baker’s obituary to prove Caylee’s father was dead. It’s never been confirmed Baker is the father of Caylee and it’s still unclear the paternity of Caylee.
• Hopkins’ mother was named Jules and she had cancer. Cindy Anthony even baked a cake for a Christmas season meeting with Hopkins and his mother, but the meeting was cancelled at the last minute.
• Casey Anthony told her mother that she was in Jacksonville and was going to stay longer to attend Jules’ wedding. She was actually staying at the home of her boyfriend Tony Lazzarro and another friend’s apartment in Orlando.
• Casey Anthony told her mother at different times during the month that the girl was missing that Caylee was at Disney World, was at Sea World, was at Universal Studios. Caylee was already dead.
• “I don’t know where she is and that is the God’s honest truth,” Casey Anthony told police on July 16, 2008.

It seems if anyone doesn’t know the “God’s honest truth” is Casey Anthony. Guess we’ll see what happens in her trial.

Here’s my book about BPD:

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

Here are some good books about psychopaths:

Without Conscience: The Disturbing World of the Psychopaths Among Us

The Psychopath Test: A Journey Through the Madness Industry

The Psychopath: Emotion and the Brain

Handbook of Psychopathy

The Mask of Sanity (Mosby medical library)

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2. Understanding Borderline Personality Disorder from WHYY
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Mind Reading: Psychologist Simon Baron-Cohen on Empathy and the Science of Evil
By MAIA SZALAVITZ Monday, May 30, 2011

Cambridge psychology professor and leading autism expert Simon Baron-Cohen is best known for studying the theory that a key problem in autistic disorders is “mind blindness,” difficulty understanding the thoughts, feelings and intentions of others. He’s also known for positing the “extreme male brain” concept of autism, which suggests that exposure to high levels of testosterone in the womb can cause the brain to focus on systematic knowledge and patterns more than on emotions and connection with others. (Oh, and yes, he’s also the cousin of British comedian Sacha “Borat” Baron Cohen.)

Baron-Cohen’s new book, The Science of Evil: On Empathy and the Origins of Cruelty, examines the role of empathy, the ability to understand and care about the emotions of others, not only in autism but in conditions like psychopathy in which lack of care for others leads to antisocial and destructive behavior.

What do you mean when you write about “zero negative” empathy?

Zero empathy refers to people at the extremely low end of the scale. They tend to be people with personality disorders, particularly antisocial personality disorder (ASPD). I focus quite a lot on psychopathy [the extreme form of ASPD] and also on two other personality disorders, borderline personality disorder and narcissistic personality disorder.

The ‘negative’ is meant to be shorthand for this being negative for the individual but also for the people around them. It’s meant to contrast with what I call ‘zero positive’ empathy, which effectively describes the autistic spectrum.

[Autistic people] struggle with empathy just like zero negatives but it seems to be for very different reasons. I’m arguing that their low empathy is a result of a particular cognitive style, which is attentive to details and patterns or rules, which in shorthand, I call systemizing.

If we think about the autism spectrum as involving a very strong drive to systemize, that can have very positive consequences for the individual and for society. The downside is that when you try to systemize certain parts of the world like people and emotions, those sorts of phenomena are less lawful and harder to systemize. That can lead to having low empathy, almost like a byproduct of strong systemizing.

How do you account for people who are both highly empathetic and highly systematic, such as some of those with Asperger’s who are actually oversensitive to the emotions of others?

I’ve certainly come across subgroups like that. There are people with Asperger’s whom I’ve met who certainly would be very upset to learn they’d hurt another person’s feelings. They often have very strong moral consciences and moral codes. They care about not hurting people. They may not always be aware [that they've said something rude or hurtful], but if it’s pointed out, they would want to do something about it.

The other side of their moral sense is that they often have a strong sense of justice or fairness. They may have arrived at it through looking for logical patterns rather than necessarily because they can easily identify with someone, however.

People often think that autistic people are dangerous, like psychopaths, when they hear this idea that they have “no empathy.”

In a way, that was one of my motivations for writing the book. Low empathy is a characteristic of many different conditions or disorders. Often books are written where they either focus on psychopathy or autism but [not both].

We have to look at them side by side, and when we do that, we see that they are very different and it’s important to bring that out.

Is it the case, then, that autistic people are not good at the “mind reading” part of empathy, in terms of predicting people’s behavior and feelings, while psychopaths are able to do that but are not able to care?

I think the contrast between these two conditions provides some evidence for that dissociation within empathy. People with psychopathy are very good at reading the minds of their victims. That’s probably most clearly seen in deception. You have to be good at mind reading before it would even occur to you want [to deceive someone]. So you can see the cognitive part of empathy as functioning very well, but the fact that they don’t have the appropriate emotional response to someone else’s state of mind, the feeling of wanting to alleviate distress if someone’s in pain, [that suggests that] the affective part of empathy is not functioning normally.

What stunts the development of empathy in personality disorders?

In the book, I explore both early environmental factors and biological and genetic factors. I think it’s particularly clear in borderline personality disorder (BPD) that there’s a strong association between early environmental deprivation and neglect and abuse and later outcome of BPD. There’s an association [with abuse and trauma early in life] in psychopathy, but it’s not strong as in BPD.

What defines borderline personality disorder?

There seems to be quite a lot of difficulty in self-regulation, in the regulation of their own emotional state. A lot of people with BPD also have depression. Many are suicidal. Many have had a history of feeling attacked or uncared for’ they are almost hypersensitive to possible threats from others.

They react almost with a hair trigger — if they perceive they are being attacked, they go on the attack. People with BPD can be so preoccupied by their own sense of not being cared for and not being understood that they can become blind to the impact of their own behavior on others.

So how would you address increasing empathy in these conditions?

There are interesting and imaginative new approaches to treatment for empathy. Some are medications like oxytocin. Some are psychological treatments like Peter Fonagy’s work on mentalization therapy. I haven’t ever watched it done but the idea is to encourage the patient to stop and think about others’ thoughts and feelings. It’s particularly useful for BPD. When someone with that condition is mostly focusing on themselves, the therapist prompts them to take other people’s perspectives. And just through repetition and practice, people get better and better.

I don’t see how that would work with psychopaths.

People are doing some clinical approaches with psychopaths too, like getting them to meet their victims. That’s obviously got lots of traumatic risk attached to it [for the victim], but again, it’s an exercise in perspective-taking.

I think if we take seriously the idea that behavior is the result of the brain — that having low empathy [is] the result of the way the empathy circuit is functioning or has developed — it does raise moral questions. When someone is acting with low empathy, why do we judge them as bad and punish them? It does shift the locus of where [they should be treated] philosophically, from the criminal justice system to health care.

Don’t you think there are people who are actually evil, who know what they’re doing is wrong and harmful but choose to do it anyway?

I argue in the book that I don’t find the term evil very useful. Once you are down at zero degrees of empathy, all kinds of behavior become possible. I don’t find it scientifically useful to use that term. Empathy is a scientific term in a way that evil isn’t. You can try to localize it in the brain; you can look for which part of brain is activated. It’s normative behavior. Evil is kind of the opposite of good, I guess, but empathy, as we were talking earlier, is quantifiable and normal. You can measure it and look for it, whereas you don’t see evil in the brain.

It’s argued that humans were able to evolve cooperation and altruism only by having a way to detect and punish those who didn’t cooperate.

I could see an evolutionary benefit for both empathy and lack of empathy too. Low empathy allows you to act selfishly, which could be in your interest, but high empathy fosters social cohesion and it’s good for the individual to end up as part of a social network.

I speculate that maybe most people end up in the middle, which may be the optimal position. It’s good to have some empathy, so at the very least you avoid offending or inadvertently hurting someone, but too much empathy might mean never completing your own projects.

