Conduct Disorder Predicts Drug Use in Adults With ADHD (link)

April 17, 2012 @ 3:58 PM

Attention-deficit hyperactivity disorder (ADHD) has been linked to many negative outcomes. Usually first diagnosed in childhood, ADHD is characterized by impulsivity and inability to focus on tasks. Until recently, it was believed that ADHD did not widely persist into adulthood. However, new research has shown that many individuals still struggle with the symptoms of ADHD through their adult lives.

Read the rest of the article…

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Vital Signs: It is all about me, actually (link)

By CLAIRE HUTCHINSON AND TIMOTHY CAMPBELL

Let’s face it: We all get stressed sometimes, but why does stress seem to affect some people more than others? Would you say that:

» Others know what they are doing and you feel like you don’t?

» Others don’t seem to be bothered by life’s little “zings?”

» Others are moving toward something positive or away from something negative and you are stuck?

» Others have unconditional faith and you just feel lost?

» Others been able to desensitize themselves to repeated stressors and you always seem to get knocked over by them?

But let’s pose another question: Do you practice getting a daily balance of rest and exercise, ensure good nutrition and take time to take care of yourself?

These sound like great clues as to how others seem to manage so effortlessly. How can we gain the same advantage that others have and add these benefits to our lives?Let’s look at some of the practices used by individuals who are able to manage their stress levels. Many of these skills can be learned on your own; others may need the help of a professional.

Set daily goals for yourself and make sure to prioritize. Be realistic and make sure these are reasonable goals you can accomplish without adding additional stress to your day.

Make good choices. Think about the pros and cons before you make a decision. Don’t act impulsively; you have to pay for it in the end.

Take time every day for relaxation, guided imagery or meditation. Take the time for “me” — the most important person in your life.

Practice mindfulness, which is the art of living in the present moment without any judgment towards yourself. Mindfulness assists us in teaching our minds to stay focused in the present and reduce the “what ifs” that so often dominate our thoughts. Sound easy? Practice for a few minutes and gradually increase the length of time you can manage this technique. You will be amazed at how quickly stress can be managed using this skill.

Other successful stress reducers include Emotional Freedom Technique (EFT), also known as “emotional acupuncture,” which is used to balance the mind-body energy system reducing fears, anxieties, phobias and other emotional issues. This technique engages the actual tapping of acupressure points while repeating an affirmative statement to oneself.

Participate in a Dialectical Behavior Therapy (DBT) group, where one is taught the four effective stress-reducing skills of distress tolerance, mindfulness, emotion regulation and interpersonal effectiveness. You will learn to cope better. You will learn to recognize your feelings, but not become overwhelmed by them. You will discover effective ways to express yourself and have your feelings understood by others and how to set boundaries to ensure you don’t feel overwhelmed or taken advantage of by others.

Exercise on a daily basis to increase circulation and enhance mood. Being outdoors in the sunshine and fresh air is extremely beneficial to one’s well-being.

Spend quality time with friends and family.

Make sure to have a strong support system in place to assist you when times get rough. Develop a Wellness Recovery Action Plan (WRAP) to let your support system know what you need.

Participate in acudetox, a practice that allows individuals to achieve a balance of energy while reducing cravings for addictive substances or withdrawal symptoms.

Dialectic Behavioral Therapy, Acudetox, WRAP, individual and group therapy, crisis stabilization and emergency services are all available at Region Ten Community Services Board. There are a variety of other groups and programs offered throughout the Charlottesville community that can assist you with stress reduction.

Make sure to take care of yourself first, for there is only one of you.

Claire Hutchinson is a registered nurse and Timothy Campbell is a specialist with Wellness Recovery Center for Region Ten Community Services Board.

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Mentalization-based Treatment for Families (MBT-F) (Detailed)

Name of intervention:
Mentalization-based Treatment for Families (MBT-F)

Who is the programme for?:
Families experiencing relationship difficulties because of child emotional or behavioural difficulties.

Child outcome:
Improved child behaviour

Age:
Primary (5-11 yrs), Secondary (11-14 yrs), Teenage (12-18 yrs)

Classification:
Targeted

Parental needs:
Any parent

Workforce:
QCF level 4/5

Setting:
Clinic/Health centre

Format:
Individual

Contact name:
Michelle Sleed

Contact email:
Michelle.Sleed@annafreud.org

Contact place of work:
The Anna Freud Centre

Mentalization-based Treatment for Families (MBT-F) is for parents of children between the ages of seven and 16 experiencing difficulties in the parent/child relationship. Parents attend 10 to 12 fortnightly individual sessions where they learn how to understand their child’s mental states and support his or her emotional wellbeing.

MBT-F has preliminary evidence of improving children’s behaviour.

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One thing I have been saying a lot around here and in my Internet group is: “I don’t excuse behavior. I try to explain behavior.” This is where the notion that emotional dysregulation and “it’s all about his/her feelings” (IAAHF) with which the critics of my techniques have such a problem. The thing is: these critics don’t understand that when they pick up my book, those two things explain why someone with BPD would behave in the manner that they do. Emotional dysregulation is the hallmark of the disorder. Marsha Linehan has even tried to have the name of the disorder changed to something like “Emotional Regulation Disorder”. So, emotional dysregulation is not an excuse. It’s just the way these people are. They have poor emotional regulation skills. I think it’s better to know what you’re dealing with rather than to not accept it and try to fit reality into your view of how things are supposed to be.

As for IAAHF, many of my critics point to that and say “What about MY feelings!!!!” The intention of IAAHF has nothing to do with the overall relationship or about your emotional health and well-being. IAAHF helps explain the motivation behind the behavior. That is, the behavior is motivated by this person’s emotional responses to the world around them. I don’t recommend “walking on eggshells” to avoid triggers. What I recommend is that you get a clearer view of what is the cause of the behavior (the dysregulated emotions) and work on that. In my experience, if the emotions are not there, the behavior is not there.

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Psychiatry award recipient to present lecture on dialectical behavior therapy (link)

HOUSTON — (April 17, 2012) — Dr. Marsha M. Linehan, an expert in the treatment of suicidal behaviors, personality disorders – including eating disorders – and other complex mental disorders, has been selected as the recipient of the 2012 Joan and Stanford Alexander Award in Psychiatry.

The award was established in honor of Dr. Stuart Yudofsky, professor and chair of the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, who was also its first recipient.

Each year, the award honors a mental health professional who has made significant contributions in research, education and clinical or community service for people suffering from severe and persistent mental illness. The award consists of an annual prize and lecture of international scope. Previous winners have included psychiatrists Eric Kandel, winner of the Nobel Prize in Medicine, and Nora Volkow, director of the National Institute of Drug Abuse.

Linehan will receive the award and present grand rounds on Wednesday, April 25, at 10:30 a.m. in BCM’s Cullen Auditorium. Her lecture is titled “Dialectical Behavior Therapy: Where it started. Where it went. Where it may be now. Where we are going.”

Linehan is professor of psychology and director of the Behavioral Research and Therapy Clinics at the University of Washington. She developed dialectical behavior therapy – a treatment originally developed for treating suicidal behaviors that has expanded to treating borderline personality disorder and other severe and complex mental disorders. The treatment has been shown to be effective in reducing suicidal behavior and is cost-effective compared to both standard and community treatments delivered by expert therapists.

She has received several awards for her clinical and research contributions to the study and treatment of suicidal behaviors, including the Louis I. Dublin Award for Lifetime Achievement in the Field of Suicide and the Distinguished Research in Suicide Award from the American Foundation of Suicide Prevention. The American Association of Suicidology established the Marsha Linehan Award for Outstanding Research in the Treatment of Suicidal Behaviors in her honor.

Joan and Stanford Alexander are pioneer advocates for providing parity in the reimbursements for psychiatric care for the mentally ill and work to fight the effects of stigma on those who suffer from mental illness.

This marks the fourth year of the award.

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One Way to Identify Borderline Personality Disorder Is by Testing “Mentalization” Skills (link)

Borderline personality disorder probably shows up before adulthood, and now a new study has found a way to detect it in teenagers.

The conventional thinking is to diagnose personality disorders only in adults over age 18 years old, because the human personality is still forming in adolescence. However, Dr. Carla Sharp, an associate professor and director of the Developmental Psychopathology Lab at the University of Houston, believes there could be benefits to diagnosing the disorder she studies earlier.

Dr. Sharp’s specialty is borderline personality disorder, a serious condition characterized by turbulent emotional reactions, impulsive behaviors, anxiety, depression, suicidal ideation, and intense fears of abandonment. The disorder is more frequently found in women.

“We know that the brain is only fully developed by age 25, so how can we diagnose a personality disorder in someone if they don’t have a fully developed brain?” she said. “On the one hand, we are finding in our research that kids do have a stable pattern of interaction with others. Parents will describe their kids to you in terms that remain stable over time. Therefore, personality researchers have highlighted the point that teens do not wake up at age 19 and have a personality disorder on the first day of their 19th year, so there must be some precursors to the disorders. This group of people, including myself, are advocating that we do not necessarily diagnose borderline personality disorder in adolescents, but that we access for it to make sure that we don’t miss these children.”

Dr. Sharp and her colleagues worked with 111 teenagers ages 11 to 17 years old, who were being treated in a residential psychiatric facility and tested them for the way they “mentalize.” Mentalize is a technical term that means to act like an armchair psychiatrist in order to understand why others behave the way they do and to predict their future behaviors. Everyone mentalizes about other people based on their own experiences as human beings, but there is such a thing as normal mentalization as performed by healthy personalities. People with autism usually under-mentalize, which means they do not or cannot put a normal effort into understanding others’ feelings, motivations, and behaviors. People with borderline personality disorder, on the other hand, tend to over-mentalize or even hyper-mentalize, which means they think too much about others and are therefore more likely to misread other people. Since borderline personality disorder is characterized by an inability to regulate one’s own emotions, misreading other people can lead to a borderline’s “flying off the handle” and overreacting.

Dr. Sharp had the participants watch a movie about four different characters and then relate how they understood the characters’ thinking and feeling. About 23% of the participants met the criteria for borderline personality, and this group had a higher frequency of over-mentalizing their responses to questions about the movie. Hyper-mentalization was also linked to emotional regulation. When this group hyper-mentalized and then misread people, they became upset, had more problems with emotional regulation, and experienced an increase in their symptoms.

“This research is groundbreaking in that it is the first to provide empirical evidence of a link between borderline personality disorder and mentalizing in adolescents,” said Dr. Sharp. “By identifying and treating BPD early in adolescence, we can use validated treatments to help these children. The danger of not recognizing precursors in adolescents is that it can lead to years of confusion and pain for family members and the individual with misdiagnosis and lack of appropriate treatment.”

Borderline personality disorder, especially in young people, is often misdiagnosed as bipolar disorder, conduct disorder, or even as Asperger’s syndrome.

The study was published in the Journal of the American Academy of Child and Adolescent Psychiatry.

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Dr. Google and BPD

When Melodie Moore was recovering from a broken heart and wondering why her relationship had soured, Dr. Google had the answer: borderline personality disorder.

Internet advice is not meant to replace healthcare provider: doctor (link)
By: Alexandra Posadzki, The Canadian Press

15/03/2012 3:56 PM | Comments: 0

TORONTO – When Melodie Moore was recovering from a broken heart and wondering why her relationship had soured, Dr. Google had the answer: borderline personality disorder.

“I wanted to know what was wrong with me, that this boy didn’t want to be with me,” said the 22-year-old from Markham, Ont. Soon she had diagnosed herself with several ailments, including BPD and narcissistic personality disorder.

“I think I cried for a good hour,” said Moore. “I just felt really alone.”

Moore was reading about personality disorders in preparation for her psychology studies. She hopes to begin an undergraduate degree at Trent University this fall.

“We live in the information age, but information can be a catch-22,” said Moore. “It can be helpful, but the analytical side of us can also over-think things.”

Moore is experiencing what Oakville psychiatrist Dr. Kenny Handelman calls “medical school syndrome.” It’s what happens to first-year med student when they start studying various diseases. Suddenly a simple headache becomes a brain tumour, a rash morphs into flesh-eating disease.

But with the wealth of medical information now available to all of us at the click of a mouse, or at the swipe of a finger, it’s not just medical students and hypochondriacs who are likely to panic. More and more Canadians are going online to play doctor — and some of them are even replacing visits to the clinic with Google searches.

At sites like webmd.com, users can enter their symptoms and have the site generate a diagnosis for them.

Of course, having all this information at our fingertips is, generally speaking, a good thing. For one, it can help us detect problems sooner. For another, coming in to their doctor’s office well-informed can improve the quality of care that patients receive, said Handelman.

