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.

Related posts:

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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Anyway, I was reviewing a document about the general principles of CBT (called SelfHelpCourse.pdf), and it outlines an important point about events, thoughts and emotions. I have pointed out in several articles and in my book about the behavioral chain:

Event -> Thought -> Emotion -> Action Impulse -> Behavior

The document says this about the different reactions a person may have to an event:

For instance, if someone you know passes you in the street without acknowledging you, you can interpret it several ways. You might think they don’t want to know you because no-one likes you (which may lead you to feel depressed), your thought may be that you hope they don’t stop to talk to you, because you won’t know what to say and they’ll think you’re boring and stupid (anxiety), you may think they’re being deliberately snotty (leading to anger). A healthier response might be that they just didn’t see you.

No related posts.

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DBT iPhone App

Are you in DBT? Do you want to know more about it? The creator of the new DBT iPhone application has graciously provided me with a coupon code for a free version of the app. If you’d like to receive this coupon code and want to download the app to your iPhone for free, please send me a direct message on twitter @bondobbs. I only have one, so I expect it to go fast.

UPDATE: You can also claim this code by commenting on this post and providing your email address (which is not shared). I will email you the code and instructions if you have problems redeeming it.

UPDATE 2: Code is gone! Sorry. However, if you’re still interested in the app go to www.diarycard.net

UPDATE 3: I got another code. The last one went fast. If you want it comment on this post.

UPDATE 4: Sorry the second code is gone. Yet, if you want the app for free, comment here. I will not post the comment, I’ll just ask for more codes and email them if I can get them. The codes are limited. Act fast!

UPDATE 5: OK, I’ve given away several codes. I have one more… the final one for me. If you want the final code, please comment on this thread. I will not post the comment, but will send you the code.

FINAL UPDATE: All codes are now gone. Thanks to Sammy for providing them to my readers!

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1. Read my free eBook
2. DBT Self-Help App for the iPhone under works
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This app was developed by Dr. Sammy Banawan in Durham, NC. Dr. Banawan maintains a full-time private practice in Durham where he also did his internship and post-doctoral fellowship at the Duke University Medical Center. During his post-doctoral fellowship, he worked directly with Dr. Marsha Linehan and her colleagues in continuing to adapt DBT for a variety of psychological conditions.

While this app was developed by a mental health professional, it is not intended to replace a therapist. You will get the most from the app with the aid of a DBT-trained psychotherapist. Remember that if you are actively suicidal or engaging in self-injurious behaviors, you need to be working with a therapist.

This application was created in an effort to bring psychotherapy practices up to 21st century standards. As more and more people carry around mini-computers in the form of smartphones, having to use sheets of paper to record something like behaviors or emotions seems a little ridiculous. It was also designed with the utmost in customizability in mind since no two people are working on the same sets of issues or with the same sets of treatment targets.

Over years of experience treating patients using Dialectical Behavior Therapy, we started to get a sense of what most people need to track and what types of coaching is useful and that’s where the app starts. As you use it and add more of your own information into it, the app will start to be even more helpful to you.

 

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2. Bobby Baker diary wins Mind Book of the Year
3. Act Fast! I have been given 1 coupon code for a free DBT iPhone app

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F60.3 Emotionally Unstable (Borderline) Personality Disorder

A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.

Impulsive type:
The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.

Includes:

• explosive and aggressive personality (disorder)

Excludes:

• dissocial personality disorder

Borderline type:
Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).

Includes:

• borderline personality (disorder)

Related posts:

1. DSM-IV Criteria
2. Proposed Changes in the DSM-V for Borderline Personality Disorder
3. A Must-Read Interview with a recovered Borderline

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One in five U.S. adults takes medication for a mental disorder

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

9:53 AM PST, November 16, 2011

Medications to treat mental health disorders is soaring among U.S. adults, according to data released Wednesday by Medco Health Solutions, a pharmacy benefit manager.

Twenty percent of all adults said they took at least one medication to treat a mental disorder. Among women, 25% said they took such medication and 20% said they were using an antidepressant.

