The core problem with BPD is poor emotional regulation. That particular problem can cause other symptoms to arise as the person with BPD becomes emotionally dysregulated. This term emotionally dysregulated (or just dysregulated) is used to denote the state in which a person with BPD is overcome with powerful and, at many times, misaligned emotional reactions. Remember that emotions don’t arise on their own; they are based on cues or triggers from the environment and compared by our “emotional immune system” to the meaning of the cue. For a person with BPD, the meaning can be misjudged or, as is more often the case, the sensitivity to emotional cues is greatly heightened.

An example is a heat-sensing system that helps to detect and suppress fires. Sometimes companies will install heat-sensing equipment in addition to smoke detectors so that they can protect assets that need a certain temperature to operate (e.g. computer equipment which might cease working at a high temperature). The setting at which an alarm goes off might be 80 degrees Fahrenheit. In the case of someone with BPD, the setting (or “tolerance” as it is called in the control community) is naturally set much lower, at say, 50 degrees Fahrenheit. That means that the alarm will be raised much more often and lead to a reaction to the alarm. In other words, people with BPD will experience many, many (what you would consider) false alarms. However, these false alarms seem completely real to them, because their tolerance for emotional triggers is set very low. They are constantly running a fire drill. Unfortunately for you, the BP may drag you along unwillingly and unwittingly for the drill. (Pages 32-33 of WHINE)

As you can see, the position I take in WHINE is that emotional regulation is the “core issue” of BPD. This position is in line with the DBT way of thinking, which is why one of the “modules” of DBT is emotional regulation skills.

The question is today: is emotional regulation at the “core” of BPD? Or does it go deeper than that? Is there a “cause” for emotional regulation? What are the triggers and how does a person with BPD’s internal feelings affect this “systems dysregulation”?

In the American Journal of Psychiatry, Drs. Stanley and Siever recently (January 2010) publish an article entitled “The Interpersonal Dimension of Borderline Personality  Disorder: Toward a Neuropeptide Model “ in which they seem to posit (in my interpretation again, since I am a lay person and not a doctor) that this systems dysregulation actually has another cause instead of being a “core cause’ of the disorder. They begin the article like this:

Borderline personality disorder is a complex disorder associated with substantial morbidity, mortality, and public health costs. Prominent symptoms include suicidal behavior, nonsuicidal self-injury, aggressive outbursts, and emotional reactivity, all of which typically manifest in an interpersonal context. For several years, there has been an ongoing discussion about whether impulsive aggression or affective dysregulation is at the core of the disorder. While these factors are important in borderline personality disorder, it is the exquisite interpersonal sensitivity that frequently triggers both dysregulated affect and impulsive behaviors, which suggests that this sensitivity perhaps rests at the core of the disorder and may in turn drive impulsivity and dysregulated affect.

They go on to say this:

It is noteworthy that many symptoms in the interpersonal domain of borderline personality disorder are actually manifestations of intrapersonal difficulties (e.g., difficulty being alone and misperception of the intentions of others as malevolent), and this dimension could perhaps be reconceptualized as “intrapersonal dysfunction.” We suggest that an internal feeling of well-being, stability, and self-regulation in borderline personality disorder is tenuous and may rely heavily on a sense of interpersonal contact and connectedness.

So, what’s afoot here? What are they saying and what does it mean to the nons of the world?

It seems to me that they are saying two very important things about BPD that has previously been “unnoticed” as DBT has reigned the clinical community. These are:

• “…it is the exquisite interpersonal sensitivity that frequently triggers both dysregulated affect and impulsive behaviors, which suggests that this sensitivity perhaps rests at the core of the disorder and may in turn drive impulsivity and dysregulated affect.” Basically, that the interpersonal sensitivity is the “control” of is sensitive to the (emotional) heat.
• “We suggest that an internal feeling of well-being, stability, and self-regulation in borderline personality disorder is tenuous and may rely heavily on a sense of interpersonal contact and connectedness.” That means that the lack of internal well-being makes the person with BPD sensitive to interpersonal cues.

What do those two important factors mean to you – the loved one or family member? In my mind they mean that a person with BPD uses people in close personal relationships to self-regulate. In other words, being unable to self-regulate internally, they look to external people to regulate their emotions, reactions, sense of well-being and behavior.  They believe at some level that you, the loved one, is an extension of their mind, emotions and feelings and assume to you “should know what to do” when they are feeling dysregulated.

What SHOULD you do when this situation occurs? What should you do when they are triggered? What should you avoid?