“They can be active participants in their healthcare,” said Handelman. “I think that’s ideal.”

But the Internet has also been known to incite panic, especially in people who are anxious about their health. This phenomenon has become so widespread that the term “cyberchondria” has been coined to describe it.

“People may find reports online that lead them to believe they have more significant medical issues than they actually do,” said Handelman, the author of “Attention Difference Disorder.”

According to Statistics Canada, the majority of Canadian Internet users — about 70 per cent — used the Net to look up medical information in 2009. That’s up from 59 per cent in 2007.

Judy Thompson, a family practitioner at St. Joseph’s Health Centre in Toronto, says it isn’t just the young, tech-savvy generation of Canadians who are going online to diagnose their problems.

“Believe it or not, the Internet is very much as big an issue for some of my 60- to 70-year-olds as it is for the younger generation,” said Thompson. “I even have some 80-year-olds that are on the Internet.”

The trouble, she adds, is that patients can be led astray by incorrect information.

“We’re not discouraging people from reading the Internet, but one of the things I try to do in my practice is try to point them towards helpful sites like fpnotebook.com or familydoctor.org,” said Thompson.

“The Internet is meant to supplement your health care. It’s not meant to replace your healthcare provider.”

Guy-Justin Lowe, a 25-year-old customer service representative in Toronto, started using Google and webmd.com to take control of his health care when he felt like the answers he was getting from his doctor were too vague.

“I wouldn’t say that I’m a hypochondriac, but I have used the Internet before seeing him sometimes just so that I get a general idea of what might be wrong with me,” said Lowe.

“There were some great questions I had for my doctor based on treatments and symptoms I had seen online regarding sleep issues.”

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Bon: I’ve never heard of this therapy….

Narrative exposure therapy can be used with BPD patients in a standard clinical setting (link)
Published on March 30, 2012 at 4:39 AM

An investigation published in the current issue of Psychotherapy and Psychosomatics introduces a new treatment for borderline personality disorder (BPD) that ensues after a traumatic stress.

The present study demonstrates that narrative exposure therapy (NET) can within weeks achieve a marked improvement in borderline patients with comorbid PTSD, even under the often less than ideal conditions in a psychiatric ward. NET can be used with borderline patients in a standard clinical setting (out- and inpatient).

Whereas BPD is already characterized by a high rate of psychiatric problems, current evaluations indicate that the frequency of comorbid posttraumatic stress disorder (PTSD) ranges between 33 and 61% among patients with BPD. When there is comorbid PTSD, BPD symptoms are potentially intensified by the related anxiety, hyperarousal and intrusions, triggering sudden, uncontrollable and incomprehensible attacks of tension and fear. This prompts a vicious circle of uncontrollable swings in tension and dysfunctional behavioral patterns (e.g. self-inflicted pain and injuries), which in turn makes it impossible to modify maladaptive core beliefs. The present approach sought to test the feasibility of narrative exposure therapy (NET), a trauma-focused therapy suitable for both in- and outpatient settings which can be taught to clinically experienced therapists in a short-term training program and implemented in a comprehensive treatment for BPD patients with comorbid PTSD. Within an open trial, 10 women with BPD and comorbid PTSD were treated at the Center of Integrative Psychiatry in Kiel using NET. NET is a standardized, controlled short-term intervention which is based on the core assumption that a maladaptive trauma related network of memory representations has resulted from multiple adverse and fearful experiences. NET is now considered to be a comparatively well-tested therapy approach for patients who have survived different types of trauma, ranging from domestic violence and emotional neglect to organized violence. It aims primarily at reducing PTSD symptoms by changing associative memory related to the traumatic experiences through recall of the event and exposure, assigning each event the respective time and place at which it had been experienced. This promotes a coherent autobiographical memory associated with the sensory, affective and cognitive cues of the event, and in addition has non dissociative effects. During the period between January 2009 and May 2010, 12 women presenting with BPD and comorbid PTSD were recruited from a clinic. Prior to treatment, a diagnosis was reached by conducting a standardized and structured clinical interview based on the Mini-International Neuropsychiatric Interview and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. After the initial diagnosis, the Posttraumatic Stress Diagnostic Scale (PDS) was applied as an interview. This instrument records PTSD symptoms in accordance with the DSM-IV. Depression symptoms were assessed by clinician ratings using the Hamilton Depression Rating Scale (HAM-D), as well as by means of the Hopkins Symptom Checklist 25 (HSCL- 25). The severity of BPD symptoms was evaluated by self- assessment with the aid of a short version of the Borderline Symptom List 23 (BSL-23), and dissociative symptoms were recorded by means of the Fragebogen zu dissoziativen Symptomen (FDS).

Overall, it was possible to carry out NET for all patients. On average, 14 NET sessions (range: 11-19 sessions) were necessary, taking into account that the number of sessions depends on the amount and severity of traumatic events. Based on Wilcoxon tests, there was a significant reduction in symptoms of PTSD (p<0.05) as assessed by the PDS, depression (p<0.05) as assessed using the HAM-D, and dissociation as assessed by the FDS (p<0.05). With respect to BPD symptoms, recorded using the BSL-23, the noted drop would become significant if an α level of 0.10 were used. So far, the present study has demonstrated the feasibility of NET, in that a team of clinicians (psychologists and psychiatrists) who has received a 2-day training in NET, as well as subsequent group supervision, can within weeks achieve a marked improvement in borderline patients with comorbid PTSD using NET as a treatment module, even under the often less than ideal conditions in a psychiatric ward. Thus, the findings of this study demonstrate that NET can be used with borderline patients in a standard clinical setting (out- and inpatient).

Source: Psychotherapy and Psychosomatics

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An article by Amy Dresner from AlterNet:

How 3 Days in The Psych Ward Saved My Life

I had three-and-a-half years sober when I tried to kill myself by overdosing on Phenobarbital. It was the 4th of July and I’d joke later that I was still so torn up by the split of America from England that I couldn’t take it anymore. But at the time there was nothing funny or patriotic about it.

I had tried to kill myself once before, when I was 34 and living in London, by slashing my wrists with a box cutter. It was terrifying: blood was pouring everywhere and I could see the muscles and tendons and flesh inside. In my experience, the British healthcare system—especially mental healthcare—leaves something to be desired: all they did was sew me shut, give me a tetanus shot and send me on my way.

But this time was different. I was in living in Los Angeles, and I’d been to a meeting that very day. I had called my sponsor. I had sponsees. I was performing regularly as a comic and getting good reviews. And yet I still felt that deep despair—I hated myself and worried that my husband hated me too. I had been insecure about the way I looked at 20; now that I was pushing 40, I could only imagine how my slow physical decline would impact my already fragile self-esteem. I was scared—really scared. I had my addiction under control (as under control as I could have it) but my borderline personality disorder, my body dysmorphic disorder and my depression were taking a toll. I was tired of fighting to feel “normal.” I wanted out, but I was scared to pick up drugs again. My drinking and using always landed me quickly in the ER or jail. I knew that wasn’t the answer, but what was?

Read the entire post

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Does Evidence-Based Medicine Discourage Richer Assessment of Psychopathology and Treatment? (link)

By Simon Sobo, MD | April 5, 2012

Dr Sobo practices psychiatry in Northwestern Connecticut. Many of his other articles can be found at his Web site, www.simonsobo.com.

The paradigm for modern psychiatry is evidence-based medicine (EBM)—it represents proven treatments for defined diagnoses. But there are major problems with this position, starting with the fact that while they are superior to placebo, evidence-based treatments too often are ineffective. Even with treatment compliance, many patients do not return to their premorbid selves. Their ailment may last for years. A given percentage is not helped at all. Typically, 30% to 50% of depressed patients will not respond, and among nonresponders only 23.5% to 28% are helped by a second medication.1-4 The relatively common failure of evidence-based treatments to achieve remission is not unique to depression. Similar results are found throughout the full spectrum of DSM-IV disorders, which frustrates both doctors and patients.

This is not surprising. The science of psychiatry is still young, its conclusions necessarily preliminary. Psychiatry has not found its penicillin, a drug that will succeed 99% of the time in eliminating strep throat, because it kills the germ causing the illness. DSM-IV diagnoses are operational definitions, the best attempt by committees of experts to group manifestations of psychopathology into “disorders.” This cataloguing is not the same thing as understanding cause and effect. We haven’t yet discovered the etiology of any DSM-IV diagnosis.

It cannot be assumed that doing a better job classifying psychopathology diagnostically is the best way to move forward. Established diagnostic entities are as much wish as reality. The convening of experts to create DSM-5 diagnoses will probably not help researchers find new discoveries. The authors of DSM-III, DSM-III-R, and DSM-IV had it right. They also made committee decisions, but they emphasized that their conclusions were tentative: “. . . there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder . . . [and] boundary cases will be difficult to diagnose in any but a probabilistic fashion.”5

Robert Spitzer, MD, former Chair of the DSM-III Work Group, has rightfully condemned the confidentiality agreements required of DSM-5 committee participants.6 He wants detailed minutes of DSM-5 Task Force deliberations, a no-brainer for those who understand the necessary tentativeness of scientific information, but problematic for those who want to provide an illusion of consensual certainty about diagnostic categories. “EBM” is being touted for its scientific prestige, precisely as the process has forsaken the true spirit of science. Considering how much we still don’t understand, our steps forward should be exploratory, investigative, and not closed off by the chilling effects of authority.

There are those who only respect the exactness of numbers and who believe only statistics can determine what is factual and what is not. This is a given for researchers, but it is not as relevant for clinicians who may need answers for their patients that cannot be organized into questions answered with numbers. Obviously, given the choice between what is understood and proven through scientific method and what is, in essence, opinion or formulation, science should command absolute loyalty. But that doesn’t mean that using a scientific format, or waving its banner, adds validity to those who speak as “scientists.” Its virtues can act as a smokescreen. The language, the prestige, and the trappings of science can be so distracting that science’s core value is overshadowed, absolute clarity about what is known and not known.
What do diagnoses represent?

There is also a more fundamental issue, not answerable to the vote of even the most “expert” committee. For instance, we can operationally define oppositional defiant disorder, binge eating disorder, or all sorts of problematic behaviors. We can classify and subdivide them and epidemiologically count numbers that can be assigned to subcategories—but for what purpose? Does every diagnosis in DSM-IV represent an actual “real” illness, in the sense that polio, cancer, or a strept throat actually exist? Or are we reifying ephemeral qualities? We all know of children who have been diagnosed with one condition after another when behavior does not conform with defined criteria. Parents hope for that moment—“Ah-hah, your child ‘really’ has ADHD [or bipolar disorder or an anxiety disorder]. Now that we know what it is, we can treat it.”
Unfortunately, the search for the “real” diagnosis in psychiatry is often unfruitful therapeutically. The results won’t be the same as when a medical clinician discovers, for instance, a thyroid tumor or diabetes that presented atypically. In that case, elucidating the hard-to-discern illness has a purpose. We are not discovering what is really wrong. Simply finding a label; then another label; and another. (It mostly resembles the kind of diagnostic and treatment chaos that accompanies illnesses such as chronic fatigue syndrome.) I cannot help but add that, too frequently in clinical practice, providing a diagnosis isn’t even driven by the wish to follow a consensus treatment plan (itself a polling of “expert” opinions rather than one that is scientifically based). There may be no doubt the patient has pathology, but the clinician needs to indicate something on the insurance form that justifies medical attention.

Most experts and the FDA (and perhaps insurance companies in the future) argue that EBM should monopolize clinical approaches. But at this stage, the proper question is not should we exclusively use treatments that have proven superior to placebo? It is what is the best way to formulate treatment strategies when now, and in the foreseeable future, science can’t offer answers that we need? Sensible approaches, based on what we know about a particular patient, not limited to statistically validated treatments, are often more fruitful. Out of necessity, reasonable conjectures may play a significant role. Given mediocre treatment results, we need all the help we can get, the art of psychiatry as well as the science.

The core issue: our approach to patients EBM eschews the anecdotal in the name of generalized conclusions, based on the odds that the patient’s ailments are typical for their group, patients who can be diagnosed with the same illness. This is not a ridiculous consideration, but it can miss important particulars brought by the patient. Knowing a patient well can be the difference between effective and ineffective treatment. It is not unusual for patients to have psychopathology that is central to their condition and treatment, but is ignored by a diagnostic approach that exclusively focuses on symptoms described by DSM-IV. Premorbid defenses, character style, the nature of the patients’ stressors, their story can guide clinicians to a particular treatment including medication. And, it can influence dosage.7 While EBM has a place, especially when low cost is a consideration, cookbook psychiatry cannot lay claim to being optimal treatment. It is especially detrimental if this perspective acts like blinders, obscuring relevant psychopathology more than it clarifies the clinical picture.