The survey analyzed prescription drug trends among 2.5 million insured Americans from 2001 to 2010.

Medco researchers also found that adults ages 20 to 44 had the greatest uptick in use of anti-anxiety medications, atypical antipsychotics and drugs to treat ADHD. The number of women on ADHD medications was 2.5 times higher in 2010 than in 2001.

The number of children under 10 taking antipsychotic medication, which is reserved for the most severe mental illnesses, doubled from 2001 to 2010.

There was a stark drop in use of antidepressants among those 19 and under, however. Usage has fallen since a 2004 warning from the Food and Drug Administration that the drugs could increase suicidal thoughts. Prescriptions for anti-anxiety medication among people 65 and older also fell over the last decade.

Reasons behind the growing popularity of medications for mental illness is debatable. Understanding the upswing “is the next critical goal,” Dr. Martha Sanjatovic, a professor of psychiatry at Case Western Reserve University School of Medicine, said in a statement released by Medco.

Said Dr. David Muzino of the Medco Neuroscience Therapeutic Research Center: “[W]hat is not clear is if more people — especially women — are actually developing psychological disorders that require treatment, or if they are more willing to seek out help and clinicians are better at diagnosing these conditions than they once were.”

But, he noted, it was a tough decade: the 9/11 attacks, two wars and a deep recession.

The report is entitled America’s State of Mind

Related posts:

1. Benzos and BPD
2. NIHM Director Thomas Insel considers the name of “Borderline Personality Disorder”
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• Sending someone to therapy is not like having your car repaired. It involves a lot of hard work on the part of the patient/client and on the part of their loved ones and supporters.
• Therapy as usual (referred to as TAU in the studies) can actually make BPD worse in some individuals. There are several BPD-specific therapies, such as DBT, Schema-focused therapy and Mentalization-based therapy.
• Therapy requires the buy-in of the patient/client. If he/she doesn’t want to admit he/she has a problem or doesn’t trust the therapist with his/her feelings, therapy will likely not have a lasting effect.

Unfortunately, you can’t force someone to go to therapy if she doesn’t want to go (except through a court order). What I suggest is that you use the tools I offer for a while. After you do that for some time, the borderline might begin to gather some self-awareness or to share her inner thoughts and feelings with you. It is likely that these thoughts and feelings will be filled with shame, self-hatred and worry. At that point, you can say something like, “Boy, it must feel awful to feel that way about yourself. What do you think you can do to feel better?” or “That’s so painful to feel that way. Maybe therapy can help?”

My wife has resisted going to DBT because it identifies her as a borderline and she “doesn’t want to be that person.” She also resists because DBT seems like a therapy of last resort to her and, if she fails at it, she feels that she will have to be committed to a mental institution. I occasionally do reinforce to her that there are people who are trained to help her feel better and encourage her to look into it. She is in therapy, but not in DBT. My daughter does see a DBT therapist. She decided to go because she was so angry all the time, and she felt terrible. She wanted to learn how to feel better. At some point, her emotional pain reached an intolerable level.

I have tried to model these skills in my life and, by doing so, shown my wife that I can more adequately cope with emotional situations, both personal and interpersonal. This modeling encourages my wife to consider DBT (or another emotional training program) to help her feel better. My suggestion is that you practice effective tools, master them and use your mastery over emotional situations as a beacon for your borderline’s healing.

Related posts:

1. Mentalization Based Therapy Shows Promise with BPD
2. Can therapy actually hurt borderlines?
3. Ask Bon: How do I get my borderline loved one in therapy? What’s the best kind of therapy? How long will it take to cure them?

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Six patients committed suicide while in hospital. A near-miss occurred when a patient with borderline personality disorder was placed in seclusion and had to be revived after trying to strangle himself. A nurse was delayed in reaching the patient due to difficulty finding a key to the seclusion room.

I don’t know why they’d put a suicidal person with BPD in seclusion. Wow.