How does your cousin Sacha Baron Cohen, creator of Borat, rate on empathy? His work can really make you cringe, but he must be excellent at mind reading to do it.

First of all, he and I have a family agreement that we don’t talk about each other. I respect his work. I think that sometimes that kind of comedy can create what you called a “cringe reaction,” cringing with embarrassment, but that has a purpose.

Why does empathy seem especially lacking in the teen years?

It’s kind of interesting that parents comment on adolescence as being a low point in empathy. But there’s still quite a lot of maturation going on in the part of the brain that involves empathy during that period. There could also be hormonal factors, particularly in males with the increase in testosterone. That could change empathy levels.

I’m struck that if you look at the “terrible two’s,” kids who have tantrums when they don’t get their way, and teens, at one level it looks like very little development has gone on. There’s a transition at around age four to becoming able to apprehend that others have different perspectives. You would imagine that empathy would almost reach a peak in early childhood, but it seems to have a long protracted development.

It seems to me that the terrible twos and adolescence are both the most intense periods of brain development. Could that be why empathy is impaired then?

That’s really interesting. I think brain maturation is one thing and also just the experience of relationships. I think that empathy has to have an environment in which to work, and that environment is relationships. Making mistakes in relationships is all part of learning to empathize.

There was an interesting study I was part of. Women who took extra testosterone were given the ‘reading the mind in eyes test.’ [The test measures how well people can read others' emotions by looking at their eyes.] A dose of testosterone lowered scores on this test. It was one of the first demonstrations that changing testosterone levels affects your empathy.

If you’re taking an evolutionary approach, it might be very adaptive if you have to use aggression for self-defense. You’d be more effective if you didn’t have empathy getting in the way.

A U.S. doctor tried to treat autism by lowering testosterone levels, citing your work as justification, although he actually didn’t get the research right. He just lost his license because he was using a “chemical castration” drug on kids to do this.

We haven’t considering [lowering testosterone] as a treatment to study for autism. I’m not comfortable with it ethically in terms of side effects. They misquoted [our research], and cited it as evidence that there was elevated testosterone in autism when, in fact, we haven’t shown that. They presented it as if we’re endorsing it, which I’m certainly not.

See more of Healthland’s “Mind Reading” series.

Find this article at:

http://healthland.time.com/2011/05/30/mind-reading-psychologist-simon-baron-cohen-on-empathy-and-the-science-of-evil/

You can buy to book here:

See larger image The Science of Evil: On Empathy and the Origins of Cruelty (Hardcover) By (author) Simon Baron-Cohen List Price: $25.99 USD New From: $13.92 In Stock Used from: $13.92 In Stock

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Firstly, when shown the Ekman faces (just google it if you don’t know what those are), borderlines are likely to view neutral faces as angry and angry faces as extremely threatening. Borderlines think “that person is angry *at me*”. With fear faces, borderlines actually express empathy, even if Baron-Cohen says they don’t. I disagree with him in this regard. I believe the lack of empathy in borderlines occurs during a “failure to mentalize” and is not a general BPD trait.

Psychopath’s brains only activate on fear faces. Disturbingly, they get “excited” about fear in others (i.e. the pleasure centers of the brain light up).

Secondly, psychopaths are the only class of disordered individuals that use goal-directed aggression. Borderlines do not. Their aggression is reactive. Now, you may read that and think “oh my god! My ‘BP’ is a psychopath!” yet what is really happening is that you probably don’t see the trigger of reactive aggression. The trigger for a borderline (or another emotionally sensitive person) can very well be internally-generated – by ruminating or misreading the intentions of others. Psychopaths, however, LIKE to see fear in you. Borderlines just don’t like to feel fear in themselves.

The thing is… I am differentiating the groups because the skills taught in WHINE will not work with psychopaths. In fact, it will probably make them more manipulative because they can gain an understanding of your emotions (whereas they have very little ability to mentalize about others’ feelings, intentions, etc. – they just don’t care) and use that knowledge to get what they want.

For more on psychopathy, listen to Dr. James Blair’s presentation to the 2009 ISSPD.

And some books – Dr. Blair’s book included:

Without Conscience: The Disturbing World of the Psychopaths Among Us

The Psychopath Test: A Journey Through the Madness Industry

The Psychopath: Emotion and the Brain

Handbook of Psychopathy

The Mask of Sanity (Mosby medical library)

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Can Epidemiology Translate Into Understanding Major Depression With Borderline Personality Disorder?

Myrna M. Weissman, Ph.D.
Epidemiologic surveys have mapped the terrain of psychiatric disorders. Personality disorders have bedeviled the clinician’s practice. Rarely have these two been rearranged in a meaningful clinical dialogue. Using the largest psychiatric epidemiologic survey ever, the National Epidemiologic Survey on Alcoholism and Related Conditions, and among the few to venture into axis II disorders, Skodol et al. (1), in this issue of the Journal, give a community-based national view of a common clinical question: What is the effect of specific personality disorder comorbidity on the course of major depression?

The original sample included over 40,000 adults, and 2,422 met criteria for DSM-IV current major depressive disorder. Three years later, 1,996 of the original currently depressed subjects were available for reinterviewing, which makes both a respectable sample size and response rate for generalizability. However, some caution is needed, since the sample was over-represented with Caucasian, college-educated, and married respondents. Fifteen percent of participants had persistent major depressive disorder, and 7.3% of those who remitted had a recurrence over the follow-up period. These figures are within the range of longitudinal studies of patients with major depressive disorder (2). While the presence of any personality disorder elevated the risk for persistence of major depressive disorder, when all axis I and II disorders, age of onset of major depressive disorder, number of previous episodes, family history, treatment, and duration of illness were controlled, borderline personality disorder remained the most robust predictor of major depressive disorder persistence. Neither personality disorders nor other clinical variables predicted recurrence of major depressive disorder. Thus, an epidemiologic survey yielded a practical jewel. The finding, undoubtedly, does not surprise the clinician but is now confirmed nationally. As the authors conclude, borderline personality disorder should be assessed in all depressed patients and considered in prognosis and addressed in treatment.

One can raise a number of methodologic issues about this study, including the use of lay interviewers or the instrument for assessing axis II disorders. The diagnostic interview, the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (3), was developed for this survey. The personality disorders included were adapted from items in the Structured Clinical Interview for DSM-IV Personality Disorders. The test-retest and internal consistency results reported for all personality disorders are fair to good, not great. However, the agreement with clinician interviews for borderline personality disorder (kappa=0.71) is about as good as it gets (4). The only other national survey to venture into assessing all axis II disorders was the National Comorbidity Survey Replication (5), which used the International Personality Disorder Examination. The investigators carried out a clinical reappraisal in a sample of 214 subjects using clinically trained interviewers to follow up screened, positive subjects and reported excellent predictions of classification. They also noted that the International Personality Disorder Examination is commonly regarded as a conservative diagnostic assessment of axis II disorders. The community rate they generated for any personality disorder in the United States was 11%, and in the World Health Organization World Mental Health Surveys (6), involving 13 countries, the rate was 6.1%. These rates seem to be lower than those reported in the National Epidemiologic Survey on Alcoholism and Related Conditions, but different presentations make it difficult to directly compare rates between studies. No articles from the National Epidemiologic Survey on Alcoholism and Related Conditions reporting overall rates of axis II disorders could be found. Unfortunately, given the findings in the Skodol et al. article, not all personality disorders were included in the first wave of the survey, and borderline personality disorder was added in the second wave. Both of these landmark studies used state-of-the-art measures. While they are imperfect, these are the best available. It is too bad they could not share the same methods.