I believe that the most effective answer is to help them learn to self-regulate and self-validate. This “lack of well-being” is an unpleasant feeling (I would imagine) and probably feels like a HUGE lack of control. I mean, if a person has to rely on other (unpredictable) people to self-regulate, how must that feel? Having compassion for that feeling is definitely a goal. However, before that comes (and it can be cultivated BTW), one can listen, ask, redirect the choice, validate, normalize and cheer lead when appropriate. Don’t defend or minimize. Living a life in which you’re always waiting for the other shoe to drop has got to be unpleasant.

Related posts:

1. Emotional Tolerance and BPD
2. On My Side
3. When Tools Become Triggers

Shame and Implicit Self-Concept in Women With Borderline Personality Disorder

* Nicolas Rüsch, M.D., Klaus Lieb, M.D., Ines Göttler, M.D.,
Christiane Hermann, Ph.D., Elisabeth Schramm, Ph.D., Harald Richter, Ph.D.,
Gitta A. Jacob, Ph.D., Patrick W. Corrigan, Psy.D., and Martin Bohus, M.D. *

*OBJECTIVE: *Shame is considered to be a central emotion in borderline personality disorder and to be related to self-injurious behavior, chronic suicidality, and anger-hostility. However, its level and impact on people with borderline personality disorder are largely unknown. The authors examined levels of self-reported shame, guilt, anxiety, and implicit shame-related self-concept in women with borderline personality disorder and assessed the association of shame with self-esteem, quality of life, and anger-hostility.

*METHOD: *Sixty women with borderline personality disorder completed self-report measures of
shame- and guilt-proneness, state shame, anxiety, depression, self-esteem, quality of life, and clinical symptoms. Comparison groups consisted of 30 women with social phobia and 60 healthy women. Implicit shame-related self-concept (relative to anxiety) was assessed by the Implicit Association Test.

*RESULTS: *Women with borderline personality disorder reported higher levels of shame- and guilt-proneness, state shame, and anxiety than women with social phobia and healthy comparison subjects. The implicit self-concept in women with borderline personality disorder was more shame-prone (relative to anxiety-prone) than in women in the comparison groups. After depression was controlled for, shame-proneness was negatively correlated with self-esteem and quality of life and positively correlated with anger-hostility.

*CONCLUSIONS: *Shame, an emotion that is prominent in women with borderline personality disorder, is associated with the implicit self-concept as well as with poorer quality of life and self-esteem and greater anger-hostility. Psychotherapeutic approaches to borderline personality disorder need to address explicit and implicit aspects of shame.

http://ajp.psychiatryonline.org/cgi/content/abstract/164/3/500

Related posts:

1. DSM-V Changes to Personality Disorders
2. Role of Shame in BPD
3. Role of Shame in BPD

I post this message here because I am doing a review of my postings and discovering content that can be helpful or relevant to the non-BPD people out there. This particular one concerns the shame, self-image and pain of someone with BPD.

[Male member of list to female member: You asked him to "modify" his behavior.  That literally means he needs to change.  And, as you wrote to me, if people feel they're right -- they'll feel they don't need to change.  In other words, he's good.]

My reply: I will respectfully and forcefully disagree. No, he is NOT fine and that is his very issue. He KNOWS he is flawed, he KNOWS he “needs” to change. He is shameful about himself. He uses tools to make himself feel better – to escape his suffering. Those tools are: alcohol and drugs, cutting, suicide attempts and raging. He does this not because he is being criticized, he does this because he believes deep down he DESERVES to be criticized. What works better is to give him new tools – but doing that non-judgmentally is the key.

Jealousy has the same root as the suffering. Of course he thinks he “should be appreciated” but it ain’t because he is not appreciated, it is his deep sense of shame that he doesn’t DESERVE to be appreciated that scares the shit out of him and makes him rage. He thinks “you’re not appreciating me”, then “you think I’m a loser” and then “I am a loser”. But when you are being threatened, you fight back. He feels threatened because he is being “found out”.

[Male member to me regarding female member’s husband’s words: What about the underlying positive stuff... the "I'm hot, I'm brilliant, I'm special, I'm sexy, I'm fascinating, I'm irresistible, everybody loves me, I'm meant to be famous, etc.”  What filter is that?]

My reply: That’s the “I don’t really believe this, but I’m going to say it so you will confirm/validate it so I might start to believe it”. It is the needy, sad, shameful self, desperately seeking approval. The filter ain’t what he says, it’s what he HEARS.

