A free eBook – 4X4 for Nons
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This is an excellent blog post with a letter included from an ex-addict suffering from BPD. I’ve written about opiod issues and borderline personality disorder before. The thing that struck me about this article was this line: “The opioid made me feel unlike I had ever felt– like I was “normal” in a way, and happy, which was unusual for me.” My wife has reported exactly the same thing. She doesn’t feel “normal” or “happy” (typically) without a small dose of opiates in her system. She reports that they make her feel “normal”. However, she doesn’t take them often, because she understands the danger of addiction.
Anyhow, here is the article:
Buprenorphine for BPD?
By J.T. Junig, MD, PhD
I would like to discuss a comment from a reader:
I have been a recovering addict for 12 years. I was addicted primarily to Lortabs (active ingredient is hydrocodone) and Ultram. I was never an extreme user but I was consistently trying to modulate my feelings and feel better. I also have been battling BPD (Borderline Personality Disorder) for a very long time which appears to be my primary issue. I have been married for 17 years and let’s just say our relationship is difficult due to my inability to be present and emotionally and psychologically sound.
As with most other addicts, I distinctly remember the first opioid I took, even though I don’t remember my first sexual experience. The opioid made me feel unlike I had ever felt– like I was “normal” in a way, and happy, which was unusual for me.
Since I quit using 12 years ago I have only had a few days, yes, days, where I have truly felt good, and that was after intense work with someone for hours and hours at a time to help me get through an intense emotional roller coaster ride. I will feel “normal and happy” for a few hours or maybe a day and then I feel the despair creeping back in. I cut my thumb the other day and the first thought that I had was, I wonder if this injury will be sufficient enough to allow me a Lortab? I just never feel right without an opioid in my system.
I have been researching drugs available to help me. I have tried many different antidepressants which were never helpful. I am wondering about a small dose of Suboxone (maybe 2 mg/day) which I have read may decrease some of the problems associated with BPD. I have been reading that persons with BPD have shown to have an opioid deficit and that 40% of those with BPD are addicts.
Over the last 12 years I have only taken a handful of narcotics (not at one time!) for legitimate pain. In fact, when I was using I really used a very small amount, like an average of 2-3 Ultram/day or 2 Lortab (5mg)/day. I was able to see how I could get my use out of control so when I found out that my brother was an addict I quit using. Continue reading Buprenorphine for BPD? →
On the BPD Cafe page on Face Book, the owner of the page posted a link to downloadable versions of various CBT worksheets, including some from REBT and DBT. These are really nice to have. There are a lot of them, so I joined the SugarSynch page that allows me to download them en masse. One note about that: if you do that, you’re going to have to “un-select” one of the documents, which appears to be stuck in “synching” mode. The document that is stuck is called PsychosisSelfHelp.pdf. Also, if you want ALL the documents, you have to scroll down to the bottom of the list to make them all load.
Anyway, I was reviewing a document about the general principles of CBT (called SelfHelpCourse.pdf), and it outlines an important point about events, thoughts and emotions. I have pointed out in several articles and in my book about the behavioral chain:
Event -> Thought -> Emotion -> Action Impulse -> Behavior
The document says this about the different reactions a person may have to an event:
For instance, if someone you know passes you in the street without acknowledging you, you can interpret it several ways. You might think they don’t want to know you because no-one likes you (which may lead you to feel depressed), your thought may be that you hope they don’t stop to talk to you, because you won’t know what to say and they’ll think you’re boring and stupid (anxiety), you may think they’re being deliberately snotty (leading to anger). A healthier response might be that they just didn’t see you.
 DBT iPhone App Are you in DBT? Do you want to know more about it? The creator of the new DBT iPhone application has graciously provided me with a coupon code for a free version of the app. If you’d like to receive this coupon code and want to download the app to your iPhone for free, please send me a direct message on twitter @bondobbs. I only have one, so I expect it to go fast.
UPDATE: You can also claim this code by commenting on this post and providing your email address (which is not shared). I will email you the code and instructions if you have problems redeeming it.
UPDATE 2: Code is gone! Sorry. However, if you’re still interested in the app go to www.diarycard.net
UPDATE 3: I got another code. The last one went fast. If you want it comment on this post.
UPDATE 4: Sorry the second code is gone. Yet, if you want the app for free, comment here. I will not post the comment, I’ll just ask for more codes and email them if I can get them. The codes are limited. Act fast!