The major issue now is not a debate about the methods of personality disorder assessment but about the future of personality disorders. The DSM-5 committee is working on the next version of psychiatric classification (7). In parallel, the National Institute of Mental Health is working on moving diagnosis away from clinical presentations to understanding of syndromes based on pathophysiology in a new project called Research Domain Criteria (8). These efforts will certainly effect how personality disorders are described, classified, or reimbursed in the future.

DSM-5 raises issues about the categorical conceptualization of personality disorders because of the high concurrence among disorders, both within and across axes, and the difficulty in differentiating normal from pathological. How dimensions will solve the problem of a lack of understanding of the pathophysiology underlying the disorders is unclear. Some cutoff along the dimension will need to be established for clinical practice.

The Skodol et al. study, based on an epidemiologic survey, may add light to the issue or, at least, generate a hypothesis about diagnosis that can be translated into a more experimental approach. Borderline personality disorder, defined categorically, and not the other axis II disorders explained the persistence of major depressive disorder over 3 years. Other axis I disorders may map out to different axis II disorders. The National Epidemiologic Survey on Alcoholism and Related Conditions, because of its large sample, could be mined for these clues about the relationship between specific axis I and II disorders.

The Research Domain Criteria project, in the long run, may offer more enlightenment for personality disorders if its goals can be achieved. The primary focus is on neural circuitry, with levels of analysis progressing from measures of circuitry function to clinically relevant variation or downward to the genetic and molecular cellular function (8). In the final analysis, the new molecular and neurobiological parameters will need to predict prognosis or treatment response. They will need to do as well as borderline personality disorder in predicting major depressive disorder persistence. If the Research Domain Criteria approach is successful, more than prediction of prognosis might be achieved, including a deeper understanding of the biological mechanism underlying the joined symptoms.

The epidemiologic finding that borderline personality disorder contributes to poor prognosis of major depressive disorder might be viewed as a hypothesis that can be translated into methods in the neurosciences to understand the mechanism behind this association. The features of borderline personality disorder, particularly the pervasive instability of the regulation of emotions and impulse control, would seem ripe for the Research Domain Criteria approach. When these symptoms occur in conjunction with major depressive disorder, a different syndrome may be present. Further experimental work may test how the symptoms of borderline personality disorder contribute to the prognosis of major depressive disorder. But what about the persistence of borderline personality disorder without major depressive disorder? Can the epidemiologic data provide any clues? In the meantime, the clinician treating major depressive disorder would be wise to assess for borderline personality disorder, even as currently defined.

 

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Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’

… which in combination with this finding: People with Borderline Personality Disorder over diagnosed with Bipolar Disorder …could have some interesting ramifications for the medical community.

The text of the article:

Bipolar depression unrecognised in primary care
03 Mar 11

By Christian Duffin

Up to a fifth of primary care patients with depression may have an undiagnosed bipolar disorder, a UK study suggests.

The researchers argue that their findings have important implications for GP diagnosis and assessment, because prescribing antidepressants as monotherapy for patients with bipolar disorder may result in mania and frequent mood swings.

The researchers believe that their study is the first to investigate the extent to which bipolar disorder is misdiagnosed as major depressive disorder among UK primary care patients.

The study involved a two-phase sampling technique to produce three estimates of unrecognised bipolar disorder.

The researchers initially collected diagnostic, clinical, psychosocial functioning and quality of life data from 11 GP practices in south Wales for patients with a diagnosis of unipolar depression.

576 of the 3,117 patients contacted sent back completed Hypomania Checklist (HCL-32) and Bipolar Spectrum Diagnostic Scale (BSDS) screening tool questionnaires, both used to test for bipolar disorder.

Of these, 154 were then given a comprehensive diagnostic and clinical assessment. 29 met the diagnostic criteria for bipolar disorder.

The researchers calculated three estimates of the prevalence of previously undiagnosed bipolar disorder, ranging from 3.3% up to 21.6%.

The estimates were based on different assumptions. The most conservative estimate assumed that all individuals who dropped out of the study did not have bipolar disorder.

Assuming that all of those who were invited to interview but did not attend did not have bipolar disorder resulted in a prevalence of 9.6%, while assuming all who were invited and attended had bipolar disorder resulted in a prevalence of 21.6%.

Lead researcher Dr Daniel Smith, a clinical senior lecturer in psychiatry at Cardiff University, said: ‘Although challenging, these are findings with potentially considerable implications for they way in which GPs approach the diagnosis and treatment of their patients with depression, especially when we consider how commonly antidepressants are prescribed in primary care and the potential for harm when antidepressants are used as monotherapy for bipolar disorder.’

He added: ‘It will be important that GPs are supported in developing strategies to ensure that their patients with depression receive the correct diagnosis with regard to the possibility of a primary bipolar illness.’

Dr Thomas Shackleton, a GP from Bottisham, near Cambridge with an interest in depression, said the research should serve as a reminder to GPs that they should screen for manic symptoms when they make they make a diagnosis for depression and during the follow-up at 5-12 weeks.

Dr Shackleton, also an advisor to NICE for its guidelines on depression, added: ‘This is a big issue because the majority of first presentations are depressive, and if you prescribe antidepressants you can induce a manic episode in someone who has bipolar disorder.

‘It can be difficult for GPs because if patients have impulsive or risky behaviour, such as risky sex or gambling, they tend you hide it from GPs. But GPs can explore patients’ histories and ask them if their family have had any concerns about them.’

Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’

NICE GUIDELINES ON BIPOLAR DISORDER
-
- GPs should fully involve patients in decisions about their treatment and care, and determine treatment plans in collaboration with the patient’s preference.
- GPs should discuss contraception and the risks of pregnancy with all women of child-bearing potential, regardless of whether they are planning a pregnancy.
- People experiencing a manic episode, or severe depressive symptoms, should normally be seen again within a week of their first assessment, and then regularly at appropriate intervals, for example, every 2–4 weeks in the first 3 months and less often after that, if response is good.
- The treatment of bipolar disorder is based primarily on psychotropic medication, but side effects and potential harms will determine the choice of drug. A range of psychological and psychosocial interventions can also have a significant impact.
CG38 Bipolar disorder: NICE guideline, October 2006

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Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive
By A. G. SULZBERGER and BENEDICT CAREY

TUCSON —What are you supposed to do with someone like Jared L. Loughner?

That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.

“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”

Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”

Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.

Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.

“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).

But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”

Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”

At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.

The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.

Many others feel the same way.

Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.

“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”

Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.

This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.

A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.

“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”

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Personality pathology recorded by severity: national survey
Min Yang, MD, MPH
Division of Psychiatry, School of Community Health Science, University of Nottingham, Nottingham

Jeremy Coid, MD, FRCPsych

Queen Mary College, London, Forensic Psychiatry Research Unit, St Bartholomew’s Hospital, London

Peter Tyrer, MD

Centre for Mental Health, Imperial College, London, UK

Correspondence: Correspondence: Professor Peter Tyrer, Centre for Mental Health, Imperial College, St Dunstan’s Road, London W6 8RP, UK. Email: p.tyrer@imperial.ac.uk

Declaration of interest

P.T. is the Chair of the World Psychiatric Association Section on Personality Disorders and the Chair of the World Health Organization Personality Disorder Working Group for the ICD–11 Classification. He is also Editor of the British Journal of Psychiatry but had no part in any decisions about this paper.

Background

Current classifications of personality disorders do not classify severity despite clinical practice favouring such descriptions.

Aims

To assess whether an existing measure of severity of personality disorder predicted clinical pathology and societal dysfunction in a community sample.