BPD is an emotional disease. It is a disability. I’m not trying to let anyone off the hook here, but I think that you have assumed that everyone is slightly neurotic, but basically mentally healthy and extended that to this husband with BPD. I disagree because he has a mental illness (an emotional illness actually) and he thinks in a different fashion than you do. Inside he is profoundly shameful and dreads judgment. If anyone even HINTS at that, he blows up – either in a rage or with self-injury or with drugs or whatever. He is using those things to escape his suffering and to hide his shame from even himself. Those tools work: cutting makes the pain go away – but they are not “healthy” tools. He desperately protects that shame and when she says: “We have to discuss money” he hears: “You are a no good son-of-bitch who is crazy and lazy”. Why? Because he is disordered and has disordered thoughts. He is afraid that she can see right through him and see the shameful broken person inside.

When working with a BP, you have to think about what they’re REALLY saying and you have to think about what they’re REALLY hearing as well.

Related posts:

1. Paranoia, Shame and Judgment Sensitivity
2. Why Shame is Corrosive in a BP/Non-BP relationship
3. Runaway Shame?

Non-BPDs and self-image

I have starting thinking about the concept of “trade” words. What that means is that we nons “trade” certain words for other words. The purpose behind this is to re-make our ways of thinking – it helps to combat black-and-white thinking, shame and fear in ourselves. One of the concepts that I expound on in “When Hope is Not Enough” is the idea that one’s own language shapes one’s thoughts. While in that section of the book, I focus on the non-bp’s thoughts and words in relation to the person with BPD, here I am interested in how a non-BP thinks about his/herself.

Here are some examples of “trade” words and phrase that I have either discovered or developed:

Old Word: Must
Trade Word: Prefer, would like to

Old Word: Should
Trade Word: Choose to

(from now on the old word/phrase will appear first, the trade word next – just so I don’t have to type “Old Word:” “Trade Word:” over and over again…)

Can’t
Choose not to

Have to
Want to

Ought
Had better

All
Many or most

Always
Often or typically

Can’t stand
Don’t like

Awful
Undesirable

Bad Person
Bad Behavior

I am a failure
I failed at

Anxious
Concerned

Depressed
Sad

Angry
Annoyed or frustrated

Hurt
Disappointed

Guilt
Remorse about

Jealous
Concerned about the relationship

Never
Not often

is
seems like

is
feels like

I am certainly open to more suggestions. Here are some examples when thinking about yourself:

“I must do well” = “I want (or wish) to do well”
“I shouldn’t do that” = “I prefer not to do that”
“I am a bad person” = “I did a negative thing”
“I need love” = “I want love, but not need it to live”
“I can’t stand this” = “I don’t like this”
“I am a loser” = “I lost (or failed) at a task”

Related posts:

1. Emotional Independence
2. Values vs. Emotions
3. On My Side

Are you and your BP on the same team?

When someone is highly emotional, they need to know that they have an advocate and that someone is on “their side.” I often ask my consulting clients (especially partners of people with emotional regulation issues) if they feel that their partner and they are “on the same team.” Many times the answer is no. Why does someone have a desire to have someone on their side, even when the “sides” are not desired, intended or even clearly delineated? The answer in my mind comes down to shame and rejection sensitivity.

If a person has shame (or even low self-worth, which is similar), then the person is likely to have a high level of rejection sensitivity. Being rejected by others is painful, especially for emotional people. Having an advocate of their “side” of the issue, which is essentially answering, “I am on your side no matter what the situation,” is tantamount in these highly emotional, social interactions that involve rejection. One can be “on their side” emotionally without condoning whatever behavior that one doesn’t agree with.

There are teaching moments and there are times that one doesn’t teach. If you try and teach, punish or impart values during a period of emotional dysregulation, the relationship will be damaged and nothing effective will be accomplished. Instead, emotional validation and support can be used to cool the bonfire. Once it is cool, then a teaching moment can present itself.

Related posts:

1. MySpace Suicide
2. Rejection Sensitivity and BPD
3. Tough Love is not an effective approach to BPD

Shame is corrosive to a relationship because it keeps the BP or NP in “pretend mode” where they are behaving “as if” they are engaged in the relationship, but in reality their only real goal is to protect themselves from discovery. The closer you get to it, the more panicked they become. Often the shame is never revealed to others and covered up with bullshit (in the art term, not the common term). If a person is bullshitting their way through something (and sometimes they bullshit themselves too) then they are not genuinely engaged in the relationship. THAT is corrosive, especially when it is discovered and you think “was this EVER real?” That’s what leads people to think BPs can’t really love. But the bullshit is a defense mechanism to protect against mind numbing shame. In fact it could be argued that all defenses are at some level bullshit (or pretending things are ok). Still, we need them on some level to protect us from the brutal truth at times. Acceptance is not bullshit, it is taking things how they really are. If a BP can’t accept themselves as they are (and want to change) then you’re in for a steaming pile of bullshit in the form of protecting their shame – and that is no way to have a genuine relationship. Still, if they had no defenses against experiencing shame, they would all commit suicide.