UPDATE 5: OK, I’ve given away several codes. I have one more… the final one for me. If you want the final code, please comment on this thread. I will not post the comment, but will send you the code.
FINAL UPDATE: All codes are now gone. Thanks to Sammy for providing them to my readers!
Recently read an article in Psychiatric Times in which the author of the article argued that the new DSM-V “dimensional” approach to borderline personality disorder specifically and personalty disorders in general would be much too time-consuming to implement than the criteria of the ICD-10. Here are the ICD-10 criteria:
F60.3 Emotionally Unstable (Borderline) Personality Disorder
A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.
Impulsive type:
The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.
Includes:
- explosive and aggressive personality (disorder)
Excludes:
- dissocial personality disorder
Borderline type:
Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).
Includes:
- borderline personality (disorder)
This question often is the first question that my group is asked. Many family members of those with BPD believe that therapy is the answer. And for some with BPD therapy CAN be the answer. However, there are some complications when it comes to therapy and borderline personality disorder. They are:
- Sending someone to therapy is not like having your car repaired. It involves a lot of hard work on the part of the patient/client and on the part of their loved ones and supporters.
- Therapy as usual (referred to as TAU in the studies) can actually make BPD worse in some individuals. There are several BPD-specific therapies, such as DBT, Schema-focused therapy and Mentalization-based therapy.
- Therapy requires the buy-in of the patient/client. If he/she doesn’t want to admit he/she has a problem or doesn’t trust the therapist with his/her feelings, therapy will likely not have a lasting effect.
Unfortunately, you can’t force someone to go to therapy if she doesn’t want to go (except through a court order). What I suggest is that you use the tools I offer for a while. After you do that for some time, the borderline might begin to gather some self-awareness or to share her inner thoughts and feelings with you. It is likely that these thoughts and feelings will be filled with shame, self-hatred and worry. At that point, you can say something like, “Boy, it must feel awful to feel that way about yourself. What do you think you can do to feel better?” or “That’s so painful to feel that way. Maybe therapy can help?”
My wife has resisted going to DBT because it identifies her as a borderline and she “doesn’t want to be that person.” She also resists because DBT seems like a therapy of last resort to her and, if she fails at it, she feels that she will have to be committed to a mental institution. I occasionally do reinforce to her that there are people who are trained to help her feel better and encourage her to look into it. She is in therapy, but not in DBT. My daughter does see a DBT therapist. She decided to go because she was so angry all the time, and she felt terrible. She wanted to learn how to feel better. At some point, her emotional pain reached an intolerable level.
I have tried to model these skills in my life and, by doing so, shown my wife that I can more adequately cope with emotional situations, both personal and interpersonal. This modeling encourages my wife to consider DBT (or another emotional training program) to help her feel better. My suggestion is that you practice effective tools, master them and use your mastery over emotional situations as a beacon for your borderline’s healing.
Q: How do I get my borderline loved one in therapy? What’s the best kind of therapy? How long will it take to cure them?
A: Unless your borderline loved one is a minor or you have a court order, you can’t force anyone into therapy. Therapy must be a choice of the person that needs it. It will probably be much more effective if the person with BPD chooses to go to therapy. Yet, therapy is not like sending your car in for repairs. It’s not as if you send the person in to therapy, he/she gets a new part and comes out fixed. That’s not the way therapy works.
For BPD, the “gold standard” of therapy is Dialectic Behavior Therapy (DBT). It is an “evidence-based” treatment – meaning the therapy has been researched against “therapy as usual” (TAU) and been shown to be more effective than TAU. However, DBT is generally measured on reducing suicidal impulses and self-harm. DBT has been criticized for being most effective with the “lowest functioning” people with BPD. I personally like DBT in that it provides the borderline with essential skills that can make their lives more effective. DBT usually takes at least a year. It took my daughter two years to complete. For more on DBT from this blog, click here. It is also important to note that, in many circumstances, the family members can be more effective if they participate in the DBT treatment by learning the necessary skills to support the treatment.
Recently, a new treatment called Mentalization-Based Treatment (MBT) has come on to the scene – particularly in the UK. I only know of two places in the US that MBT is available. Mentalization-based therapy focusing on the skill of “mentalizing” and is an interactive therapy in which the moment-to-moment relationship between the client and the therapist helps encourage critical, integrative thinking. Mentalizing is a process and it requires participation of each person in a particular conversation. One must try to see the world through the other’s eyes and clearly express one’s own mental aspects including intent, desire, motivation, feelings and aspirations. For more on MBT on this blog, click here.