Van Praag8 in his “Nosological Tunnel Vision in Biological Psychiatry, A Plea for a Functional Psychopathology” argued that pharmacological agents can be viewed as inducing particular psychological states that, although not specifically related to diagnosis, are nonetheless the basis for their usefulness. I would like to suggest a perspective about how SSRIs affect individuals, and why they are so clinically useful for so many psychiatric conditions. SSRIs can be effective in conditions as disparate as borderline character, depression, obsessive compulsive disorder, anorexia nervosa, panic disorder, social phobias, and so forth because increasing serotonin has a psychological affect that is nonspecific to the disorders in question. Alcohol(Drug information on alcohol) will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis. Analogously, SSRIs typically affect individuals in ways that are not specific to diagnosis. What is that effect?

The most frequent description that I have heard from my patients is “Don’t sweat the small stuff,” or “What’s the big deal?” It is this calm that I believe is a unique blessing of SSRIs. It means relief from worry, relief from the feeling that something is missing, something needs to be done, something needs to be fixed, “my makeup isn’t right,” “the sky is falling,” “I won’t be able to pay my bills,” “I’m not smart enough,” “I won’t be able to tolerate the loneliness if I leave my lover” (even if he/she is abusive).

SSRIs supply, if not always happiness, a nice contented feeling that all is well and will be well. They can allow parents to be able to play with their children more, fret less over the details, appreciate what is, actually want to do the proverbial modern mantra, stop and smell the roses.
According to this theory it is the “well, whatever” feeling, emotional blunting, that is so useful in the great variety of different syndromes. Thus, for a person with anorexia nervosa to react with “well, whatever” after they have gained a pound or two is to get at the heart of the problem. The same can be said for body dysmorphic disorder, a condition in which a person’s life is completely distorted by imagined or slight body defects (such as thinning hair, a big nose, and the like). In obsessive-compulsive disorder the ability to treat compulsions and obsessional thoughts in this manner is a godsend. Similarly, a depressed person’s preoccupation with the hopelessness of their situation, the gravity of their errors and defects, the inadequacy of their decisions, and so forth will be enormously relieved to regain a less negative perspective.

In panic disorder, a condition characterized by exquisite sensitivity to body sensations, and a catastrophizing of consequences, SSRIs have been found to be effective because the sense of catastrophe leaves. For similar reasons social phobias and bridge phobias and flying phobias often become manageable on SSRIs, as do intermittent explosive disorder which may improve because it is harder to press the patient’s button. Alcoholism, pathological gambling, overeating, and the like may respond if a sense of frustration has significantly contributed to the pathological behavior. (They may worsen these conditions if a heroic disciplined battle is being waged against temptation, which is then weakened by a “well whatever” letting down of the guard.) SSRIs can help perfectionists (“obsessive compulsive personalities”) give themselves a little slack. They can allow borderline personality disorder patients to cool their heels, to not be tortured, like a wounded lover, when the person, upon whom they have passionately centered their survival, is not reciprocally involved with them. And so we can apply this perspective about SSRIs down a long list of DSM-IV defined disorders that have been empirically found to be treatable by a change in brain chemistry.

This perspective also suggests itself as useful in psychological circumstances where a specific DSM-IV diagnosis is not at issue. Thus, for instance, a not uncommon treatment scenario is teenagers who are having a very rough go of it with their classmates, kids who are picked on precisely because of their vulnerability. The popular students are the ones who are cool; that is, they don’t blush easily, are bold with the opposite sex, and so forth. It is not unusual for adolescents to come to therapy because they feel like misfits and to put it bluntly, the use of SSRIs may be very helpful here to magically assist them in having a thicker skin, which is exactly the quality they needed all along to not get picked on and possibly even have the cool to be popular.
Let me describe an unusual use of meds. A patient with PTSD for over 10 years presented on high doses of Adderall that had been given to him for what his family physician diagnosed as adult ADHD. (He had reported difficulty concentrating.) His physician then became uncomfortable administering stimulants and sent him to me. He didn’t have ADHD. But he reported that on the Adderall his PTSD was the best it had been in over a decade. The explanation appeared to be found in his history. He and his fiancé had been trainees at a state police academy. His fiancé committed suicide, blowing her brains out. My patient found her. He couldn’t clear his mind of the scene. During the day, during his dreams, it remained vivid. Even with SSRIs and benzodiazepines, his PTSD not infrequently took control of his mind. This no longer happened with the addition of Adderall.

My guess was that the Adderall brought back his premorbid, state policeman defensive structure. Instead of experiencing his trauma again and again as a helpless passive victim, the essence of the psychological position occupied by those suffering from PTSD, on the Adderall he had returned to being a take-charge kind of guy. Coincidentally I was also seeing another patient with PTSD. She was a drug rep who had been a workout nut. She spoke in short staccato sentences. Boom boom, bam bam, not a trace of sentimentality in her, not a soft syllable in her repertoire. She had been in a car accident and broken her collarbone, right arm, and one of her legs. She couldn’t work out. She kept re-experiencing her helplessness in the accident. She was on SSRIs which were helpful but not curative. The addition of Adderall worked like a charm.

This is not an endorsement of Adderall for PTSD. It is an endorsement, when formulating a treatment, to think about a patient’s defenses, personality structure, and the like, and how their symptoms may be helped by the psychological consequences of a medication. Diagnosis per se may not be critical in this process. Let me add another example.

A patient presented to me on Wellbutrin for his panic disorder. It is one of the few antidepressants that is not recommended for this condition—it may give an edginess that sets off further attacks. So I took him off it. He got worse. It turned out that he was a procrastinator and his panic attacks were precipitated when something was about to hit the fan, when the passive aggressive mess he invariably made, was on the verge of being discovered.
As a dopaminergic agent, the Wellbutrin was a motivator, an energizer. It helped the patient get things done. I have since discovered that while dopaminergic agents can make anxiety worse, they can have the opposite effect when a patient’s anxiety is specifically driven by the pressure of undone work hanging over their heads. The drug energizes them, helps them to initiate and complete their chores. Thus, with certain generalized anxiety disorder patients, it is an effective treatment.

For what it is worth, let me also mention a seemingly bizarre clinical vignette. I saw a patient with severe obsessive-compulsive disorder (supposedly a serotonin-based illness) whose symptoms completely disappeared when he joined the Jehovah’s Witnesses. He gained a sense of innocence, of safety, of the world and his personal experience making sense, of being directed by a benign and helping force in the universe, a parent watching over him and loving him. He felt it deeply. And that did it. No symptoms. Three months later, when disillusionment began, the symptoms came marching back, some of them as religious compulsive rituals. But still, what is the clinical meaning of his initial cure?

There is one other perspective worth noting for the purpose of illustrating what DSM-IV represents. Let us consider congestive heart failure as a model. It can be described in terms of observable symptoms that respond to specific treatments—evidence-based treatments. But congestive heart failure has many different causes. For argument’s sake, let us say our knowledge base remained at the turn of the 20th century and hypothyroidism was causing the heart failure of a given patient. Thyroid extract would fail miserably when tested in a larger population of patients whose disorder had been defined as congestive heart failure. It might worsen, in particular, the illness of those patients whose congestive heart failure was, for instance, caused, or exacerbated, by atrial fibrillation as a result of hyperthyroidism.

From the perspective of the heart failure diagnosis, the few patients it might help may be described in individual case studies, but would probably be rightly dismissed as anecdotal, if proponents argued that it should be used as a general treatment for congestive heart failure. The fact remains that it is precisely the correct treatment for congestive heart failure as a result of hypothyroidism. My point is obvious. As reasonable as evidence-based treatment protocols for symptom-defined disorders might seem to be in psychiatry, they are, in fact, pathetic compared with what will be possible when a true understanding of etiology can be used to provide rational care.

There are many other examples of treatments that are not evidence based. Clinicians may confirm or not confirm the strategies I have illustrated here. The important issue, however, is the legitimacy of approaching patients in the ways I have described. The journals should be full of similar clinical vignettes and unique perspectives from other authors. The exclusive respectability of scientific psychiatry, based on diagnosis alone, should be ended, until, at least, that perspective has provided us with what only science can provide, proven cause and effect. I don’t believe it is going to come from diagnostic psychiatry and evidence-based treatments, but time will tell.

Collaboration is key
In the meantime, we need to end the tyranny of the paradigm that EBM and diagnostic psychiatry has had on the medical literature and legitimize the many good ideas we can share with each other. It means editors and readers will have to use their judgment about the quality of the presented ideas, rather than exclusively rely on statistical validation. (It might also mean that the FDA allow pharmaceutical salesmen to refer to these articles rather than consider it a crime.) Presumably some of the ideas will work. This beats committees and doctrines and all the certainties of approaches that aren’t getting the job done.

Clinicians need all the help they can get. They can begin by getting to know the particulars of their patients better. Residency training programs might also help this process by teaching greater psychotherapy skills rather than only giving it lip service.

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They enjoy caring for and empathizing with others and they cherish being passionate about what is important to them. Helping others feel at ease and being able to” read” people is positive for them. They have an understanding of others’ emotions that can be helpful.

At the same time, intense emotions get in the way of relationships. Many (51%) have stopped being friends with more than five people because they hurt you. Many of you (52.6%) also hide your feelings from others most of the time. You find the emotions of others burdensome at times, perhaps because so many of you ( 78.8%)  have been complimented on your compassion for others and see yourselves as being loyal to the point it is not in your best interests.

Most of you (79.3%) can sense others feelings even when they don’t say or show how they are feeling. Several of you mentioned how difficult it was to not experience the emotions of others and 57% of you cannot watch the news without getting upset. Most of you are introverts or someone who reenergizes by being alone (72%).

Emotionally sensitive people don’t like feeling like their mood is at the mercy of people around them. Other people have far too much influence on their mood , so ESPs hold back on what they say. They also tend to overanalyze people’s words and behaviors out of fear of being hurt. At times they feel paranoid, focused on what they believe others think of them. Many are afraid of their emotions (53.7%). Anger is the most difficult emotion for the emotionally sensitive to manage.

Many of you have found therapy helpful (88%) and the most common issue was depression (71.2%). Exercise helps calm emotions for a large percentage (71.4%).

Read the entire entry.

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Dialectical Behavior Therapy vs. Mentalization-Based Therapy: What are the Differences? (link)
Feb 07, 2012

Dialectical Behavior Therapy (DBT) and Mentalization-Based Therapy (MBT) are two therapies often used in Borderline Personality Disorder (BPD) treatment. Both strive to help those who are severely disordered and highly emotionally dysregulated to manage their emotions. But what is the difference between the two?

Dialectical Behavior Therapy (DBT)

Marsha Linehan’s initial goal in developing Dialectical Behavior Therapy was to address the needs of suicidal women, but she discovered she was working almost exclusively with clients who had Borderline Personality Disorder. DBT treats BPD based on the understanding that it is caused by a combination of biological and environmental influences.

DBT provides the tools needed to reduce the intensity of your emotions and impulsivity in your daily life so you can improve your relationships and make good decisions for yourself. DBT was extensively tested and established as an effective treatment in the 1980s, and has continued to evolve.

Here is some more information about Dialectical Behavior Therapy:

- DBT focuses on teaching skills to tolerate distress, stabilize emotions, be more mindful, and maintain healthier relationships. These DBT skills are reinforced in individual therapy and DBT skills classes.

- While in DBT treatment, you will track your emotions, impulses, urges, and any substance use (including alcohol, drugs, and caffeine) on a daily basis.

- Phone coaching with a DBT therapist provided between sessions and DBT skills groups can help you use skills to get through difficult moments.

- DBT therapists work in a team to keep them supported so they can effectively help clients and receive support themselves.

- DBT has undergone several research studies during the past 20 years and continues to be found very effective in each.

Mentalization-Based Therapy (MBT)

Peter Fonagy expanded upon research in the field of mentalization and applied it to treatment of Borderline Personality Disorder. Mentalization helps you with the capacity to form personal attachments, which when lacking cause emotional instability and difficulty relating to others. If you did not form proper attachments in early development due to sexual, physical, or emotional abuse, you may have difficulty with self-awareness and interpreting others’ emotions and intentions.

Mentalization-Based Therapy (MBT) provides a way to increase your capacity to make personal attachments and therefore reduce the emotional intensity you experience. Initial research has proved that mentalization is effective for BPD treatment as compared to the usual treatments in the field.

Here is some more information about Mentalization-Based Therapy:

- MBT focuses on understanding your mental state, such as emotions, feelings, and thoughts and that of others so you can manage your emotions and improve your relationships.