Related posts:

1. Role of Shame in BPD
2. Fear and Shame
3. Shame and BPD

If we look at the diagnostic criteria of BPD, I’d say some of those features are REQUIRED to have the disorder (again this is my opinion). From the DSM IV:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following – and the diagnosis only applies to 5 or more of ANY of these traits….

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

OK, almost EVERY borderline I have come into contact with or have learned about has this feature including my wife. I didn’t think this was a big deal in my wife until she went into a crisis with one of her close friends and she told me (about the friend) “Don’t touch abandonment! That’s my ISSUE!” Abandonment by her father has had DEEP wounds for her. However, while it is very common, I don’t think it is required.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

I think this is a requirement, but not a “distinguishing characteristic” of BPD. Nons would not have a problem if this wasn’t an issue. It’s about splitting – however, splitting is not a feature that is exclusive to BPD. You see it in other disorders (although it might not be a diagnostic feature of others). You see it in PTSD, you see it in emotional immaturity… it is a very common cognitive distortion.

3. identity disturbance: markedly and persistently unstable self-image or sense of self.

I don’t know if this is required. I think this could be replaced with pervasive SHAME (which IS required IMO). The sense of self is more than “unstable” – it seems a bit self-judgmental… the invalidating of one’s emotions leads to shame, because it is wrong to feel like one feels. I think that causes an “unstable sense of self” because people have (or you yourself have) invalidated your very essence. It is not OK to be the way you are, so you have to search for a different way to be – in vain. That’s where acceptance can help.

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

Personally, I think the impulsiveness is a requirement too. Maybe not the behaviors mentioned here… but BPs are in my experience incredibly impulsive. If you look at this from wikipedia you will see how other countries view BPD:

Comparable diagnoses

The World Health Organization’s ICD-10 has a comparable diagnosis called *Emotionally unstable* personality disorder – Borderline type (F60.31). This requires the following, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.

The Chinese Society of Psychiatry’s CCMD has a comparable diagnosis of *Impulsive Personality Disorder (IPD)*. A patient diagnosed as having IPD must display “affective outbursts” and “marked impulsive behavior”, plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10′s Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.

5. recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior

Self-mutilating… probably not. Although I have known of many, many BPs that do cut, burn or pull at their hair. Or starve themselves. I think suicidal ideation is a given. According to some sources 75% of BPs attempt suicide at sometime in their lives.

6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

THIS is IMO the CORE feature of ERD (and possibly BPD if it is the same diagnosis – see WHO above). This – in combination with impulsiveness – seems to the the very foundation for BPD/ERD. I don’t think someone can have the disorder that I describe in my book (which I call BPD – or at least my experience with it) without this. This is the main thing the skills in my book try and address, because IMO this is the engine of all other feelings and behaviors. If this can be healed/managed most other things will fall away. Again I am NOT a doctor.

7. chronic feelings of emptiness

Probably important, but not required. I think many BPs DO feel this. It is difficult for me to see this from the outside (or for any non, unless the BP reveals it).

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

Again, this is probably required and is what gets most nons to seek help. I think this is an out-growth of emotional dysregulation and shame. They FEEL angry, because angry is a powerful emotion and a natural reaction to threat – even if the threat is “imagined” (although felt).

9. transient, stress-related paranoid ideation or severe dissociative symptoms

Well, this is a hard one. I have seen this in my wife a couple of times. She walked around talking to pillows as if they were people at one point. It’s tough to say if this is “required.”

So, I have a certain view of the disorder that I think works in most cases (but possibly not all). I would encourage you guys to read the book and try it out. It takes some time to figure out what I’m saying though… because of the above view of BPs/nons is slightly “unstandard”. Again I’m not a doctor.

Related posts:

1. DSM-IV Criteria
2. The Myth of the High-Functioning Borderline
3. Reopened the diagnosis poll

UPDATE: see this link.