There are other therapies that can be effective with BPD including schema-focused therapy, STEPPS and transference-focused therapy.
Both DBT and MBT are quite expensive at this time.
Here is an article about medical mistakes costing people their lives. A brief quote from the article about BPD:
Six patients committed suicide while in hospital. A near-miss occurred when a patient with borderline personality disorder was placed in seclusion and had to be revived after trying to strangle himself. A nurse was delayed in reaching the patient due to difficulty finding a key to the seclusion room.
I don’t know why they’d put a suicidal person with BPD in seclusion. Wow.
Behavioral Research and Therapy Clinics (BRTC) on the University of Washington campus is accepting applications for a Dialectical Behavior Therapy (DBT) Family & Friends Skills Group. Here is some information from their webpage:
The BRTC is primarily a research clinic, offering treatment to members of the community as part of our clinical trials. We are not currently recruiting for any clinical trials, but we periodically have openings for new clients in our Treatment Development Clinic (TDC). Through TDC, clients receive Dialectical Behavior Therapy from doctoral students under the supervision of licensed psychologists.
TDC is currently accepting new clients in our FRIENDS AND FAMILY DBT Skills group. This group is designed for family members, friends, and caregivers of people with chronic mental and physical health problems like borderline personality disorder, bipolar disorder, and Alzheimer’s disease. For more information on this group, please call 206-543-3765.
I would urge all family members to consider attending this class (or a similar class). These DBT-FST (Dialectical Behavior Therapy Family Skills Training) are invaluable in understanding your family member with borderline personality disorder and creating a healing environment in the home.
In a recent article/review of Borderline Personality Disorder treatment options and management methodologies, the author quotes the Dr. John Gunderson in the New England Journal of Medicine May 26 issue:
“…BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics,” writes John G. Gunderson, MD, from the Psychosocial and Personality Research Program, McLean Hospital in Belmont, Massachusetts. “Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury. Such episodes result in an average hospital stay of 6.3 days per year and nearly 1 emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder.”
As you can see BPD has a major financial impact on the health care system, not to mention the distress for the patients and their families.
When reviewing the various treatment options, the author says this about mentalization therapy:
Mentalization-based therapy is a cognitive or psychodynamic therapy including individual as well as group therapy. While assuming a “not-knowing” stance, the therapist insists that the patient “mentalize,” or examine and label his or her own experiences and those of others. This emphasis on thinking before reacting may be a process central to all effective therapies.
That “not-knowing” stance is what I tell the nons that I know: Be a detective, not a judge.
I’ve had conversations with several BPD “experts” about borderline behavior. There seems to be an assumption that many people with BPD are “silent” or “high-functioning” and do not engage in dangerous and/or ineffective behavior often attributed to the “typical” borderline.
In my group recently, a non-BPD was questioning his own “sanity” (I put it in quotes because I don’t believe that people with BPD are insane) and speculating that he was the one with BPD. One of our longer-time posters replied:
If you’re not throwing full-blown temper tantrums, freaking out because EVERYONE is out to get you, threatening to hurt or kill yourself, running away from those who love you because you’re afraid they’re going to leave you first, complaining that NOBODY loves or respects you AND popping pills and guzzling alcohol all at the same time… then, I think, you can go ahead and disqualify yourself.
Based on the polls that I have conducted over the past few months, I believe that she is right on the money. Here are the poll results from the last few polls about borderline behavior:
 Borderline Behavior Poll Results As you can see by these polls results, more than 73% responded that their borderlines (or themselves if they have the disorder) indicated that they have engaged in self-injury, suicide attempts and/or substance abuse. While these polls are certainly not scientific and it’s pretty much impossible for me to understand the profile of a person that responded, they results are, for me, striking. If 7 out of 10 (or more) individuals engage in these “low functioning” or ineffective borderline behaviors at some point in their lives, what should that tell us?
I believe that it tells us that the “typical” profile of someone with BPD is the “low functioning” or “classic” borderline. While I am sure there are others out there that operate in pretend mode (and pretend everything is ok while they “white-knuckle” their way through life), the vast majority of people with BPD seem to be caught in a spiral of ineffective and often dangerous behavior. They seem to me to be sending the message that they are in a great deal of emotional pain and are suffering greatly – that they will do anything to stop the pain that they feel. It also indicates to me that it is vital for parents of child with borderline-like traits and feelings do their best to get the child into appropriate treatment before their teenage years.
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