- Work in sessions helps you understand the steps that trigger any episodes of extreme emotions and behaviors that occurred during the week.

- You and your therapist decide each session what you will work on until your next meeting.

- Initial research shows significant reduction in suicide attempts and suicidal ideation, hospitalization due to suicidal or feelings of/intent to self-harm, and trips to the emergency room.

If you are looking into BPD treatment using either Dialectical Behavior Therapy or Mentalization-Based Therapy, be sure to research both to determine which would work best for you given your diagnosis and preferences.

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Mentally ill people in Hampshire ‘locked up in cells’ (link)
7 March 2012 Last updated at 16:08 ET

Hundreds of mentally ill people in Hampshire are being locked up in police cells rather than being taken to NHS facilities, the BBC has found.

More than 1,000 people were detained under the Mental Health Act in the past year with 640 taken to cells.

People in custody should be assessed within two hours but in Hampshire the average is more than 17 hours.

Hampshire police said it was making progress to cut waiting times but admitted more needed to be done.

Frances Ayling, who suffers from borderline personality disorder, has tried to take her own life four times in the past year and each time has been arrested and taken to a cell.
She said: “It is literally a metal door, you’ve got a bed and a metal toilet, that is all you’ve got.

“You’re left there looking at four walls basically, you’re stripped of everything you’ve got on you.

‘Really difficult’

“It’s quite noisy as you have other people who have been arrested for crime shouting at the police to let them go.”

People detained under the Mental Health Act need to be taken somewhere secure for their own safety and the safety of the public.

Guidance from the Royal College of Psychiatrists and other professional bodies says custody suites should only be used to house people with mental illness in exceptional circumstances.

Ch Insp Paul Bartolomeo, from Hampshire police, said progress was being made but there are issues.

He added: “The mental health assessment has to be completed by approved mental health professionals… and medical professionals.

“Sometimes it is getting those two people together to complete the assessment, particularly out-of-hours, which makes it really difficult.”

There are currently seven health facilities in Hampshire where police can take people, but many only have one bed to take someone who has been detained under the Mental Health Act.
Southern Health NHS Foundation Trust said it was working hard to improve the situation.
Dr Paul Warren, clinical service director, said: “One of the things that we have been doing is a lot of training both of beat officers and custody suite officers so they make better decisions about where somebody should be brought.

“There are circumstances when we can’t accommodate somebody and that might be because there is already somebody waiting to be assessed.

“But it is very unusual that we would have to turn somebody away.”

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When Hope is Not Enough

Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change

I Don't Have to Make Everything All Better

The Power of Validation: Arming Your Child Against Bullying, Peer Pressure, Addiction, Self-Harm, and Out-of-Control Emotions

Parenting a Child Who Has Intense Emotions: Dialectical Behavior Therapy Skills to Help Your Child Regulate Emotional Outbursts and Aggressive Behaviors

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Mindfulness

Mindfulness, which features focused awareness training, is increasing in popularity among mental health professionals. Mindfulness training em­phasizes focused attention to internal and external experiences in the pres­ent moment of time, without judgment. While mindfulness interventions have been used in treatments for stress, chronic pain, anxiety, depression, borderline personality disorder, eating disorders, and addiction, researchers suggest that this type of training also can be beneficial in everyday life.

Most research and writing on mindfulness training has been about adults. In this paper, the authors argue for adapting mindfulness techniques for work with children. The authors propose that training in mindfulness has the potential to enhance children’s attention and focus, and improve memory, self-acceptance, self-management skills, and self-understanding. Specific exercises to teach children to be mindful are presented in progression, be­ginning with awareness of the external environment, then awareness of the self in the environment, awareness of the body, and finally, mindfulness meditation exercises that feature attending to cognitive processes. Suggestions are made for incorporating mindfulness into school curricula.

- from “Teaching Mindfulness to Children” by Iris E. Fodod, Ph.D. & Karen E. Hooker, Psy.D.

Read the entire research paper (PDF)

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A broken therapist’s guide to happiness (link)

By Katie Bartel – Chilliwack Progress
Published: March 28, 2012 9:00 AM
Updated: March 28, 2012 9:53 AM

Get used to failure – that’s one of the main themes coming out of Mark Vegh’s self-published memoir: A Broken Therapist’s Guide to Completeness.

While Vegh is a registered clinical counsellor, working as a child and youth mental health therapist, he doesn’t profess to be perfect, or lecture his readers on what they’re doing wrong. But he does describe his own failed experiences with the intent of helping others overcome conflict a lot better than he used to.

“Everyone has problems big and small,” he said. “Us humans want to be resilient and push ourselves through. We do a lot of weird things to get through our problems that often leave us delusional, tainted, fragmented.”

Of which A Broken Therapist’s Guide to Completeness outlines.

Vegh is hosting a book launch on Saturday, March 31 at VQA Wines in Sardis from 2 p.m. to 4 p.m.

This isn’t your typical, know-it-all, Dr. Phil like self-help book. While Vegh has extensive experience in counseling and has a bachelor of arts degree in pastoral theology, a masters in family counseling, and specializes in dialectical behaviour therapy, which is the advice he presents throughout the book, he’s taken a more humble approach.

Vegh is the first to admit he’s failed – a lot.

“I explain my own follies in the book,” he said. “Probably my biggest being twice divorced by the time I turned 27; both marriages combined totaling 11 months. I was a walking, talking paradox carrying a boat load of shame.”

Rather than confront his emotions, he put up defenses. When a friend disapproved of his divorces and told him he’d pray for him, Vegh sat at the table smiling and nodding, but in his head, he silently cursed out his friend, and couldn’t get away from him fast enough.

“My defense was I’m going to show you a smiling face, but walk away completely pissed off and maybe not talk to you again,” he said.

Had Vegh used dialectics, he believes the outcome would have been better.

Dialectical behavior therapy is a tool that uses resolution of disagreement through rational discussion and counter discussion. Rather than bottle emotions up, it’s more effective to listen and communicate, said Vegh.

“You don’t have to like or agree with the person, but you also don’t have to resent them,” he said. “You can fully listen, and sincerely try to understand their points of view, but at the same time, your identity doesn’t have to fall apart.”

Vegh never imagined himself a writer. But a year and a half ago, he started writing a letter to his three children in the hopes of leaving them something they could fall back on long after he was gone. Ten pages in, he realized the letter was something more.

“I heard a long time ago that you don’t get over yourself until you’re really old, but I wanted to do that a lot sooner,” Vegh said. “No matter what age you are, don’t wait until you’re really old to get over your hurt and bitterness. You can do that quite quickly, I think, with the way you handle your experiences.”

Vegh hopes to evolve this book into a series of books using the Broken Therapist theme.

A Broken Therapist’s Guide to Completeness can be purchased at the book launch, as well as online at www.xlibris.com for $19.99.

For more information, visit the website www.abrokentherapist.com.

kbartel@theprogress.com

See larger image A Broken Therapist's Guide to Completeness (Hardcover) By (author) Mark Vegh List Price: $29.99 USD New From: $29.98 In Stock

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Brief reactive psychosis blamed for Kony 2012 director’s outburst: What is it? (link)

By Ryan Jaslow

(CBS/AP) The family of Kony 2012 director Jason Russell says “brief reactive psychosis” caused the 33-year-old’s bizarre naked outburst that led to his arrest in San Diego last week. Russell’s wife says the director of the viral documentary on Ugandan warlord Joseph Kony got the condition as a result of stress from his sudden rise to fame.

“Doctors say this is a common experience given the great mental, emotional and physical shock his body has gone through in these last two weeks,” Danica Russell said in a statement. “Even for us, it’s hard to understand the sudden transition from relative anonymity to worldwide attention – both raves and ridicules, in a matter of days.”

What exactly is brief reactive psychosis?

Dr. Bryan Bruno, acting chairman of the department of psychiatry at Lenox Hill Hospital in New York City, tells HealthPop that the disorder is characterized by a period of psychosis that lasts at least one day and up to month that’s usually abrupt or sudden.

“By psychosis, we mean impaired reality,” Bruno said. “People have some sort of delusion or false thinking, hallucinations, severe disorganized behavior – very bizarre behavior.” Bruno is not involved in Russell’s care.

According to the National Institutes of Health, other symptoms include strange speech or language, and the symptoms are not caused by alcohol or drug abuse. Russell’s family said in the statement that the filmmaker’s behavior was not due to drugs or alcohol.

The condition can be triggered by a major trauma like a severe accident or death of a loved one. Bruno says brief reactive psychosis is “very uncommon,” usually striking people in their late 20s or early 30s, but it can happen to anyone at any age. Some research suggests people with certain personality disorders, such as paranoid personality disorder or borderline personality disorder are more vulnerable, he said.

The condition may not always manifest itself in a public outburst and could be something more subtle like a person driven by paranoia throwing out everything they own, Bruno said.

How is it treated?

Symptoms may taper off on their own after a short period of time. “In general people have good recoveries,” said Dr. Stephen Marder, professor of psychiatry at the University of California, Los Angeles.

Bruno said antipsychotic medications can be prescribed if symptoms persist for days. If the patient’s symptoms don’t go away after a month, it could be indicative of a serious condition like schizophrenia or depression with psychotic features, he said.

Russell narrates the 30-minute video “Kony 2012,” which has been viewed more than 84 million times on YouTube since it was released this month. His organization, Invisible Children, has been criticized for not spending enough directly on the people it intends to help and for oversimplifying the 26-year-old conflict involving the LRA and its leader, Kony, a bush fighter wanted by the International Criminal Court for crimes against humanity.

Russell is expected to remain in the hospital for weeks, his wife said.

“Jason will get better. He has a long way to go, but we are confident that he will make a full recovery,” she said.

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- Excerpt from Washington Times article. Read the entire article.

See larger image Mary Todd Lincoln: A Biography (Paperback) By (author) Jean Harvey Baker List Price: $18.95 USD New From: $10.10 In Stock Used from: $3.95 In Stock

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Anxiety sensitivity and borderline personality disorder: a newfound sympathy? (link)

Anxiety sensitivity, or the fear of becoming anxious, has been indicated as a factor in the occurrence of panic attacks for a long time. It is believed that many panic attacks are caused or intensified by the fear of anxiety, a self-perpetuating cycle that can eventually leave the sufferer house-bound in an effort to control their environment. New research indicates that anxiety sensitivity may also be indicated as a factor in the development of borderline personality disorder, or BPD. If this is the case, there may be new hope for treating this severe and destructive personality disorder.

Borderline personality disorder is mostly misunderstood by the general public. It can be hard to have sympathy for those who suffer with this disorder, which causes impulsive, aggressive, or needy behavior, often vacillating between rage and helplessness. Two of the main markers of BPD are splitting and a tenuous self-image. Splitting is seeing people as either all good or all bad. There can be no in-between. If someone does what the BPD person likes, they are idealized; if they make a mistake, they must be completely evil. Those with borderline personality disorder also suffer from an unstable self-image and lack a steady sense of who they are.

A recent study showed that anxiety sensitivity might have something to do with the unstable behavior of someone with BPD. While their behavior may appear destructive to outside observers, splitting and a tenuous sense of self along with all the byproduct behaviors produced by these two markers may simply be the way that someone with borderline personality disorder keeps anxiety at bay.

Outpatients who suffered with borderline personality disorder were compared with those who did not suffer from any personality disorder. They were measured for anxiety sensitivity as well as experiential avoidance, or attempts to avoid unwanted internal experiences such as anxiety. What they found was that there was a noticeably higher incidence of anxiety sensitivity and experiential avoidance in patients suffering with borderline personality disorder.

What does this mean? It could mean that borderline personality disorder is developed partially in response to anxiety sensitivity. Because the borderline fears certain situations and outcomes, they avoid anxiety-provoking possibilities through splitting and lack of a concrete self-image. How would this work?

Splitting allows the borderline to avoid facing the unpredictable nature of other people. Facing the fact that no one is all good or all bad brings up fears that the borderline will not be able to protect him or herself from other people, so blanket generalizations make it much easier for them to know how to handle interpersonal relationships. Someone does something “wrong?” Simply cut them off. The person with borderline personality disorder wreaks havoc in their relationships because of splitting, but they fear life without it.

A tenuous self-image allows the borderline to become a chameleon, behaving however they believe they have to in order to earn the love of others and keep an overwhelming fear of abandonment away. Again, they have anxiety sensitivity about the negative feelings abandonment or rejection would bring up, so they use a lack of stable self-image to lessen feelings of anxiety sensitivity.