Method

UK national epidemiological study in which personality status was measured using the screening version of the Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II) and reclassified to five levels using a modified severity index. Associations between levels of severity of personality pathology and social, demographic and clinical variables were measured.

Results

Of 8391 individuals interviewed and their personality status assessed, only a minority (n = 1933, 23%) had no personality pathology. The results supported the hypothesis. More severe personality pathology was associated incrementally with younger age, childhood institutional care, expulsion from school, contacts with the criminal justice system, economic inactivity, more Axis I pathology and greater service contact (primary care and secondary care, all P<0.001). Significant handicap was noted among people with even low levels of personality pathology. No differences contradicted the main hypothesis.

Conclusions

A simple reconstruction of the existing classification of personality disorder is a good predictor of social dysfunction and supports the development of severity measures as a critical requirement in both DSM–V and ICD–11 classifications.

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OK, I don’t normally do it, but today I went out to my old (circa 2005-2006) haunt – WTO (i.e. “Welcome to Oz”). WTO is the largest non-BP board on the Internet. It’s been around or at least 10 years and has over 4,000 members. Most of the members are quiet (like me). I used to post way back when and got into a number of “altercations” with people because I was presenting a different approach to people with BPD than the majority of the members. Mostly, it’s people who have just started trying to figure out what BPD is all about and are hurt and frustrated.

The quoted text above is a subject line of a recent post. I feel for the woman, I really do. Yet, that line seems to typify the very problem with BPD support groups. Firstly, there is an assumption that boundaries are the default tool for making a relationship work. They aren’t. I explain in great detail in my eBook “Beyond Boundaries”. However, the short version about boundaries is (from the Beyond Boundaries eBook):

If you do any research on BPD, you will find a plethora of advice from all types of people. There are Internet support groups, self-help books and personal stories that tell you what to do as a Non-BP. Some of this advice is good and works effectively with someone with BPD. Some of this advice is not good and is ineffective with someone with BPD. Some of this advice is misperceived by the Non and applied in a way that is not intended by the advice giver. The most misunderstood tool is boundaries.

If I had a nickel for every time someone joins my Internet list and says: “I set boundaries and try to enforce them.”

… or something like that, I’d be rich. Well, not really but I would probably have a couple of hundred dollars anyway.

Unfortunately, most people who try to create and apply boundaries to their BP relationship, do so improperly and with misunderstanding. This misunderstanding is amplified across the Internet and in publications about dealing with an emotionally sensitive person. The misunderstanding arises in two forms: one is the meaning of a boundary, and the second is to whom the boundary applies.

Many people believe that a “boundary” is equivalent to a rule and that they have to enforce their personal boundaries with a person who has BPD. This is not the case. A personal boundary is not a rule that needs to be enforced. Instead, a personal boundary is a limit that one puts on one’s own behavior. It is a choice that you make about your own behavior and a limit on the behavior you’re willing to engage in.

Boundaries have their place, but the assumption that boundaries (or limits) are the end-all, be-all (or even the default approach to BPD is IMO misguided. Other tools are much more important, effective and productive than boundaries.

Now as for “protecting oneself” I can certainly understand why one would feel that they need to protect themselves. However, I see a relationship not as a power struggle or “battle of wills” but as a cooperative sharing of feelings. Unfortunately, a borderline’s feelings are very overwhelming and, at times, seem to be the only feelings in the relationship. If someone is trying to hurt you, it’s quite possible that they’re not borderline, they’re a psychopath (in the true sense of the term). If you’d like to know more about true psychopath you can listen to this (the middle part is the presentation of Dr. James Blair about psychopathy).

You see borderline aggression is reactive in nature. It is reactive to what the borderline perceives as a threat. If the environment is a power struggle, they are going to be trigger continuously. If the environment is a cooperative sharing of feelings, the threat level will go down and you will get less aggression.

This pattern is not the same as a true psychopath.

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There is a diagnosable condition known as a personality disorder. According to the American Psychiatric Association personality disorder typically rears its ugly head in late adolescence but, in rarer instances, childhood. It’s subjective, but a person with borderline personality disorder, should exhibit three or more of the following:

1. Failure to conform to lawful social norms – repeatedly performing acts that are grounds for arrest;

2. Deceitfulness – repeated lying, use of aliases, or conning others for personal profit or pleasure;

3. Impulsivity or failure to plan ahead;

4. Irritability and aggressiveness – repeated physical fights or assaults;

5. Reckless disregard for safety of self or others;

6. Consistent irresponsibility – repeated failure to sustain consistent work behaviour or honour financial obligations;

7. Lack of remorse – being indifferent to or rationalising having hurt, mistreated, or stolen from another.

I’m no psychologist but if you ticked too many of those boxes for yourself or a loved one, with a GP’s referral you can see a qualified psychologist for free in Australia. One referral entitles any Medicare cardholder to 12 free consultations and 12 group sessions.

No, you’re not psychologist all right. The criteria to which she is referring is the criteria for Anti-social Personality disorder, not Borderline Personality Disorder. I think before you post something about which you know next to nothing about, at least get it fact-checked.There’s already enough stigma around BPD without having people attribute ASPD criteria to it as well.

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2. Social Problems in Teens Can Lead to Personality Disorders
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DSM-5 Type and Trait Cross-Walk

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If Bipolar Disorder Is Over-diagnosed, What Are The Actual Diagnoses?

ScienceDaily (July 29, 2009) — A year ago, a study by Rhode Island Hospital and Brown University researchers reported that fewer than half the patients previously diagnosed with bipolar disorder received an actual diagnosis of bipolar disorder after using a comprehensive, psychiatric diagnostic interview tool –the Structured Clinical Interview for DSM-IV (SCID). In this follow-up study, the researchers have determined the actual diagnoses of those patients.

Their study is published in the July 28 ahead of print online edition of The Journal of Clinical Psychiatry.

Under the direction of lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, the researchers’ findings indicate that patients who received a previous diagnosis of bipolar disorder that was not confirmed by a SCID, they were significantly more likely to be diagnosed with borderline personality disorder as well as impulse control disorders.

Their research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.

Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, “In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder.”

The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.

Zimmerman and colleagues note that “we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive.”

In their previously published study that concluded bipolar disorder was over-diagnosed, they studied 700 patients. Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. The authors state that the over-diagnosis of bipolar disorder can have serious consequences, because while bipolar disorder is treated with mood stabilizers, no medications have been approved for the treatment of borderline personality disorder. As a result, over-diagnosing bipolar disorder can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.

Zimmerman concludes, “Because evidence continues to emerge establishing the efficacy of certain forms of psychotherapy for borderline personality disorder, over-diagnosing bipolar disorder in patients with borderline personality disorder can result in the failure to recommend the most appropriate forms of treatment.”

Along with Zimmerman, other researchers involved in the study include Camile Ruggero, PhD; Iwona Chelminski, PhD and Diane Young, PhD, all of Rhode Island Hospital and Brown University.

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The reason I am posting this message though is because both of them seem to have a craving for affection, attachment and love. It appears to me that each had all these children such that they could be unconditionally loved by as many people as possible. I wonder what happened in their childhood (or if anything happened) that would drive this strong desire to have as many children as they have had.

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Wednesday, Mar. 11, 2009

Redefining Crazy: Researchers Revise the DSM

By John Cloud

If you wanted to make a list of important books you should read, what would you choose? Anna Karenina, maybe? The Bible? How about the Diagnostic and Statistical Manual of Mental Disorders?

It may not be at the top of your list, but the DSM, as it’s usually called, is one of the most important books in the world. It attempts to categorize, describe and give a code number to literally every problem that can occur in your mind, from schizophrenia to borderline personality disorder to something called mathematics disorder, which is essentially being so bad at math that it amounts to a mental problem.