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

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

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

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

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

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

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

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

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

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

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

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

And now NPD:

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

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

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

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

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

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Related posts:

1. Remission Common in BPD, but functioning still a problem
2. The myth of Hoovering
3. How mentalization and attachment might explain “high-functioning” BPD

I think that many BP’s get paranoid about their self-image with other people. The combo of fear of judgment – which they perceive as judgment of their emotions and therefore judgment of their SELF mixes with the shame they feel about their self. Am I off-base here?

My wife has told me she has felt shameful about “the way she is” for years. Does that lead to personalization and thus to paranoia?

What do you think?

Related posts:

1. Rejection Sensitivity and BPD
2. Fear and Shame
3. Runaway Shame?

http://www.soulselfhelp.on.ca/drm10shame.html

The Role of Shame in BPD
© Dr. Richard Moskovitz

Can you discuss shame? Is shame not one of the most significant core wounds that must be healed in order to recover from BPD?

Shame is fundamental to the experience of anyone with BPD and is the most crucial emotion that must be addressed if recovery is to occur. Shame is often confused with guilt, but these emotions have very different meanings. Shame is about who we are, while guilt is about what we do. Shame therefore reflects more lasting beliefs about the self than guilt. When we feel guilt, we expect retribution for what we’ve done. When we feel shame, we expect contempt from others and feel contempt for ourselves.

Shame is connected with a wealth of negative self-beliefs that may include fundamental assumptions of defectiveness, the belief that one is helpless to survive alone, beliefs about physical defectiveness (“I am fat, deformed, repulsive to others), mental defectiveness (I am stupid, incompetent, inarticulate), or sexual defectiveness, and the belief that one is unworthy of the love and attention of others.

We feel shame about anything about ourselves that we would prefer others not to see. The body language of shame is about being invisible or not acknowledging being seen by others. We become small in posture by slouching or turning away. We avert our gaze from that of others, which is reminiscent of a baby covering its own eyes and imagining that it has become invisible to others. As adults, however, failing to meet another’s gaze is also a sign of submission.

We also feel shame whenever we fall short of our own expectations of ourselves, however unrealistic they may be. Impossible goals, such as the total eradication of body fat, inevitably lead to deepening shame, which in turn may be reflected in an increasingly distorted self or body image. This is the cycle of shame that fuels the compulsive self-starvation of anorexia nervosa. Shame is therefore connected with the fantasy of how we imagine we are supposed to be and obstructs our vision of who we really are.

While shame has many roots, it is a natural consequence of abuse and neglect. What all forms of abuse have in common is the contempt that an abuser has for a victim. The deeper pain of being abused is the shame that derives from being an object of contempt. Many abusers show their contempt explicitly in the form of degrading words, but all abusers show contempt by their assumption that their victim’s primary role is as an instrument for their gratification. Shame in turn results in submissiveness that tends to perpetuate the cycle of abuse.

Dr. Donald Nathanson has pioneered the study of shame and its relationship to the psychotherapeutic process. He defines four categories of learned responses to shame, which he visualizes as the four points on a compass. On one axis lies “Withdrawal” at one pole and “Avoidance” at the other. On the other axis lie “Attack self” and “Attack others.”

“Withdrawal” behaviors include various forms of hiding from others, ranging from averting ones eyes and maintaining silence in the presence of others to reclusiveness and flight. Withdrawal can lead to isolation and feelings of abandonment, confirming the belief that we are unworthy of the company of others and therefore reinforcing shame.

“Attacking self” includes a repertoire of behaviors that are designed to protect us from abandonment at all costs. These are self-negating, submissive gestures that acknowledge the superior power of another, whose presence has become important to us. This can also contribute to the cycle of abuse.

“Avoidance” includes all the behaviors that are designed to keep from feeling the shame. This ranges from the use of drugs and alcohol to obliterate feeling to the distractions of sexual indulgence, materialism, and vanity. Avoidant behaviors include a variety of things we do to cover up the defects that we imagine others see in us. They are often cosmetic in quality and serve to distract both ourselves and others from these defects.

“Attacking others” includes a repertoire of desperate behaviors that serve to belittle others as a last ditch attempt to rescue self-esteem by feeling bigger at another’s expense. The attacks may come in words or actions. These behaviors inevitably distance us from others, again raising the threat of abandonment. These behaviors also result in shaming others and pass the wounds along.

These four kinds of responses to shame are all intricately interrelated, are self-defeating, and therefore perpetuate the cycle of shame. They are behind the many impulses with which people with BPD must struggle. They are connected with the terror of abandonment that characterizes BPD as well as with the difficulty that people with BPD have in achieving intimacy.

Related posts:

1. Role of Shame in BPD
2. Shame and BPD
3. Fear and Shame