While the behavior of a person with BPD is ultimately more harmful than helpful, they begin using these behaviors and beliefs as self-protection. In recent years, dialectical behavioral therapy, or DBT, has shown great promise for treating this disorder—once thought untreatable. Still, further research into the link between anxiety sensitivity and BPD may uncover even more treatment options and offer hope to a group of people who’ve struggled for so long with misunderstanding and pain.

© Copyright 2007 Insight Journal Online Magazine.

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Brené Brown studies vulnerability, courage, authenticity, and shame.

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Marshall thanks therapist (link)

Linehan, in turn, credits Bears receiver for being to diligent about treatment

By David Haugh, Chicago Tribune reporter

March 18, 2012

In his first public appearance since being traded to the Bears, Brandon Marshall naturally thanked the McCaskeys, coach Lovie Smith, former Dolphins coach Tony Sparano, former Dolphins teammates, his agent, his attorney, his wife and Marsha Linehan.

Marsha Linehan?

“She’s one of the pioneers for the therapies for borderline personality disorder (BPD) known as dialectical behavior therapy (DBT) that allows individuals to understand their emotions to control themselves as far as regulating them,” Marshall said.

Without the treatment Linehan developed and Marshall underwent last summer after being diagnosed with BPD at McLean Hospital outside Boston, he doubts he could face the future optimistically. Informed of Marshall’s gratitude Friday night, Linehan returned the thanks.

“I very much admire him for what he’s doing and wish him well,” said Linehan, a therapist and researcher at the University of Washington who also has been diagnosed with BPD. “Brandon is such a good role model. It is powerful and wonderful he’s doing it. The most important thing he’s standing up and telling people, ‘I can change, so can you.’ ”

Linehan, 68, explained what she called “the gold standard of treatment.”

“The reason it’s called dialectical is it brings the synthesis of opposites,” she said. “It primarily synthesizes the concept of radical acceptance with change. If you radically accept things you can also change them. It is a skill, like emotion regulation and mindfulness. Stress tolerance has two sets: How do you get through a crisis without making things worse and how do you radically accept a situation that isn’t what you want?”

A Chicago connection: Linehan earned her bachelor’s, master’s and doctorate degrees from Loyola, where she made a transformational breakthrough in the area of radical acceptance. Marshall’s grasp of the terminology and methodology suggested to Linehan that he got the most out of his time at the McLean Hospital last summer.

“Learning new behavior is no different than learning football drills they do,” Linehan said. “You practice, practice, practice and I’m sure that’s what he did because I know the DBT program at McLean.”

Can a patient with Marshall’s troubled past really alter his behavior in the midst of professional upheaval?

“Change could be difficult for him,” she said. “However, change with a lot of support and validation and serious work on doing his skills ought to get him through it. Whatever set off anger in the past probably will set it off in the future but now he is skillful at dealing with it. I would say he’s going to avoid it in the future because he has new skills.”

Copyright © 2012, Chicago Tribune

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Bon: I love the Emotionally Sensitive Person blog over at Psychcentral. Here is a post about an orderly environment and the effects on an emotionally sensitive person.

Mom Was Right: Clean Your Room
By KARYN HALL, PHD

In his book Redirect: The Surprising New Science of Psychological Change, Timothy Wilson described the “broken windows” theory of James Wilson and George Kelling.

This theory is about neighborhoods and safety. Wilson and Kelling believed that the appearance of neighborhoods made a difference in preventing criminal activity. They proposed that the environment communicated to people information on what behavior was appropriate.

Broken windows and graffiti were signals to people that a neighborhood was deteriorating and breaking the law was acceptable.

Researchers in the Netherlands tested this idea. One of their experiments was to put a five-euro bill in an envelope with a clear window so the bill could be seen. They placed the envelope halfway out of a mailbox so people walking by could see it. When there were not signs of lawlessness, only 13% took the money. When there was litter on the ground or graffiti on the mailbox, the percentage doubled.

People are apparently sensitive to information they get from the environment to the point that it influences decisions they make about what is moral and what is acceptable behavior. For emotionally sensitive people, the message from environmental cues seems to be a particularly strong. My experience is that the environment affects the mood and identity of emotionally sensitive people.

Emotionally sensitive people often have thin boundaries. They experience the border between themselves and others as flexible and transparent rather than solid and thick. I would say for some the boundary between themselves and their environment is also thin. So consider what information your home is giving to you. 

Let’s say there are dirty dishes piled in the sink in the kitchen, glasses sitting around the living room, papers and books on all the floors. Clothes are thrown around on furniture in the bedroom. This is more than disorganization. What message does this send?

One possibility is the mess says you don’t matter. You don’t matter enough to have a clean, well-kept environment. Another possibility is that your home tells you that you are out of control or can’t manage your life. Seeing that message everyday is likely to influence the way you feel about yourself. Maybe the mess in your house reflects your sense of powerlessness and helplessness.

A messy house decreases the likelihood that you would invite someone over. It is likely to increase isolation.

Wait a minute, you might be thinking. My house is a mess because I’ve been sad, depressed, scared, or overwhelmed. My house is a mess because I feel helpless. My house is a mess because I am emotionally sensitive and managing my emotions takes all my energy.

That may well be true. The problem is that having a cluttered or unkempt living situation could add to your down mood, lack of self-respect, thoughts of of helplessness, thoughts of being overwhelmed and lethargy. And, like many situations, the problem spirals downward.

If your house is messy, you may be giving yourself the message that “messy” behavior is okay. Imagine you are watching a movie on television, eating ice cream from the carton, and enjoying white cheddar popcorn in your living room – which looks like a Texas-sized hurricane passed through. There are papers everywhere, empty soda cans and candy wrappers on the floor, and stacks of unpaid bills scattered over the coffee table. You’re tired when the movie is over and lethargic from the food. What are the chances that you will put your spoon in the dishwasher, throw away the ice cream carton and put up the uneaten popcorn? What are the chances you will pay the bills?

If your house was clean and neat and if your bills were in one place where you always do your finances, the chances that you would clean up increase, maybe not that night, but the next day.

In the terms of Dialectical Behavior Therapy, cleaning your environment is a form of increasing mastery. Increasing your sense of mastery helps decrease thoughts of helplessness and increases your ability to manage your emotions.

Thinking about cleaning a messy house can be overwhelming and discouraging. You might want to commit to cleaning for ten minutes each day in one room. Maybe start with your bedroom where you wake up every day. Maybe you could clean for ten minutes in the morning and ten minutes at night. A different strategy would be to do one task each day. For example, on Monday you wash a load of clothes. On Tuesday you wash dishes.

Each individual is different. Consider how your living environment affects the way you live your life. If the impact is significant, then make a plan to change your home to a place that is more supportive. Keep the plan doable and simple. Track your progress. Reward yourself for each step that you take. (Really, rewarding yourself is important.) Maybe sort out your belongings, keeping the things that matter to you. Consider making small changes that make your home pleasant and meaningful for you.

Note to readers: Please consider taking our survey to help us learn more about emotionally sensitive people. Your responses are anonymous and we’ll discuss the results in upcoming posts. I am very grateful to each person who has helped. We are very close to our target number now and I’m looking forward to sharing the information.

photo credit: blindedbymysight

References

Linehan, M. Cognitive Behavior Therapy for Borderline Personality Disorder. New York: New Guilford, 1993.

Wilson, Timothy. Redirect: The Surprising New Science of Psychological Change. New York: Little, Brown and Company, 2011.

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Bon: Skip, over at BPDFamily.com, wrote this article about Hoovering. I find it interesting and I go a bit of a chuckle out of the sentence: “Hope is not enough (on both sides).”

BPD News: Is it a “Hoover” or is it “Relationship Recycling”
9/01/2010 BPDFAMILY.COM 2 COMMENTS

The BPDFamily.com support group reports that “hoovering” is a misleading slang term that some use to suggest that a relationship partner can “suck us back into a relationship” after we break it off. “Hoovering” in this context falsely implies a premeditated malicious effort to hurt their partner on the part of the person with Borderline Personality Disorder (BPD). It also suggests that the partner is somewhat powerless to resist returning to the relationship.

This concept is in conflict with the primary characteristics of Borderline Personality Disorder – most notably that people with the disorder are notoriously impulsive, weak and often too consumed in their own pain to be sensitive to others. This concept also suggests that someone has power over another that they could not possibly have.

Most likely what is happening is relationship recycling by both parties – breaking up, getting back, breaking up, getting back.

Relationship Recycling Takes Two

Excessive relationship recycling, or break-up/make-ups are common in some “BPD” relationships. 70% of our members having unsuccessful relationships report having had 4 or more break-up/make-ups. 23% report an unbelievable 10 or more.

Recycling is about both parties. The real dynamic is that both parties return to a place they feel is safer/easier than being apart. So, in effect, the couple struggles to work together and each struggles in weakness to be apart or alone.

Living with excessive recycling is an unhealthy place to be. When you repeatedly recycle, clearly something is very wrong.

Recycling can become the “norm” in a relationship. with both parties can becoming conditioned to it after a while. Accepting this “norm” is the ultimate boundary violation – you are not treating each other well – you are not treating yourself well.

If you have been through more than 3 break-up/make-ups in your relationship, it’s important to recognize that it is unlikely to get better if something doesn’t significantly change. Repeated recycling will not go away on its own. One person can’t fix it unilaterally (stop the breakups).

Is Recycling Always Unhealthy?

Not always. Let’s break this down. Sixty-two (62%) of relationships do not end at the first break-up. For a wife to have second thoughts about a divorce is normal. Sometimes our own self doubt makes us want to try one more time. Sometimes one partner promises to change something. To reconnect with a person after a break-up 1-2 times is really not all that unusual.

When there are more than 3-4 “break-up/make-up” cycles in a relationship there is something seriously wrong. And when this happens, the likelihood of a positive outcome are greatly diminished.

Why do we get caught up in cycles?

These are the questions we need to answer if we ever want the break-up/make-up cycle to end. Are we returning to this person because we are in love with them and the relationship has a chance, or are we returning to this person because they feel safe?

* Are we afraid to be alone?

* Do we have our own abandonment issues?

* Are we fearful that we cannot find someone as good as them again?

* Are we fearful of the next step (dating, financial issues, etc.)

Why do our “BPD” partners recycle?

It is hard for us to understand why our partner is expressing an interest after they left in a torrent of bad behavior (e.g., cheating, raging and telling us that we are a horrible people). “If they don’t love me, why this?” The answer is much of the same reasons as we have… plus a few others that are related to the disorder.

* Inability to deal with acute loneliness

* Severe insecurity / needing validation (from someone that highly values them)

* Shame / wanting to prove they are a good person (to us or themselves)

* Immaturity/Manipulation/Control – the break-up was just a way to get their way.

If You Want to Stay in the Relationship

The ability to end break-up/make-up cycles and stay in a relationship takes a deep commitment by both partners. This often means structured rehabilitation (counseling, workshops, classes, self-help programs, etc.).

If you are both open to restarting the relationship, remember the problem isn’t going to go away without work. Hope is not enough (on both sides).

You may believe that your partner has changed, will change, is sincere this time, will get into treatment if only you come back. They may believe that the you changed. But unless there is specific work on a serious level going on – don’t count on it.

If You Want to Exit in Relationship

The power to end the relationship and end the toxic break-up/make-up cycles lies with you… not your partner. Don’t avocate your responsibility here. It may be comforting to blame our partner – but it is simply denial on our part. This is a common problem in the last stage of BPD relationships. You need to step up and deal with it – as hard as it is. And, it is hard. Just look at these numbers of break-up/make-up cycles in a recent BPDFamily.com poll.

Number of break-up/make-up cycles
————————–
None
12.8% had 1-2 recycles before it ended (not unheathy)
14.9% had 3-5 recycles before it ended (unhealthy)
38.3% had 6 – 10 recycles before it ended (very unhealthy)
8.5% had 10 or more recycles before it ended (wow)
23.4% still haven’t broken up (still recycling)

If you are truly finished with the relationship, if you have expressed this to the ex and he/she continues to contact you, it is best to go to reduce your frequency, timing, and the personal nature of your communications (controlled contact) – possibly all the way to ending it (no contact). If you stop engaging the other person will usually move on. It’s not more complex than this.

Is He/She Sincere or is this just More Toxic Recycling?

Many of us spend much time trying to figure out if the attempted “re-engagement” is sincere by the other party.

To understand this, it’s important to understand the emotional make-up of someone with BPD. They are not crazy/insane – their behaviors are often predictable – especially if we understand the disorder and their history with us. So it is reasonable to accept that the person with BPD is sincere in wanting to reconnect. It is important to consider, however, that pwBPD can be highly impulsive and those impulses can change quickly. So sincerity is not the issue. The issue is whether the person with BPD (as well as you) can follow through with the commitment.