The DSM is important not only because it is wildly ambitious but also because mental-health professionals around the world have adopted its classification system. In the U.S., it is virtually impossible to get reimbursed by an insurance company for treatment unless a mental-health professional identifies your condition by a DSM code number. (The number for mathematics disorder, if you were wondering, is 315.1. The code for Tourette’s syndrome is 307.23; the code for sexual sadism is 302.84. As I said, the DSM tries to cover everything.) (See the top 10 medical breakthroughs of 2008.)

The American Psychiatric Association (APA), which owns the DSM, is in the process of rewriting the book, which was first published in 1952. The DSM-V, as the fifth edition will be called, is set to be published in 2012. But the process of researching it began way back in 1999 — five years after the publication of the last major revision, the DSM-IV — meaning the new book’s production will take 13 years overall. (Read about how we get labeled by the DSM.)

Why so long? Last week, a research organization called the American Psychopathological Association (which goes by the acronym APPA, to distinguish it from the APA) brought many of the key players in the development of the DSM-V to a conference in New York City to discuss some of the reasons the writing of the book is so complicated.

One obvious reason is that so many people have a stake in what the world defines as crazy and what it calls normal. Famously, homosexuality was listed as a DSM condition until a 1974 vote among APA members removed it. Other groups of mental-health professionals and patients want certain disorders to be added (and covered by insurance): sexual compulsivity, for instance, is not in the DSM, even though “sexual aversion disorder” (302.79) — the persistent and distressing avoidance of genital contact not explained by another disorder like depression — is included. (Read an interview with an author who has bipolar disorder.)

Debates about what should and shouldn’t be in the DSM are fascinating and often bitter, and as I have pointed out before, the book makes at least one fundamental error in the way it conceives of mental problems: it ignores causes almost entirely. If you feel sad and tired for a couple of months, have trouble sleeping and making decisions, and gain weight, you can be given a DSM diagnosis of depression (296.31 or 296.32, mild or moderate, recurrent) and prescribed drugs for it — even if the reason for your funk is that you just lost your job. Such physiological responses as insomnia are evolutionarily natural (and sometimes helpful, in a jump-starting sort of way) when you suffer a trauma like losing your job. But according to the DSM, only perfect is considered normal. Another basic problem with the DSM: it tries to reduce the vastly complex experiences of your mind to a single number.

At last week’s conference, there were tantalizing hints that the DSM-V might fix some of these problems. Dr. Steven Hyman, provost of Harvard, a former psychiatry professor at its medical school and a former director of the National Institute of Mental Health, agitated at the meeting for a new DSM framework that would stop trying to divide mental problems into discrete all-or-nothing categories. That method is appropriate for some medical problems — you either have leukemia or you don’t — but depression, for instance, doesn’t work like that. (Read “Why Do the Mentally Ill Die Younger?”)

Rather, Hyman argued that many mental illnesses are problems that lie along a continuum from normal and functioning to disordered and tragic. To the annoyance of some old-fashioned DSM defenders, he made the case that the DSM should regard mental illness as “continuous with normal”: less like leukemia and more like hypertension. You don’t get diagnosed with hypertension until you meet a cutoff point for high blood pressure that takes into account other extenuating factors: your age, for instance, or the conditions under which the blood-pressure reading is taken. Depression should be the same: if you are sad because you just got divorced, the DSM shouldn’t necessarily consider you to have an illness.

Such a diagnostic model wouldn’t be simple, though, which is one reason the DSM is taking 13 years to rewrite. And in the meantime, the book still has to be useful to everyday clinicians seeing patients who need a code number for insurance companies. “It’s like wondering how you repair the airport while the planes are still flying,” Hyman said at the conference.

Hyman noted that medical problems, whether in the mind or in the body or both, are usually caused by some combination of genes, environment, behavior and chance. Despite the comforting modern notion that severe psychological illnesses are simply due to an unfortunate genetic inheritance, it is the exceedingly rare mental condition that is caused only by genes. (Rett syndrome is one example.) Rather, if you take something like generalized anxiety disorder (300.02), there may be a variety of causes that set it off: genes that cause excessive activity in the fear-producing part of the brain called the amygdala, a stressful job that stimulates that activity, engaging in dumb behavior like having an affair that exacerbates your anxiety, then randomly getting into an anxiety-heightening situation like a car accident. The DSM has to try to account for all of that complexity — causes, effects, unintended consequences — and still be definitive.

Hyman said in an interview that one way the DSM currently handles this complexity is to have what he described as a “wastebasket” diagnosis — called “not otherwise specified” (NOS) — that captures just about anything that doesn’t easily fit the categorical model. One major problem with the NOS diagnosis: pretty much anyone can qualify for a diagnosis that, by definition, is not specified. A 2005 American Journal of Psychiatry paper found that nearly half of a group of 859 people who sought psychological help in Rhode Island could be considered to have a DSM personality disorder if diagnosticians were allowed to include the NOS option. Another problem: how do you adequately treat patients whose illness is unspecified?

A continuum model like the one Hyman proposes could help solve this problem by recognizing that people aren’t always one thing or another. They’re sometimes just a little depressed or a little anxious. To avoid medicalizing normal stress, the DSM-V would set a cutoff point within the spectrum. Of course, determining the right cutoff point for the DSM’s 350 illnesses would take an enormous research effort, one that has begun for some disorders like depression but probably hasn’t even been thought about for rare problems like sexual sadism.

Other attendees at the APPA conference indicated that the new DSM will almost certainly adopt a continuum model for mental illnesses. But don’t be surprised if the book doesn’t come out as scheduled in 2012. If the three-day conference came to any solid conclusion, it was that toting up all the ways our minds can fail is a lot harder than, say, explaining why your appendix might burst.

Read “Tallying Mental Illness’s Costs.”

Read “I’m O.K. You’re O.K. We’re Not O.K.”

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Celebrities’ bad behavior is rooted in mental illness, according to “Dr. Drew” Pinsky, who is best known as the host of Celebrity Rehab and Loveline — a nationally syndicated radio show that invites listeners to call in with questions about sex and drugs.

In his latest book, The Mirror Effect (on bookstore shelves Tuesday), he spells out a theory that stars are predisposed to narcissistic personality disorder long before they become famous. Their dysfunctional behavior is rewarded by Hollywood and portrayed as normal by the press.

“As reporting on celebrity behavior becomes even more ruthless and mean-spirited, I am struck by this disconnect between how a
celebrity’s behavior is portrayed in the media, and the very real problems that underlie their actions,” wrote Pinsky.

He argues that the media fails to acknowledge that celebrities are mentally ill when holding them up as role models, so everyday people have begun to emulate their unhealthy behavior.

In 2006, Pinsky and his co-author Mark Young published the first systematic study of celebrity psychology in the Journal of Research in Personality. The new book explains that research and how it fits into the larger context of our culture, which they argue has been soiled by shameless producers, agents and paparazzi.

The first three chapters read like a history textbook, recapping famous celebrity mishaps and an era when those unfortunate episodes were carefully hidden from the public. It gives readers a glimpse of just how conservative Pinsky really is. He seems to prefer the  good old days when movie studios were able to keep Rock Hudson in the closet.

The celebrity doctor is not a fan of MySpace or Facebook either, because they allow people to seek attention by acting out like celebrities — posting provocative pictures and personal stories about irresponsible behavior.

“Without appropriate monitoring, these social networking platforms are subject to abuse by those who are most vulnerable to the endless feedback loop they create,” wrote Pinsky. “This is known as an urge/compulsion/reinforcement cycle, and it’s very similar to what happens to those who crave drugs or other addictive substances.”

