A little while ago, I posted an study about the over-lap between Major Depressive Disorder and Borderline Personality Disorder. The last sentence of this study was “In the meantime, the clinician treating major depressive disorder would be wise to assess for borderline personality disorder, even as currently defined.” That was because the study found a large correlation between the two disorders. Today, I was reviewing an article by Marsha Linehan called “Two-Year Randomized Controlled Trialand Follow-up of Dialectical Behavior Therapyvs Therapy by Experts for Suicidal Behaviorsand Borderline Personality Disorder” which I had planned to write something up about. I’ll have to do that later, but the reason these thoughts of MDD and BPD came to mind is that in the first paragraph of Linehan’s article she states:
“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.
Epigenetic inheritance of the negative impact of stressful events across generations
Depressive, impulsive and antisocial symptoms caused by severe chronic stress during childhood are transmitted epigenetically from one generation to the next. This has now been demonstrated by researchers at the University of Zurich and ETH Zurich.
Peter Rueegg
In human, chronic severe stress or traumatic experiences during childhood can lead to various psychological and mental disorders in adult life, such as borderline personality disorder and bipolar depression. A study carried out by a team under the supervision of the neuroscientist Isabelle Mansuy has used mice to demonstrate that such negative experiences can also have an impact on following generations. Mansuy holds a double professorship at the University of Zurich and ETH Zurich.
Stress during childhood, problems during adulthood
The scientists used mice as an experimental model, and exposed newborn pups to chronic and unpredictable maternal separation for two weeks. They also exposed the mother to additional unpredictable stress during the separation. This procedure was designed to induce extremely severe stress in the young mice, and is thought to simulate neglect and traumatic upbringing that children sometimes experience in uncaring, negligent or violent families. The young mice reacted so dramatically to the separation that they became depressive and impulsive as adult, and had social problems.
In particular, these animals were unable to deal appropriately with unfamiliar or adverse situations, and easily lost control of their behavior. For example, they lost their natural sense of caution when exploring new territories, and were no longer able to evaluate the potential risk of unfamiliar situations. They also reacted with apathy and despair in adverse conditions, and did not struggle for life in contrast to mice that grew up in normal conditions.
The traumatized mice retained these altered behaviours during their entire life and strikingly, «transmitted» these behaviours to their offspring. The researchers even provided evidence that transmission was across three generations, and that the offspring of that offspring was also affected.
Epigenetics determines behaviour
However, these behavioural changes are not attributable to mutations in the genetic make-up of the traumatized mice, since the genome is fixed and cannot be modified by stress. The researchers demonstrated that instead, stress interferes with the epigenome, in particular with the profile of methylation of certain genes in the brain and the sperm of male mice. This epigenetic plasticity is based on changes in chromatin structure, that alters the expression of the affected genes. In a way «Stress confuses the methylation machinery in the germline of the stressed pups, and the confusion persists and is transmitted», explains Isabelle Mansuy.
“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.” – from the interview
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.
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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.
Here is a Ted Talk by Michael Shermer on the pattern-finding power of the human brain. After I watched this video, I was struck that this is probably why people with Borderline Personality Disorder or just highly sensitive people develop the belief that people are out to hurt them or that they are being judged and degraded by others.
You can purchase a copy of his latest book at Amazon below.
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.
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. Continue reading Borderline patients unfairly labelled violent →
In psychiatry we have a a whole recipe book of diagnoses called the DSM IV-TR, soon to be replaced by the DSM-V. The original DSM was derived from an army handbook used by psychiatrists in WWII, much of which was taken from handbooks developed by German psychiatrists from their observations in the late 19th century. The rest of the army handbook was derived from psychoanalytic thinking — the theories of Freud and his followers. In the DSM I (1952), there were two kinds of illnesses, for the most part, psychosis and neurosis. Psychotic illnesses were defined by a break from reality (as in paranoid or religious delusions in schizophrenia or manic psychosis), and neurotic illnesses were considered to be reactions to psychological stressors and events.
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. Continue reading Love and Opium. Borderline Personality Disorder and pain-killers →
ANNE* ALWAYS felt she was different from everybody else and, having had a difficult early childhood, by the time she was a teenager she did not think she belonged in this world.
ANNE* ALWAYS felt she was different from everybody else and, having had a difficult early childhood, by the time she was a teenager she did not think she belonged in this world.
“I believed I was invisible – I didn’t think people saw me,” she says. “I was insecure and very mixed up about my own identity; I did not know who I was, or how to fit in to life.”
From her mid-teens on, she attended a succession of psychiatrists and counsellors and was prescribed various medications for her “mood”. However, becoming a wife and mother gave her a new, positive feeling of belonging, and she moved on to become a mature student, followed by short-term work placements and voluntary work.
But when, in her 40s, life threw up challenges over which she had no control, her thoughts and emotions began to change rapidly.
Old fears of being abandoned returned; she became angry and impulsive. She started to self-harm and contemplate suicide; she misused alcohol and became dependent on prescribed medication.
It was only then that she was diagnosed with borderline personality disorder (BPD) and she began to understand the impact it had on her.
BPD is a broad category of mental health problems, often defined by “really powerful emotional distress and sometimes a lot of problems in relationships”, says Jim Lyng, a counselling psychologist with Cluain Mhuire, a community-based adult mental health service in the southeast of Dublin.
Affecting an estimated 1-2 per cent of the population, the disorder is characterised by impulsive and often life-threatening, self-destructive behaviour. Problems tend to start to show before a person reaches adulthood, as they begin to cope with their emotions in extreme ways.
“In a heightened state, people start to make desperate choices,” he explains. Talking of deliberate self-harm or attempts at suicide as “cries for help” misses the point, he suggests. “They are desperate attempts to cope.”