It’s also important to look at ourselves and question whether we are doing the same thing; often we are.

Author: Skip

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Using real-time brain imaging, a team of researchers have discovered that patients with Borderline Personality

Brain Scans and BPD

Disorder (BPD) are physically unable to regulate emotion.

Brain Scans Clarify Borderline Personality Disorder (link)

By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on September 4, 2009

Using real-time brain imaging, a team of researchers have discovered that patients with Borderline Personality Disorder (BPD) are physically unable to regulate emotion.

The findings, by Harold W. Koenigsberg, MD, professor of psychiatry at Mount Sinai School of Medicine suggest individuals with BPD are unable activate neurological networks that would help to control feelings.

The research will be published in the journal Biological Psychiatry.

Using functional magnetic resonance imaging (fMRI), researchers viewed how the brains of people with BPD reacted to social and emotional stimuli.

Koenigsberg found that when people with BPD attempted to control and reduce their reactions to disturbing emotional scenes, the anterior cingulate cortex and intraparetical sulci areas of the brain that are active in healthy people under the same conditions remained inactive in the BPD patients.

“This research shows that BPD patients are not able to use those parts of the brain that healthy people use to help regulate their emotions,” said Dr. Koenigsberg.

“This may explain why their emotional reactions are so extreme. The biological underpinnings of the disordered emotional control systems are central to borderline pathology. Studying which areas of the brain function differently in patients with borderline personality disorder can lead to more targeted uses of psychotherapy and medications, and also provide a link to connect the genetic basis of the disorder.”

According to background information in the article, borderline personality disorder is a common condition, affecting up to two percent of all adults in the United States, mostly women.

Characteristics of BPD include being so emotionally overreactive that they suffer alternating bouts of depression, anxiety and anger, are interpersonally hypersensitive, and are impelled to self-destructive and even suicidal behavior.

Patients with BPD often exhibit other types of impulsive behaviors, including excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

The disorder is found in 10 to 20 percent of people in psychiatric care, and about 10 percent of people with this condition ultimately die of suicide. Only recently have researchers begun to identify underlying biological factors associated with the condition.

Source: The Mount Sinai Medical Center

APA Reference
Nauert PhD, R. (2009). Brain Scans Clarify Borderline Personality Disorder. Psych Central. Retrieved on March 9, 2012, from http://psychcentral.com/news/2009/09/04/brain-scans-clarify-borderline-personality-disorder/8184.html

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Bon: Interesting article from a woman with BPD…

I Want To Kill You Before There Is A Chance That You’ll Break My Heart (link)
Posted August 14th, 2010 at 3:33AM

I love him enough to want him dead. I’ve never giving my heart to anyone before and wasn’t really intending to do so ever. My plan was to plan the perfect life and live it… I didn’t really know about all the feelings I was ‘supposed’ to have for a partner. When I learned about this feeling and the vulnerability of love, I realize that it’s a dangerous game. I don’t want to play.

I don’t think he realizes that the ‘petty’ arguments and random hurtful comments, that might seem so insignificant in other peoples relationships are not so small to me. You see, now you’re my enemy, you are no longer on my side, you are attacking me. It’s now you or me and for survival I now have to take you out (if I don’t make myself my own enemy and crave my own death again). This constant cloud/battle of wanting his death vs my own is new. I think it’s because I’m in a program to no longer self harm and my intense emotions still need to be expressed and if it’s no longer inwards which was partinally to protect others from me, then I’m left with out wards now.

Sleeping beside him at night, I watch him breath in and out and the throbbing pulse of his neck, he’s so fragile in his sleep and I love him. I love him to death.

He’s not abusive or anything. His personal ‘issues’ trigger me (bpd) beyond what I can stand. We have been together about six years (broke up for one year and got back together). Having a spouse is just too risky, I get worse as I get older and I’m crazy and dangerous on my own but with him, I’m no longer just chaotic but instead I’m on high suicide risk and a ticking time bomb to his death.

He knows this, we’ve talked about it and I wont leave him and he says he can’t leave me either. So he’ll eventually cheat on me (again) and we will fight all the time and then one of us will die. It may not even happen for four more years but I can feel it and battle that anxiety of it each day (with a smile on my face because I don’t want to miss the good moments in the present or at lease don’t want him to know).

I just want him to hold me. I hate love. I hate feelings. I hate this, I’ve never been THIS before. I even find myself hoping that he’d get hurt and then he’ll need me. Or even get someone to hurt him. Sounds horrible. I’m horrible for thinking of this.

Sorry about the crazy talk but don’t have friends anymore because of bpd.

I’m rambling and he likes to do research and background checks on me and others around me and go through stuff of mine and so I’m hoping he wont hack into my account and read all my personal stuff

Me or him, me or him, me or him?

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http://youtu.be/967Ckat7f98

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See larger image Diary Drawings: Mental Illness and Me (Paperback) By (author) Bobby Baker List Price: $22.95 USD New From: $13.94 In Stock Used from: $11.50 In Stock

In 1996 the artist Bobby Baker was diagnosed as having borderline personality disorder. Her subsequent struggle to overcome severe mental and later physical illness lasted for 11 years, and was unknown to anyone outside her close family, friends and colleagues. The 158 drawings and watercolours in this book, selected by Bobby from the hundreds more that she created daily as a private way of coming to terms with her experience, are an astonishing record of her slow and harrowing journey to eventual recovery. Moving, startling, shocking and hilarious in turn, these diary drawings reveal the stark realities of living with mental illness and of society’s lack of understanding.

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Therapy keeps negative emotions in check (link)

Rolling up her sleeves, Phyllis Johnson reveals the scars she had inflicted upon herself in the past.

Known simply as “P.J.” to her friends, the Sioux City woman would often cut herself as a way to release the pain she was feeling in her life.

Diagnosed with a borderline personality disorder which has negatively impacted her relationships with others and led to repeated suicide attempts and incidents of self-harming, Johnson said she is resolute in learning how to cope with overwhelming emotions.

As a patient of Mercy Behavioral Care Clinic’s Pathways Outpatient Mental Health Program’s dialectical behavioral therapy (DBT), Johnson is looking to heal the scars on her arm as well as the ones in her heart.

Developed by psychology researcher Marsha M. Linehan, DBT, the  psychotherapy combines behavioral science with the concepts of acceptance and mindfulness.

Used for people being treated for bipolar disorder, post-traumatic stress disorder as well as borderline personality disorders, DBT utilizes a mixture of homework, discussion and breathing exercises inspired by Eastern philosophies, explained Pathway’s Lynn Marksbury.

“Living with a borderline personality disorder is like living life with the volume knob turned all the way up,” she said. “There’s so much noise and confusion going on that it’s hard to find your bearing.”

Through DBT, patients learn the skills needed to get them through a crisis.

Such skills (or “modules”) include distraction (reading, exercising or even breathing when a crisis is imminent); mindfulness (not obsessing in the past and staying in the moment); distress tolerance (managing painful situations without resorting to harmful behaviors); emotion regulation (managing one’s emotions instead of being managed by them); and interpersonal effectiveness (reducing one’s anxiety and the stress of confrontation).

“Sometimes a person’s brain is ‘hard-wired’ to experience emotions more intensely,” said Pathways’ therapist Melissa Wallace. “Through DBT, we’re helping people change the ways they respond to those emotions.”

Having gone through DBT, Johnson no longer feels the need to cut herself.

Instead, she turns to her art or even writing out the schedule of the Iowa Hawkeyes basketball team to distract her when emotions threaten to flood.

“I used to see my life in black and white,” Johnson said. “With DBT, I’m happy to see moments when grey is being able to shine through.”

Read more: http://siouxcityjournal.com/lifestyles/health-med-fit/therapy-keeps-negative-emotions-in-check/article_5cd92b6b-43cc-576c-9f38-ebeb57f229ed.html#ixzz1nnqk0W3T

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An article from Alsia Valdes about BPD and her relationship.

To Fix Your Body, First You Must Fix Your Soul
by Alisa Valdes
1/24/2012

It’s funny how things are all connected, when you really sit down to look at them. Well, not funny in a comedic sense, but funny as in interesting. For years, I have had trouble controlling my impulses. Many people who knew me understood this. I, unfortunately, did not.

I never realized I had a problem until it was pointed out to me by someone I loved. While others had tried to point out that I had a problem, they were usually people I was fighting with, and I was able to brush it off as “they just hate me.”

This man who loves me, though, noticed early on in our relationship that there was a pattern in my life of what he called self-destructive failure to control my impulses. He was quite clear in letting me know that any relationship we were to have would be contingent upon this pattern of mine being fixed. No fix, no relationship.

This pattern of impulse control failure had manifested itself most obviously in various unwise moves I’d made with regards to my career, online. I’d posted scathing letters and blog posts about my employers or business associates, for example, over the past decade, and though I’d incredibly thought at the time that such actions would help me to gain sympathy, these things always turned around to bite me. In the end, the only person who ended up hurt by my public tantrums was…me.

What I didn’t realize until very recently is that there were all sorts of other ways in which this same pattern of failing to control my most base and emotional impulses was harming me. Pretty much any area of my life you wanted to look at, there it was. Failure to control impulses.

DIAGNOSIS: BORDERLINE PERSONALITY DISORDER

I began to research this, realizing it was absolutely holding me captive in my own life, and was led to a therapist who wasted no time in diagnosing me with a mood disorder. I have what is called Borderline Personality Disorder. This disorder has a very bad rap among mental health specialists, because we’re the people who go nuts when someone breaks up with us, we’re the ones who try to kill ourselves, we’re the ones who sometimes turn on our own therapists, even, because we tend to have very black and white thinking. BPD has such a bad rap, in fact, that I hesitate to disclose this to you now, but I do so because I truly believe the truth will set us free. I’m not perfect. I have a disorder. I got it honestly, through a combination of biology and suffering, and I am working very, very hard to figure out how to handle it before it’s too late.

I’d gone through 42 years of life blindfolded, and this diagnosis was the first time anyone had lifted the cloth from my eyes long enough for me to see myself as I really was, and, most importantly, to catch a glimpse of a solution to this problem that had ruined just about every part of my life from the time I was 16 years old and it first reared its ugly head.

People with impulse control issues tend, among all of their other charming behaviors, to overeat. This is not a surprise. Eating right requires control. Self-control. Borderlines are notoriously lacking in this skill. Eating right also requires mastery over one’s emotions, if you are an emotional eater as so many of us are. It is no surprise, then, that Borderlines like me have higher rates of eating disorders and obesity than the rest of the population. Yes, we’re a lovely bunch, aren’t we?

There are complicated reasons I ended up this way, most of them sad and having taken place when I was a kid and had no say over what happened to me, and not worth burdening you with here. There is also a silver lining to my disorder—it has made me a very empathetic person who is able to live most happily in her imagination, where she can control everything—in other words, it made me a writer. So I’m not saying being a Borderline is all bad, though I am working very hard to correct it. I hope to remain a writer, even after the disorder that made me one goes away.

In short, my disorder, my lack of impulse control, made me fat. That’s what I ‘m trying to tell you. I see that now. I think that for many of us—though certainly not for all of us—issues with overeating and obesity can be traced to other, larger issues that likely plague other areas of our lives. In my case, I could not even begin to fix the weight problem until I honestly addressed the mood disorder. It wasn’t as simple as “eat less, exercise more” in my case. There was so much more to it.

A JOURNEY OF HEALING

I am embarking upon a journey of healing, with professional help, trying to get a handle on this monster on my back. And to my great delight, one of the unexpected side effects has been a healthier relationship with eating, and a loss of weight. We often say that there is a bias against fat people in our culture, but I don’t think it’s that simple. I think there is a biological basis for this inherent revulsion toward people who are obese. The physical body is truly a manifestation of our emotional well-being. People who are fat, as I was, walk around wearing their extra pounds as a flashing neon sign to others, advertising their emotional problems. Our bodies are the best barometer we have of how well we are doing, mentally. I know this statement will upset a lot of people, but I posit that most of that upset comes from the discomfort of recognizing a difficult truth.

To fix our bodies, we must first fix our souls. It’s as simple as that.

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Discriminating variables were entered in a multivariate logistic regression model to define predictors of High-Lethality status. High-Lethality attempters were older, with children, less education, and lower socioeconomic class (SES) than Low-Lethality attempters. They were more likely to have Major Depressive Disorder (MDD), co-morbid Antisocial Personality Disorder (ASPD), and family histories of substance abuse. They reported greater intent to die, more lifetime attempts, hospitalizations, and time in the hospital. High-Lethality status was best predicted by low SES, co-morbid ASPD, extensive treatment histories, and greater intent to die. These characteristics resemble profiles of patients who complete suicide, are not specific for BPD, and do not include impulsivity, aggression, or severity of BPD criteria.