After that rather stiff introduction, the book becomes a psychology lesson with celebrities as examples.

Pinsky seems fond of interpreting behavior in the light of evolution, and gave this explanation for the asinine stunts performed by Johnny Knoxville and Steve-O on the show Jackass.

“Some have speculated that such acting out may be deeply rooted in our genes, as a way to display genetic prowess and adaptability,” wrote Pinsky. “In this theory, males (in particular) who survive dangerous stunts are displaying their biological capacity to survive in adversity.”

In their 2006 study, Pinsky and Young found that celebrities from reality television score the highest on the Narcissistic Personality Inventory. Pinsky is convinced that the producers of those shows carefully select contestants with psychological problems, because they will bring extra drama to each show.

“Having served as a consultant to several reality shows, I know what the producers are looking for in contestants,” wrote Pinsky. “The standards regarding mental health are extremely fluid.”

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http://www.youtube.com/watch?v=WktborljI_o

The actual scene starts at 5:35 and be careful there are some pretty graphic things before the 5:35 mark. The scene involves Carroll’s (played by Leonardo DiCaprio) mother not giving him money for drugs. Carroll is a heroin addict at the time. It’s worth seeing just to see tough love in action. If you watch you will see that the tough love is tough on both of them and, more importantly, the mother chooses to use her boundary (“I will not give my son money for drugs”), rather than try and control HIS behavior, which many people think boundaries and tough love are all about.

Anyway, I started looking into Carroll on wikipedia and stumbled across this picture of Carroll taken last year (ok, he’s only 57 in the photo).

Here is another photo taken of him in 2000 (when he was 50).

I mean, Jeez, what happened to him? Some have speculated heroin again, but it looks like meth or AIDS to me. Here’s a blog post about Carroll’s reading from last year. It’s just so sad.

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Beware catching this from your spouse

• Story Highlights
• Studies: Emotional contagion in marriage can harm spouse with bad moods
• Wives more likely to get hardening of arteries from hostile fights with husband
• If your husband is in nasty mood, go for a walk and recognize it’s his mood
• In happy marriage, one spouse’s optimism can rub off on partner

By Kathyrn Matthews

(OPRAH.com) — For better or for worse, when you get married, you sign on for a life of sharing –bedsheets, bathroom space, cold germs. Moods, too, as it turns out. And it’s becoming increasingly clear that “emotional contagion,” the unconscious tendency to mimic the emotions of others, affects spousal health.

Heart bypass patients with neurotic and anxious spouses, for instance, were much more likely to be depressed 18 months after surgery — independent of their own personality — according to one study led by John M. Ruiz, Ph.D., assistant professor of clinical psychology at Washington State University.

The findings are troubling because depression is known to put recovering cardiac patients at higher risk of further heart attacks and death.

Another study showed that hardening of the coronary arteries was more likely in wives when they — or their husbands — expressed hostility during fights.

As for how one catches a partner’s foul humor, the brain’s aptly named “mirror neurons” are to blame, says John T. Cacioppo, Ph.D., director of the Center for Cognitive and Social Neuroscience at the University of Chicago and co-author of “Emotional Contagion.”

These neurons fire in response to other people’s actions and intentions, especially when you care about the individual. So if you see that your husband is anxious or depressed, you literally feel his pain. There are, however, a few ways to prevent spousal mood infection. Oprah.com: What’s really going on in his head!

Disengage

When he makes a nasty remark and you give it right back, you’re off to the races. You can avoid getting stuck in this loop by planning how you will respond to his negativity. One option is to walk away: Take a stroll around the block, go for a bike ride. Once you’re on your own, you can see how much your partner’s mood is really affecting you. If it’s substantial, you might schedule more alone time in your relationship.

Or ask him to exercise with you or visit a therapist (see “Play as a Team”) to try to improve his mood. If you’re the problem, leaving the premises when you feel a funk coming on is also a good way to keep him — and the marriage — healthy.

Let him see the light

His doldrums could be a symptom of seasonal affective disorder — yours too. If either of you is worse in the winter, cheerier when it’s sunny, try installing bright full-spectrum lighting.

Play as a Team

Demanding that he go to a shrink is often not an effective way to motivate him to get help, Cacioppo says. Suggesting that you see a couples therapist together may prove more successful.

Keep your spirits up

People who are content in their relationships are much less vulnerable to a spouse’s neuroticism, according to Ruiz’s research. On the flip side, in a happy marriage, one partner’s optimism may rub off on the other — an actual health benefit. Did someone say optimism? The good news is, you can catch that too.

By Kathyrn Matthews from “O, The Oprah Magazine” © 2008

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There’s good self-consciousness, and then there’s toxic, paralyzing,
raped-by-Bedouins self-consciousness. I think being shy basically means
being self-absorbed to the point that it makes it difficult to be around
other people. For instance, if I’m hanging out with you, I can’t even
tell whether I like you or not because I’m too worried about whether or
not you like me. (David Foster Wallace)

You see, I often hear Non-BPs (the loved ones and family members of people with BPD) tell me that they feel that their loved one with BPD is extremely “selfish” or very “Narcissistic.” I always try to caution them on this statement because, when someone is in pain, yes, they will tend to look inward, but it’s not selfishness or Narcissism, in my opinion. It’s the ravages of deep shame and shyness that cause people with BPD to take such a view of the world. A person with BPD will dread the judgment, punishment and/or disapproval of other people. That is the kind of self-consciousness that is present in BPD.

To further follow up on this idea, here is a quote from me to a member of the ATSTP list from about two years ago. I was responding to the “lack of empathy” that his significant other (SO) was showing toward him:

It is frustrating and part of it seems very selfish on their part. My
wife actually showed sympathy for me this morning – I had a bit of an
upset stomach, so she said “I hope you feel better” a couple of times.
Of course, initially she thought I was mad at her or something (there
was still a lingering feeling that it was about her).

I also think there’s a step beyond empathy, and that’s compassion. I
think if you look at the spectrum of understanding for other people
you have something like self-centeredness (but not necessarily
positive) – pity – sympathy – empathy – compassion. (and there’s
probably a bunch of feelings in-between. The spectrum seems to run
from extreme self-interest to selflessness, of course, I could be
wrong on all of that – just an idea. It is easy to have compassion and
unconditional love for your kids, but for your SO it can be more
difficult because there are expectations on each side of the equation.
When your SO doesn’t live up to those expectations, even if they are
simple consideration, it is disappointing. I know it is difficult with
my wife as well – some of the time. Even my kids are wary of my wife’s
behavior at times.

I wonder if our SO’s don’t have much understanding of other people’s
pain because of the judgment factor. Perhaps they believe that
with “understanding” comes a level of judgment at least for
themselves. Or it could be that they believe no one actually
understands them, so the process of understanding others is pointless.

Related posts:

1. Toxic Shame
2. Understanding Emotional Agony Through David Foster Wallace’s Eyes

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October 21, 2008

Mind

When All Else Fails, Blaming the Patient Often Comes Next

By RICHARD A. FRIEDMAN, M.D

Doctors and psychotherapists generally don’t like it when their patients don’t get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That’s often when the trouble starts.

I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. “Even my therapist agreed with me,” he said. “She said that maybe I don’t want to get better.”

I could well imagine his therapist’s frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

“I think he has an unconscious desire to remain sick,” she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.

I decided to challenge him. “How come you’re feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?”

“Well, I guess I just think like that when I’m down.”

Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It’s easy to understand why the patient couldn’t see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient’s depressive symptoms and tell him, in effect, that he didn’t want to get better?

For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier — and less painful — to view the patient as intentionally or unconsciously resistant.