Luckily for Anne, she is living in one of the few areas of Ireland where the successful, evidence-based treatment programme of dialectical behaviour therapy (DBT) is available. Within weeks of diagnosis, she started DBT at Cluain Mhuire.
DBT was developed by Dr Marsha Linehan from the University of Washington to help people with a history of repeated self-harm and suicidal behaviour, many of whom would be classified as having borderline personality disorder.
An ATSTP list member responds to a question of whether another’s borderline wife will ever change because of emotional validation:
I found validation isn’t as effective until the underlying agenda tilts more towards acceptance rather than change. This may sound strange, but after we accept that the situation may not change (and behave accordingly), it then grows room to change.
For many, reality is hard to accept. Unexpected and overwhelming events like lost jobs, physical illness and financial problems can make us want to give up or refuse to acknowledge the realities of our circumstances.
In Dialectical Behavior Therapy, the ability to accept life, the reality of circumstances in which we find ourselves and the painful events that each of us must endure is taught as a skill.
These skills can be difficult to teach and learn because the ability to respond to the world as it is, is an underlying attitude towards life. These skills, taught in the Distress Tolerance Module of the skills training group, include strategies to get both our bodies and our minds into more accepting attitudes.
Below are a few exercises on acceptance:
Body Awareness
To cultivate a more accepting state of mind, increase awareness of your body. Start by simply bringing your awareness to the position of your body. This can be done any time and any place. Whether you are walking, standing or sitting, notice your position. Become aware of the purpose of your position. For example, are you folding your arms across your chest in a defensive stance or are you tapping your foot in anxiety. If you notice that your mind has drifted, bring your attention back to your breath. It can be helpful to practice breathing exercises, such as counting each breath or saying “in” with each inhale and “out” with each exhale. Continue reading Dialectical Behavior Therapy: Radical Acceptance →
Jessica Cahill tried to kill herself a month ago. She is 28 and has lived with severe anxiety and deep depression since she was 12. Cahill has been hospitalized nearly 30 times in her short life. One psychiatrist recently said she has borderline personality disorder.
Mental illnesses such as depression and anxiety disorders are complex and difficult to explain to those who haven’t lived through them. Cahill described her afflictions eloquently and with clarity over several hours of interviews.
She invites the Star’s readers inside her mind with the hope that it helps at least one person:
I want to talk about suicide because no one talks about it. Maybe if we talk about it, other people won’t feel so alone like I do right now.
I tried to kill myself on Nov. 1. My boyfriend was supposed to be gone all night, but he came back early. By then I had taken about a hundred pills and was unconscious. I was in a coma in the hospital and got out five days later.
I was even more down than usual that day. I usually wake up sad. Mornings are the worst. It takes a while to fall asleep because my mind is overactive. When I do fall asleep, I just want to sleep forever.
And I was just so tired of depression. Everyday I wake up sad and struggle to smile. Every day is the same. I can’t leave the house. I’m just not happy in my life. I felt hopeless and was done.
I wasn’t thinking properly. I was thinking about my parents, who worry so much. I wrote them a note and said I thought it would be better if I go so they can move on and not worry about me anymore.
But then they told me after that that’s ridiculous. I just think that I’m such a problem in their life. My mom is really involved. She wants me to get better, but I don’t know if she really understands I might not ever get better.
I got mixed up with OxyContin. I felt great when I was on Oxy. It numbs my feelings. It slows your brain down because it’s moving too fast otherwise. Millions of thoughts go through my mind — it’s overwhelming. And there are good thoughts mixed in with bad thoughts, but I always focus on the negative thoughts.
Those two months on Oxy were really fun, then it became problematic, and finally it’s hell and you have to have them. At that point, you’re sick when you’re off them and it’s a big fear if you don’t get your pill. You get muscle spasms, then you’re cold and you’re hot, and you got to find money for the next batch because you’ve got to get it.
I’ve been on everything, including Clonazepam. My mom hates Clonazepam. I love it, but I’ll abuse it. The relief I get when I take it is amazing. Within 20 minutes I’m a new person. I can be lying on the couch crying, take a pill and be up half an hour later.
It’s supposed to make you tired, but for me it gets me up, I can go out, talk to people and do everything I usually don’t do. I’m normal. That’s why I love it, but then I get a little anxious about losing that feeling, so I take more. I guess it’s ironic that I get anxious about running out of anti-anxiety pills while I’m taking anti-anxiety medication.
I just can’t take them properly, I pop them too close together and it builds up and I lose inhibition and go crazy.
My anxiety came early. I was a nervous child and really sensitive. I remember every remark and what other children thought. I cared more about what kids would say. In high school, a few boys would consistently make fun of me. They’d laugh at me when I had to speak in front of the class because I was nervous.
You know that butterfly feeling you get when you’re nervous? I have that all the time, although it’s not that bad in my stomach. Much of my anxiety seems to be trapped in my throat, like that frog-in-your-throat kind of feeling. It’s probably also from so much crying.
Since high school, I spent a semester at college, dropped out and have had about 30 jobs. I’d quit or miss shifts and get fired. I just don’t want to leave home. I’m on welfare and feel like a complete drain on society. I want to get a job.
I try to have a little hope. I’m supposed to start school in January at George Brown College. I hope it works out. But I’m worried already that I’ll have to take substances to go. Or I’ll miss class and fall behind. I’m just worried about everything all the time.
It’s hard to even walk down the street. I think people are looking at me, judging me and I feel uncomfortable. It’s scary. I’m lightheaded. And I’m always crying, even outside, even on the bus. And a lot of people don’t get it. They think I’m weak, but I just can’t help it. It’s me. I’ve become anxiety. I’ve become depression.
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