Read the entire study in PDF format.

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New approach could more effectively diagnose personality disorders (link)
February 20th, 2012 in Psychology & Psychiatry

(Medical Xpress) — Personality disorders could be more effectively diagnosed by identifying and targeting the disrupted neurobiological systems where the disorders originate, report Cornell researchers.

The way that these mental illnesses are now classified — based on particular patterns of thought and behavior — is misguided and has little hard evidence to support it, reports Cornell neuroscientist Richard Depue and his colleague in a special issue of the Journal of International Review of Psychiatry (23:3).

“The behavioral features used to diagnose personality disorders do not coalesce into coherent disorders in any research,” says Depue, professor of human development in the College of Human Ecology, who co-authored the article with graduate student Yu Fu. “As currently defined, the different personality disorders have overlapping behavioral symptoms that also merge imperceptibly with normal behavior. A diagnosis should define a coherent behavioral pattern and predict a particular course, prognosis and treatment. No personality disorder diagnosis can do that.”

Their findings fly in the face of current medical practice. Nearly one in 10 Americans suffers from a personality disorder, a group of disabling conditions characterized by serious, sometimes catastrophic, problems with relationships and work. Behavioral features can vary widely, from pervasive disregard for the law and the rights of others (antisocial personality disorder) to extreme mood instability (borderline personality disorder).
The researchers drew their conclusions by conducting a detailed review of the brain systems that underlie the major human personality traits.

Humans have about six major personality traits, each with its own neurobiological foundation that influences such behaviors as how anxious or impulsive we are, Depue notes. For example, the underlying systems and associated personality traits in their model include anxiety/stress-reactivity (thought to underlie neuroticism and negative emotionality) and neural constraint (thought to underlie conscientiousness), among others. The variety of behaviors associated with personality disorders arise from the influence of an individual’s genetic make-up and environment on neurobiological functioning, they say.
In their multidimensional model, a person’s personality traits can be plotted in three-dimensional space where the axes represent the underlying neurobehavioral systems. The patterns of behavior associated with personality disorders emerge from the interaction of extremely high or low values or levels of normal traits; such extremes lead to impaired interactions, they say.

“Our model links personality traits with the underlying neurobiology, which provides a better framework for understanding how and why personality disorders develop and how they can be treated,” he says. “It allows us to better predict interventions, such as certain drugs and/or environmental interventions, which may be of benefit. We can also start thinking of treatments that modify multiple neurobiological variables, rather than just one or two.”

And recent discoveries in neuroscience point to the important role environment plays, particularly during early childhood, in how genes are expressed, Depue says. “So, risks for personality disorders can be either magnified or reduced by the interaction of the individual’s circumstances with their genetic make-up, in a process called epigenetics. We see evidence for this in personality disorders, which are much more prevalent in those who have suffered from a variety of childhood stresses and abuse.”

Their theoretical analysis has implications for the criteria used for classifying personality disorders in the Diagnostic and Statistical Manual of Mental Disorders. It also contributes to a growing body of evidence that calls for a rethinking of the approach to classifying these illnesses, based on the underlying biochemical and neural processes that result in the symptoms.

Provided by Cornell University

“New approach could more effectively diagnose personality disorders.” February 20th, 2012. http://medicalxpress.com/news/2012-02-approach-effectively-personality-disorders.html

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Louise Neathway

I don’t typically post crime-related issues or ones that “diagnose” anyone (except for my arm-chair diagnosis of celebs). Yet, this story stuck a chord with me. Reading through the story, it sounds a lot like BPD. This woman can use some mental health care, I’d say.

Manhattan woman arrested on charges of harassing Yankees General Manager Brian Cashman

A single mother with a history of stalking has been busted on charges of harassing and extorting money from Yankees General Manager Brian Cashman.

Prosecutors portrayed Louise Neathway, 36 – who said in an interview published Thursday that she was Cashman’s mistress – as a con artist who pestered him for cash.

“The defendant extorted approximately $6,000 from the victim and attempted to extort over $15,000,” prosecutor Eric Iverson said at Neathway’s Manhattan Criminal Court arraignment Thursday.

He said it wasn’t the first time Neathway had tried to “control and manipulate” Cashman, 44.

Her lawyers, Alan Abramson and Stephen McCarthy, countered that prosecutors rushed to judge Neathway, who has a 14-year-old daughter.

“This is a married man who has an inappropriate relationship with a single mom – it ended badly,” said McCarthy.

Neathway, a British citizen who also goes by the name Louise Meanwell, was arrested Wednesday afternoon in front of her Tribeca apartment building on Leonard St. A source said Cashman helped lure Neathway into a police dragnet.

She was charged with aggravated harassment, stalking and grand larceny. She was being held on $300,000 bond on Thursday night.

Cashman told detectives he met Neathway in April. The complaint charges she called and texted Cashman “hundreds” of times during the 10 months she’s known him.

In the fall of 2011, she asked Cashman to pay for an unspecified $15,000 medical treatment and threatened to contact the press and his family if he didn’t pay, the complaint says.

On Jan. 18, Cashman gave in and deposited $4,000 into one of her bank accounts and $2,000 in another, the complaint says.

Between Jan. 29 and 30, Neathway made “multiple and harassing telephone calls” to Cashman, demanding more money, the complaint says.

A judge ordered her to stay away from Cashman, his wife and their children.

The Yankees declined to comment. “Brian is very grateful that this matter is being handled by law enforcement,” Cashman’s spokesman said.

Prosecutors said Neathway’s criminal history dates back to 1998, when she was arrested for trespassing in North Carolina.

She also has two open upstate warrants for harassment, and is on probation in New Jersey in a stalking-related case, prosecutors said.

Neathway received a conditional dismissal in 2010 for harassing her ex-boyfriend, an East Village resident. The crime was set to be expunged from her record on Feb. 15 if she stayed out of trouble.

“I am fearful for my safety and I have no idea what this woman is capable of,” the ex-boyfriend wrote in a statement to police in July 2010.

A neighbor, who called her “psychotic” said Neathway parties hard nearly every night.

“She screams up and down the hallways when she drinks,” the neighbor said. “She would run up and down the halls banging on doors and screaming, ‘Stop complaining about me!’ “

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Substance Abuse and BPD

Rage. Instability. Mood swings. Impulsivity. These characteristics make people with borderline personality disorder (BPD) prone to substance abuse as well as over-spending, promiscuity, eating disorders and other compulsive behaviors. In fact, studies suggest that 50 to 70 percent of those with BPD also have a co-occurring substance use disorder.

The Challenges Of Treating Addicts with Borderline Personality Disorder (link)

February 17, 2012

Rage. Instability. Mood swings. Impulsivity. These characteristics make people with borderline personality disorder (BPD) prone to substance abuse as well as over-spending, promiscuity, eating disorders and other compulsive behaviors. In fact, studies suggest that 50 to 70 percent of those with BPD also have a co-occurring substance use disorder.

Addicts with co-occurring borderline personality disorder are known as some of the most difficult patients to treat. Here are a few of the most common challenges, along with insights into the most effective research-based treatments:

Treatment Compliance

Addicts with BPD have been described as both treatment demanding and treatment resistant. Research shows more positive outcomes the longer an addict with BPD stays in treatment, yet keeping them in treatment is no easy task. In a study of patients in a detox program, those with BPD were significantly more likely to have an unplanned discharge than those without BPD.

While a number of treatments have proven effective for BPD, therapies for BPD patients with co-occurring substance abuse are less established. Studies suggest that the most promising treatments include dialectical behavior therapy, cognitive-behavioral therapy and psychodynamic approaches. A combination of support and management from an experienced dual diagnosis treatment center can improve retention rates, along with ongoing involvement in self-help groups such as AA and NA.

Therapist-Patient Relationship

Dropout rates among patients with BPD and substance use disorders are high largely because of the difficulties engaging this group in a therapeutic relationship. In one moment, the patient may view the therapist as a much needed source of support. At the first perceived sign of rejection, criticism or disapproval, the therapist becomes an enemy who cannot be trusted. The patient may become resistant, passive, or stop attending therapy sessions altogether, while the therapist may feel increasingly helpless and angry. 

Without appropriate skills and knowledge, working with individuals with co-occurring BPD and substance abuse can take a toll on the treatment professional. Negative attitudes and stigma can compromise the effectiveness of treatment, and finding the balance between validation and behavioral change can be an ongoing challenge. Professionals who regularly work with this group need specialized training to understand the nature of the problem, maintain boundaries, provide consistent, nonjudgmental support, and prevent negative countertransference.

To work successfully with addicts with BPD, the therapist requires many levels of support. A team approach is typically best. Having a trusted group of colleagues to turn to with frustrations and questions about treatment planning can prevent burnout and damage to the therapeutic relationship. A team that works cohesively and maintains ongoing communication guards against splitting (playing one member of the treatment team against another) and provides seamless care.

High Relapse Rates

Patients with dual diagnosis are at high risk of relapse. Among addicts with BPD, underlying issues (such as trauma) may be driving addictive patterns. Integrated dual diagnosis treatment provided by a multidisciplinary team of medical and mental health care professionals is essential to address all issues simultaneously. Relapse prevention must focus not only on substance abuse but also self-harm, noncompliance with medications and other risky behaviors.

Dysfunctional Relationships

Even though they crave attention and affection, addicts with BPD typically have turbulent interpersonal relationships that result in the very rejection they fear most. Studies show that social deficits are associated with a range of problems, including substance abuse, unemployment, delinquent behavior and poor academic performance. Twelve-Step groups, online forums and group therapy can aid in building social skills and a sober social support network.

Family relationships also may be marked by conflict and communication problems, which may be both a contributing factor and consequence of BPD and addiction. In treatment, families must be educated about both illnesses and provided with support and skills training in order to improve the functioning of the family system. Many families find self-help support groups such as Al-Anon helpful.

Suicidal Behavior

Individuals with BPD are at increased risk of suicidal ideation, recurrent suicide attempts and self-mutilation (e.g., cutting, burning, or overdosing) in an attempt to cope with difficult emotions. When under the influence of drugs or alcohol, these risks are even greater. Randomized controlled trials have shown that dialectical behavior therapy can be particularly effective in addressing suicidality.

Medication

Studies of pharmacotherapy for BPD and addiction have produced mixed results. While certain medications, such as SSRIs, mood stabilizers, and antipsychotics, may be helpful in treating BPD, their efficacy isn’t well-established. Similarly, medications approved for chemical dependency, such as naltrexone, haven’t been adequately studied in patients with co-occurring BPD and addiction. The addictive potential of opioids and benzodiazepines could put patients at risk and should be prescribed with caution.

Other concerns that arise when medicating patients with BPD include noncompliance, overdose, demands for frequent changes in medication, and failure to accurately report when a medication is easing symptoms or worsening them. In addition, patients may be either resistant to the idea of medication or demand medication at the start of treatment.

Dual Diagnosis Treatment Rises to the Challenge

While the challenges are numerous, addicts with BPD can be effectively treated so long as specialized programming is set up to meet their unique needs. Effective dual diagnosis treatment begins with a comprehensive assessment that takes into account suicide risk and crisis management. It also includes a stable, supportive treatment environment; individualized care from a coordinated team of professionals familiar with the issues of borderline personality disorder and addiction; and long-term continuing care. Not every treatment program is equipped to manage co-occurring BPD and substance abuse, but those that are offer a great deal of hope to these patients and their families.

David Sack, M.D., is a board-certified addiction psychiatrist and CEO of Elements Behavioral Health, a network of addiction treatment centers that include Promises Treatment Centers, The Ranch, The Recovery Place, and The Sexual Recovery Institute.

Related posts:

1. DBT for Substance Abuse
2. It’s time to reject the notion that people with personality disorders are beyond help
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Beyond Boundaries at LuLu

The Kindle Version of Beyond Boundaries

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Ricky Williams and BPD

Ricky Williams retired from football this year. This article mentions that he had been diagnosed with Borderline Personality Disorder (BPD). I had never heard that before.

Ricky Williams retires again, but this time with respect
Posted Tuesday, Feb. 07, 2012
By CLARENCE E. HILL JR.

So the long, strange trip that was Ricky Williams’ NFL career is over.

At first glance, it has left you wanting.

Neither the Hall of Fame nor mention as one of the league’s all-time greats are in his future after a career dotted with drug suspensions, early retirement and just weird behavior.

Once considered a joke, however, Williams, who played 11 seasons with the New Orleans Saints, Miami Dolphins and Baltimore Ravens, leaves the game with something some thought he would never get: respect.