I recall an elderly woman who was referred by a colleague for intractable depression, in which I have a special interest. I was eager to help her.several months and many treatments later, I began to get frustrated that she was no better and noticed that my thinking about her shifted. I wondered whether there was something about the sick role that she found rewarding.

After all, she had constant visits from friends and family members, not to mention an army of medical experts who were all trying, in vain, to cure her. If she got better, she might lose all that care and attention.

Then one morning, shortly after starting a new combination of antidepressants, she called. I did not recognize the cheerful voice. “I’m feeling really good,” she told me. “Not depressed at all.”

My delight aside, I felt chagrined that I had begun to write her off as a help-rejecting crank.

Of course, it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve. But this is a double-edged sword.

Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.

“She’s pretty aggressive and demeaning, and we think she has some serious character pathology,” one of the residents told me.

But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her “personality disorder” melted away, along with her provocative behavior.

This patient had frustrated her clinicians with her lack of response to treatment. In turn, her doctors reacted by changing her diagnosis to a personality disorder. The change in thinking shifted the blame from the clinicians to the patient herself, who was now viewed more as bad than sick.

To be sure, some patients really do want to be sick. People with Munchausen syndrome, for example, deliberately produce physical or psychological symptoms for the express purpose of assuming the sick role. And they will go to extraordinary means to defeat doctors who try to “treat” them.

But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

Related posts:

1. Interesting Article from Time Magazine on BPD
2. Article in Time about the DSM
3. A new article about BPD in NY Times and the reaction

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A POSSIBLE NEW NAME FOR BORDERLINE PERSONALITY DISORDER

Many people would like to change the terminology of the “borderline personality disorder” to a new term that more accurately describes the illness. The term “BPD” in and of itself is as if the whole person (and the personality) is flawed, rather than looking at the BPD as a medical problem it actually is.

The term “borderline personality disorder” implies that there is no hope for treatment as many mental health professionals unfortunately still believe. There is thought that this illness borders on schizophrenia, thus the term “borderline.”

What then is borderline personality disorder? These questions have been posed to Dr. Leland Heller, expert in treating borderline personality disorder.

Q. What do you think about the term “borderline personality disorder”?

A. “I think it’s a horrible, insulting label for a real medical illness. The name alone reduces serious research, stigmatizes victims, and implies the person is crazy. It denies the medical nature of the process, and implies simply a personality problem.”

Q. Do you think “borderline personality disorder” is an accurate description?

A. “No I don’t. It implies a character problem. While I’ve encountered many people with a bad character who had the BPD, most borderlines I’ve treated (over 2100) do not have character problems. “Borderline” means patients live “at the border” between psychosis and reality. When borderlines are well treated medically, psychotic experiences are few and far between – and can be treated well. Borderlines don’t live at that border, they simply go into psychosis too easily under stress.”

Q. What is the BPD?

A. “The BPD is a medical problem, likely a form of epilepsy (brain cells firing inappropriately and out of control). The characteristic symptoms include inappropriate moodiness, chronic anger, emptiness, boredom, dysphoria (anxiety, rage, depression and despair) and psychosis. The other criteria are symptoms related to these medical problems.

ALL neurological disorders can have an effect on the personality, such as Parkinson’s disease which isn’t called the ‘shaking personality disorder.’ ”

Q. What does this term “Dyslimbia” mean?

“ ‘Dys’ means malfunction, and limbia meaning from the limbic system.

‘Dyslimbia’ is malfunction of the limbic system. While other neuropsychiatric disorders involve malfunction of the limbic system, the limbic system dysfunction is profound in the BPD. I chose Dyslimbia for my patients to take the stigma away. The BPD needs a new name, one that emphasizes healing not labeling.

I don’t care if it’s renamed ‘Dyslimbia’ or not, but a more honest, humane, and hopeful name needs to be made for this illness. Patients deserve to get medical attention for ‘Dyslimbia’ (or an equivalent name), rather than have doctors and therapists shun them because they are ‘borderlines.’”

I’d like to write more about the struggle for a new name… but one of the things to note is that most researchers in this area have recommended dropping the word “personality” from the name and reclassifying it Axis I. The most common and likely new name is “Emotional Regulation Disorder (ERD).”

More on this later.

UPDATE: Well, the DSM-V has been previewed and it appears that the term “Borderline Type” is being considered.

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

Related posts:

1. Four reasons bipolar disorder is accepted and borderline personality disorder is not
2. Emotions and Borderline Personality Disorder
3. Understanding Borderline Personality Disorder from WHYY

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UPDATE: see this link.

Today’s subject is the Myth of the High-Functioning Borderline. I have been scouring the research on BPD to find out if anyone in the research or therapeutic community uses this term or concept high-functioning versus low-functioning Borderline. I have yet to find any author in either the research community or therapeutic community reference this concept. It crops up in the support community (in “Stop Walking on Eggshells” and on both bpd411.org and bpdcentral.com). It also crops up in the “cross-over” community (see more later) but only in a sarcastic way. The idea of high vs. low-functioning BPD doesn’t seem to hold much weight in any other community than the support community.

What do I mean by referencing these “communities”? I think that there are basically three BPD/Non-BP “communities” out there: the research community, the support community and the therapeutic community.

The research community is comprised those scientists doing medical research (and psychological research) on BPD. They publish scholarly articles and research in medical and psychological journals. Some “supposed” psychological researchers publish in the less-well-known and scientifically suspect journals (see my article about “Demonic Possession and BPD” for an example of this type of researcher). For the most part, these researchers don’t try and “cure” BPD, they merely provide data to other professionals about the configuration of BPD, the biology of BPD and the “common” features of BPD. This group of people does not differentiate between high-functioning and low-functioning BPs. In fact I have found no reference to high- or low-functioning BPD at all in any of these research papers or reports.

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

The therapeutic community is those practitioners (mainly psychologists, psychiatrists, social workers, other “therapists” and consultants) that try and “cure” or remediate BPD in patients. Some (very few) also serve the families, friends, spouses, children, etc. (the Non-BPs). Their purpose in life is to help the BP overcome or to effectively manage their disorder. In this group of people, I have found no mention of high- or low-functioning BPs. The only “partial” mention is that of Dr. Paul Mason, who co-wrote “Stop Walking on Eggshells” with Randy Kreger. Several of these people within the therapeutic community have written popular books about BPD, including “Sometimes I Act Crazy,” “Lost in the Mirror,” “The Angry Heart,” and “I Hate You, Don’t Leave Me.” None of these books, as far as I can tell, refer to the idea of high-functioning vs. low-functioning BPD. Of course, Dr. Marsha Linehan and Dr. John Gunderson are prominent individuals within the therapeutic community. Their theories about BPD have a distinct influence on how therapy is conducted with people with BPD.

The final community is the support community. This community is comprised of ex-BPs, Non-BPs and others who provide advice about how to “deal with” BPD or with someone with BPD. This community includes myself, the authors of “Stop Walking on Eggshells,” the author of “Tears and Healing,” A. J. Mahari, the proprietors of bpd411.org and others. Only in this community have I seen any mention of high- vs. low-functioning BPD.

Some individual and organizations actually straddle the support/therapeutic (or even the research/therapeutic) community split. These include: myself (at least I hope so), TARA, A. J. Mahari and others. Some of these are more therapeutic (or at least psycho-educational) like TARA. I try and be both psycho-educational and to offer support resources to Non-BPs; yet, in doing so, also try and dispel the many, many myths about BPD (where possible).