Along the way he found himself, learned some things about life and possibly taught us that you must be true to yourself.

As for Williams, this is not the end but the beginning of the rest of his life, which will likely be even more fascinating and fulfilling than his football career.

On his Twitter account, Williams wrote: “Thank you all, but this ain’t it, I’m gonna do something really special. ‘Be you and change the world.’”

As part of a statement released Tuesday, he wrote:

“The NFL has been an amazing page in this chapter of my life. I pray that all successive adventures offer me the same potential for growth, success and most importantly, fun.”

Williams will always be revered at Texas, where he set the NCAA career rushing record, won the Heisman Trophy in 1998 and is a member of the school’s Mount Rushmore of football players along with Earl Campbell, Tommy Nobis and Vince Young.

“One thing I know for sure, Ricky accomplished a lot on the football field, but he aspires for even more in his career after football,” Texas coach Mack Brown said in a statement.

But so much more was expected of Williams in the NFL. Just ask Mike Ditka and the Saints, who traded away a whole draft for the rights to select Williams in 1999.

Ditka was later fired while a misunderstood and injured Williams largely was a bust in New Orleans.

But Williams seemed to be finally living up to expectations as a bona fide NFL superstar after being traded to the Miami Dolphins in 2002, rushing for 1,853 and 1,372 yards in consecutive years.

But just when we thought Williams had it all together, he was gone. He retired in 2004 because he was facing a suspension for violating the substance abuse program.

He was labeled as quitter and a disgrace for abandoning his team.

Even a return to the NFL in 2005 didn’t quiet the storm as he was soon gone again with another failed drug test that had him suspended for the entire 2006 season.

Williams has no regrets and admits the time away might have been the best thing for the life and career of a man who was too sensitive and too honest to fit our stereotype of a football player.

He was clinically diagnosed with social anxiety disorder, avoidance disorder and borderline personality disorder. He said he used marijuana as part of his therapy.

We later found out during an honest assessment of him in an ESPN documentary that he had his personal demons. He was abused by his father as a child, which also led to some of his failings as a father, husband and ultimately a teammate.

He also was found to be a spiritual person who didn’t fit the image of the human battering ram.

Williams returned to the Dolphins in 2007 after adhering to a strict regimen of drug tests. He says he no longer smokes and does yoga to cope.

He spent the past few seasons as a reliable backup and teammate. The time away had robbed him of stats, but it preserved his legs and gave him a new appreciation for the game.

Ravens teammate Ray Rice characterized him as a true professional whom he looked up to and admired.

Ravens coach John Harbaugh said he had the utmost respect for Williams and he would be missed.

Williams finished his underappreciated career with 10,009 yards rushing, more than Campbell and ranking 26th in NFL history.

Most of all, a career that was a deep personal struggle that hit rock bottom before he found himself ends by being regarded as a respected professional and wanting nothing.

Who wouldn’t want that?

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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.

I have gone to therapy consistently for over 7 years, I have been involved with the 12 step community and currently attend about 3 meetings per week, I work with recovering addicts 2 days/week, I meditate every morning, I pray, I read the Bible, and I still feel like s$#@. I have trouble remembering things, I get angry and can’t seem to control the inner dialogue in my head, I dissociate… but I can function in the outside world.

My marriage is a different story. (I am) unable to feel the love. Prior to me stopping my drug habit, I felt like I was able to be more ‘myself’ within my marriage. I was more relaxed and happier. I have a fantastic husband, but most of the time I don’t care.

Do you think that a low dose Suboxone each day could help me?

This is a great letter, for a number of reasons. The writer is operating at a high level of function; I made no corrections of spelling or grammar, and she expresses herself in a very coherent and organized way. At the same time, she describes constant, severe suffering. One can understand, by the end of the letter, why people with BPD sometimes cut themselves, in an attempt to focus vague emotional suffering into focus of physical pain, or to gain a sense of control over their suffering.

I invite readers to stick with me on this one. Spend some time reading the letter, as I believe that the writer does a good job of expressing where many of my patients find themselves. There are a number of areas to take the discussion:The increased risk of addiction for someone who feels the way the writer feels, if she were to develop a chronic pain condition such as low back pain.

Whether it is appropriate to start buprenorphine or Suboxone in a person with a low opioid tolerance.

Whether buprenorphine or Suboxone should ever be used to stabilize mood—or to reduce EMOTIONAL suffering.

Which medications are helpful for BPD?

She is off substances now, but feels like she was more ‘herself’ when she was using…. she could tolerate closeness with her husband, and thinks she was ‘happier’ then. Now she is active in the steps. Which is the ‘real’ her?

I will discuss these issues in the next post, and I hope you’ll watch for it.

I am a Psychiatrist and PhD Neuroscientist in solo, private practice in NE Wisconsin. I treat adults, children and adolescents for all psychiatric conditions, with an emphasis on improving the strength of the doctor/patient relationship through longer appointments, greater access, and frequent e-mail communication. I teach psychiatry at the Medical College of Wisconsin, and provide psychiatric servicies for the U of WI Oshkosh Campus. Finally, I provided expert witness testimony for a wide range of cases related to psychiatry, neurology, addiction, and chronic pain. I am Board Certified by the American Board of Psychiatry and Neurology, and lifetime-Board Certified by the American Board of Anesthesiology.

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Understanding the Levels of Validation
By KARYN HALL, PHD

Marsha Linehan, Ph.D., from the treatment creator of Dialectical Behavior Therapy, identified six levels of validation and noted that she believes it is impossible to overestimate the importance of validation.

If you care about someone who is emotionally sensitive, validation is one of the most important and effective skills you can learn. If you are an emotionally sensitive person, then learning to validate yourself will help you manage your emotions effectively.

Linehan suggests using the highest level of validation that you can in any situation.

The First Level is Being Present. There are so many ways to be present. Holding someone’s hand when they are having a painful medical treatment, listening with your whole mind and doing nothing but listening to a child describe their day in first grade, and going to a friend’s house at midnight to sit with her while she cries because a supposed friend told lies about her are all examples of being present.

Multi-tasking while you listen to your teenager’s story about his soccer game is not being present. Being present means giving all your attention to the person you are validating.

Being present for yourself means acknowledging your internal experience and sitting with it rather than “running away” from it, avoiding it, or pushing it away. Sitting with intense emotion is not easy. Even happiness or excitement can feel uncomfortable at times.

Often one of the reasons other people are uncomfortable with intense emotion is that they don’t know what to say. Just being present, paying complete attention to the person in a nonjudgmental way, is often the answer. For yourself, being mindful of your own emotion is the first step to accepting your emotion.

The Second Level is Accurate Reflection. Accurate reflection means you summarize what you have heard from someone else or summarize your own feelings. This type of validation can be done by others in an awkward, sing-songy, artificial way that is truly irritating or by yourself in a criticizing way. When done in an authentic manner, with the intent of truly understanding the experience and not judging it, accurate reflection is validating.

Sometimes this type of validation helps the emotionally sensitive person sort through their thoughts and separate them from their emotions. “So basically I’m feeling pretty angry and hurt,” would be a self-reflection. ”Sounds like you’re disappointed in yourself because you didn’t call him back,” could be accurate reflection by someone else.

Level Three is Reading a Person’s Behavior and Guessing What They Might be Feeling or Thinking. People vary in their ability to know their own feelings. For example, some confuse anxiety and excitement and some confuse excitement and happiness. Some may not be clear about what they are feeling because they weren’t allowed to experience their feelings or learned to be afraid of their feelings.

Often, emotionally sensitive people mask their feelings because they have learned that others don’t react well to their sensitivity. This masking can lead to not acknowledging their feelings even to themselves, which makes the emotions more difficult to manage. Being able to accurately label feelings is an important step to being able to regulate them.

When someone is describing a situation, notice the emotional state. Then either label the emotions you hear or guess at what the person might be feeling.

“I’m guessing you must have felt pretty hurt by her comment” is Level Three validation. Remember that you may guess wrong and the person could correct you. It’s her emotion, so she is the only one who knows how she feels.

Level Four is Understanding the Person’s Behavior in Terms of their History and Biology. Your experiences and biology influence your emotional reactions. If your best friend was bitten by a dog a few years ago, she is not likely to enjoy playing with your German Shepherd. Validation at this level would be saying, “Given what happened to you, I completely understand your not wanting to be around my dog.”

Self-validation would be understanding your own reactions in the context of your past experiences.

Level Five is normalizing or recognizing emotional reactions that anyone would have. Understanding that your emotions are normal is helpful for everyone. For the emotionally sensitive person, knowing that anyone would be upset in a specific situation is validating. For example, “Of course you’re anxious. Speaking before an audience the first time is scary for anyone.”

Level Six is radical genuineness. Radical genuiness is when you understand the emotion someone is feeling on a very deep level. Maybe you have had a similar experience. Radical genuineness is sharing that experience as equals.

Validation strengthens relationships and helps with managing emotions. By communicating acceptance, validation empowers your and others. For emotionally sensitive people, self-validation and validation by others helps them manage their emotions more effectively.

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2. Ask Bon: Why do you emphasize emotional validation so much?
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“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

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2. BPD: What’s the Cost?
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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.

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

Diagnosing Borderline Personality Disorder And Finding Treatment That Works

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

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

David: And the cause of Borderline Personality Disorder?

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

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

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

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

crazy32810: How is self-injury related to BPD?

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

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

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

See larger image The Believing Brain: From Ghosts and Gods to Politics and Conspiracies---How We Construct Beliefs and Reinforce Them as Truths (Hardcover) By (author) Michael Shermer List Price: $28.00 USD New From: $10.99 In Stock Used from: $11.58 In Stock Release date May 24, 2011.

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Borderline patients unfairly labelled violent

January 20, 2012 By Mary Anne Kenny

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright Emily Deans, MD

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

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The Emotionally Sensitive Person

By Karyn Hall, PhD

An Emotionally Sensitive Person is one who experiences more intense emotions than most other people do. When someone is emotionally sensitive, they often hear statements like “Stop overreacting,” or “You’re so dramatic.” Many are labeled as being “too sensitive” because their emotional reactions are quicker, last longer, and are stronger than other people expect.

Life is so complicated that we typically try to simplify it, often by putting people and events into black and white categories. But like much of what we tend to simplify in that way, being an emotionally sensitive person is not a you-are or you-are-not kind of descriptor.

Despite the emphasis our culture has on logic and self-control, the emotional part of everyone’s brain is pretty powerful, particularly given the right circumstances. Jonathan Haidt, in The Happiness Hypothesis, talks about the brain being like an elephant with a rider. Picture a huge six-ton elephant, with a rider on top. This represents the two basic systems in our brains.

Haidt says the rider is the logical, rational part of the brain that is reflective, it’s the part of you that deliberates and analyzes and plans for the future. The elephant represents the emotional system, the one that is instinctive, that feels pleasure and pain and wants gratification right now. But the rider is so small relative to the elephant, anytime the six-ton elephant and the rider disagree about which direction to go, the rider is going to lose. And that happens more than you might realize.

Anyone who has eaten a bag of potato chips when they said they would only have twelve, or who has compulsively called an ex when they vowed they wouldn’t, or who has said angry words they later wished they hadn’t, understands the power of emotion. And that’s just for everyday issues, not for the really big, this-matters-to-the-core kind of situations. For people who are emotionally sensitive, the elephant (the emotional part of the brain) is even more skittish and more difficult to manage.

Some individuals may have a focused sensitivity. This means they are noticeably more emotional than most people about a certain issue, like their weight or their children, or that they may be emotionally sensitive at certain times. Some may have always been emotionally sensitive and some may have experienced events that have led to or added to their sensitivity.

For others, their sensitivity is more general and varies along a continuum. At one end of the continuum are the individuals who are slightly more sensitive than the majority of people and at the other end of the continuum are those who are so emotionally sensitive it is difficult for them to function.

Because of the pain they feel and our culture’s tendency to value logic, some emotionally sensitive people may wish they didn’t experience emotions at all. Wouldn’t life be easier without sadness and fear? But emotions provide important information and skills such as signaling when to get out of dangerous situations (fear), the ability to be in relationships (love) and a capacity to appreciate positive experiences (joy). The emotional part of the brain provides motivation and commitment and is just as necessary for living as logic.

Being emotionally sensitive has its challenges and for some those challenges require professional help. Some people suffer deep pain on a daily basis because of their emotional sensitivity. At the same time, those who are emotionally sensitive often have a deeper capacity for caring about others, can be artistic and creative, and are often the people who bring about change through their passion for causes. Learning to manage your emotions so that the pain is lessened and there is room for joy can help you use the energy from your emotions effectively, make balanced decisions and be more effective in problem solving.

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