The problem with assigning either high-functioning or low-functioning to a person with BPD is that the very nature of the disorder debunks these categories. BPD is chiefly an emotional disorder (with impulse control issues). Emotions are ever-changing, like waves that carry the mind along for the ride. Whether someone is high-functioning or low-functioning at any given time will be subject to their current emotional state. If a BP is emotionally dysregulated they will adapt to that (usually) painful state in whatever way that they have learned will assuage the pain. Some people with BPD will cut themselves, take drugs, avoid situations or behave in other ways that might be considered harmful to themselves or those around them. If a BP is not dysregulated, he/she has no need to behave in these ways. The core point is that BPD is about emotional instability and no person with BPD will be always high- or low-functioning. A person with BPD will swing – sometimes wildly – between several polar ways of feeling and behaving.

I suspect many “high-functioning” BPs do not have BPD at all. I have read many, many posts on Internet boards in which the “BP” in question clearly does not have the disorder. Many times, if you read carefully, you will find that these “high-functioning” BPs are diagnosed by their (usually) ex-wives, just because the “xBPh” (ex-husband with BPD) raged or was selfish during their relationship. BPD is more than raging – and as a Non just because you’re “walking on eggshells,” it doesn’t mean that your “BP” has the disorder at all. In fact, recently the list owner of WTO (the Welcome to Oz Internet list) asked the women Nons on the list if there husbands (or, more appropriately, ex-husbands) exhibited the symptoms of Narcissistic Personality Disorder (NPD). Every “Non-BP” that responded to that request confirmed that their “BP” met the criteria for NPD.

New! An eBook that can help you in your relationship with someone with Borderline Personality Disorder. Beyond Boundaries is the next step in the evolution of the Non-BPD/BPD relationship.

NPD (which IMO is more likely a disorder that appears to be “high-functioning ‘BPD’”) and BPD are distinctly different disorders. There may be a slight bit of overlap – deep, deep down within the psyche of the individual (and that is shame, most likely), but the basic configuration of the disorders are quite different. People with BPD do not like themselves, for whatever reason. People with NPD adore themselves, for whatever reason. That alone separates the two disorders. While people with BPD may exhibit “deserving” behavior (that they deserve love, riches or whatever), people with NPD believe that being “special” is their birthright and want to be surrounded by important or exclusive groups of people. The thing to note with BPD is that the “deserving” behavior is counter-balanced with “undeserving” behavior – polar opposite feelings and behavior that is the hallmark of BPD. So, it seems unlikely to me that “high-functioning” (or low-functioning) BPs can actually exist.

Let’s briefly look at the DSM-IV diagnostic criteria for BPD and NPD , and we can illustrate the differences. First, BPD:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called “splitting.”
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in (5).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

And now NPD:

1. has a grandiose sense of self-importance
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. believes that he or she is “special” and unique
4. requires excessive admiration
5. has a sense of entitlement
6. is interpersonally exploitative
7. lacks empathy
8. is often envious of others or believes others are envious of him or her
9. shows arrogant, haughty behaviors or attitudes

Clearly, these two conditions are different. Some interpersonal aspects may seem similar (#8 in BPD and #6 and #7 in NPD); however, the emotional aspect of BPD (#6) is not present in NPD. There seems to me to be a split between self-hatred and the instability of self (in BPD), and self-importance and self-love (in NPD). I’m not sure this a gulf that can be bridged sensibly between the two disorders.

Why does it matter? Well, IMO it matters a lot, because the “prescription” that is effective for BPD is not the same prescription that works with NPD (or other variants on the Narcissistic spectrum). NPD is not a chiefly an emotional disorder, and emotional tools that are so effective with BPD will not be effective with someone with NPD. Now, you might say, “My ‘BP’ is diagnosed and he/she is always thinking about his/herself.” That may be true, yet, IMO, this type of “thinking” about oneself is really experiencing overwhelming negative emotions. It is difficult for anyone to think about anyone else when they are in deep emotional pain. As I have said in the past, I have coined (with the help of others) the term IAAHF (it’s all about his/her feelings) to help represent this state to Non-BPs.

Which brings me to my final point: self-diagnosis. It is dangerous to diagnose your loved one with BPD (or any other mental disorder). Only a trained and knowledgeable (and yes, I know, there are too few of these) professional can diagnose a person with any disorder. Assuming on your own that your loved one has BPD can be troubling for the relationship (at best) and damaging to their (and your) mental health (at worst). After reading a self-help book, such as “Stopping Walking on Eggshells” (SWOE), one has to be careful to diagnose someone else with the disorder. Even my book, “When Hope is Not Enough” (WHINE), can be used to “diagnose” your loved one with BPD, but I’d like to dissuade you from doing so. Instead, I would suggest you use the tools in my book (or, for that matter, SWOE) and see if they work. If my tools do not work, I suspect either you haven’t practiced enough (it takes time, believe me, it took me 2 years) or your loved one does not have an emotional disorder. I personally tried what I learned in SWOE for months before I realized that those “tools” were not effective in my life – which is why I bothered to write a book in the first place.

If you are tempted to introduce yourself to a support group with the statement, “I am married to a high-functioning BP…,” I’d suggest you take a step back and see if your loved one has the other signs of an emotional disorder (which BPD is and NPD is not).

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1. The myth of Hoovering
2. Net BPD Myth Debunking from “Tides…”
3. How mentalization and attachment might explain “high-functioning” BPD

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While DID (a.k.a.. “multiple personality disorder”) is not uncommon, I have seen a few. They all also have the BPD. I view the DID as what happens when even psychosis no longer protects against crushing pain.

I find this quite interesting. He seems to be saying that when certain behaviors, including psychotic behavior and BPD-like disassociative  behaviors, are no longer effective to reduce crushing pain, DID can develop to protect the person from the pain. In other words, I read this as a “pain-control” spectrum issue with DID on the far end of the spectrum. I wouldn’t say that BPD is on the other end, because I think it’s probably closer to the DID end than substance abuse (in absence of BPD)  to manage pain.

Certain people have, for whatever reason, an inhibited ability to manage their pain and (I think it’s clear) more (emotional) pain than the “average” person. This pain IMO is a combination of a biological propensity to dysregulated emotions and an invalidating environment. I don’t think most Non-BPs intend to be invalidating, but I think most people are invalidating when faced with dysregulated emotional states. They (including parents, friends and partners) just have no idea what to do. The typical reaction is to tell the other person that they are “too emotional” or it’s “not that big a deal” or they should just “get over it.” All of these responses are invalidating to the emotional reaction of the other person. They don’t help a person learn to self-soothe and, ultimately, that is one of the goals of recovering from BPD.

Related posts:

1. Four reasons bipolar disorder is accepted and borderline personality disorder is not
2. Emotions and Borderline Personality Disorder
3. Could this be the first medication for Borderline Personality Disorder?

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Borderline Personality Disorder is called this because patients have many traits from different psychiatric disorders. They have very unstable moods, like bipolar disorder. They often have strange experiences, like people with schizophrenia. Their relationships with others are usually quite unstable. They often don’t have much of a sense of who they really are or where they are going. They often cut themselves. Most of the people with this problem are female. If you have ODD/CD and are female, you have approximately a 15% chance of getting this.

There is also info about Antisocial Personality Disorders. My question is: are these really separate disorders or does emotional dysregulation play a part in all of them? If someone is emotionally volatile it seems to me that they will act out in different ways depending on the emotion they feel most often – anger, sadness or guilt/shame. So, all these different “”disorders”" – ODD, CD, ADD, BPD, APD and others – are they really the same disorder (emotional dysregulation) exhibiting itself in different forms?http://www.klis.com/chandler/pamphlet/oddcd/oddcdpamphlet.htm

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1. A New Name for Borderline Personality Disorder (BPD)?
2. Experts Argue that BPD should be an Axis I disorder
3. People with Borderline Personality Disorder over diagnosed with Bipolar Disorder

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