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Coming out of the Borderline Personality Disorder Closet (Without Hitting my Head on the Door Jamb)

By SONIA NEALE

Six years ago I was officially diagnosed by a psychiatrist in a psychiatric hospital as having…drum roll please…BORDERLINE PERSONALITY DISORDER.  He said it to me in the same way he would announce he had a plague of rats infest his kitchen, discovered I had a sexually transmitted disease or that he had just found out I supported Tea Party candidate Sarah Palin.  It was delivered with revulsion, disgust and contempt.

Today I proudly come out of the BPD closet and out myself as having one of the most reviled and hated personality disorders ever constructed by the most esteemed and eminent fundamentalist gentlemen writers of the Psychiatric Bible the DSM – Diagnostic and Statistical Manual.

If mental illness is stigmatised and discriminated against within the general community, then Borderline Personality Disorder is stigmatized and discriminated against within the mental health industry.

I was diagnosed as a BPD by a psychiatrist who had spent less than an hour talking with me around about the same time my clinical psychologist (of eight years at the time back in 2005) told me I was a schizoid personality disorder.  These two personality disorders are diametrically opposed.  One is excessive emotion (think Roseanne) and the other is no emotion at all (think Sheldon Cooper – Big Bang Theory).
I have had four psychiatric hospital stays over 15 years, the first when I was on Zoloft and had three children under five with post natal depression.  The second was after dexamphetamine withdrawal; the third after a kidney cancer diagnosis and subsequent overdose of valium; and the last suffering with the excruciating side effects of akathisia from Zyprexa.

After the last visit, I decided pills were part of the problem, so I decided psychotropic medication was no longer an option for me.  Previous to my diagnosis I researched BPD and discovered that I did fit somewhat into the nine symptoms, which include emotional dysregulation, abandonment issues, relationship problems, impulsive behaviour, suicide ideation, splitting into black and white, identity disturbance, emptiness and paranoia.  But my clinical psychologist admitted she too suffered from much of the above at some point in her life but to a lesser degree, one which does not cause psychiatric issues in her life.

I took each and every sign and symptom and made major changes in my life.  It took several years to do so.  I would monitor my behaviour, thoughts and feelings with mindfulness, reflection, education and blogging.  In the over two years I have been blogging on Psych Central I have had ants crawling up my spine at the thought of putting on the internet that I have been officially diagnosed with BPD.
Only now I find it empowering to speak out and share my story.

The pre-existing condition to being diagnosed with BPD which is not in the revered and almighty DSM is to be a woman and to have an outspoken opinion.  But I was not born with BPD; I was born with a genetic predisposition towards sensitivity.  It was this sensitivity which led to heightened emotional feelings, deep insight at an early age, bullying and sexual assault by a group of girls at school, parental invalidation of who I was and how I felt, being sexually provocative and active at an early age and fighting endlessly with authority.  An inability to process the world around me led to eating disorders, relationship problems, smoking, drinking and recreational drug issues.

My relationship with my adored clinical psychologist over many years changed my brain.  I have often been criticized and ridiculed by readers of my blog because of my long-term relationship with the woman I credit with saving my marriage, my family and my life but without her love and kindness where would I be now?

Long-term psychotherapy was non-evasive brain surgery for me, eliminating those parts which caused me distress.  I didn’t need just CBT and interpersonal therapy, I needed a loving mother who would nurture and support me and raise me as her own.

It was this relationship that led me to my true calling.  I now work as a peer worker in the mental health industry.  I recently had to give a presentation speech to a bunch of dry, prune-faced, bored, disinterested, clinical-depression-grey haired, jaded and tired psychiatrists, doctors and professional people and I said:

“You are the first people to know this as it has been my secret for six years, but I was diagnosed with Borderline Personality Disorder which is the most reviled diagnosis in the DSM – so you can all throw rotten tomatoes at me now if you like.”

Not one of them batted a stony eyelid, let alone threw a red, soggy, decomposed vegetable in my eye.  Not one of them moved a finger, smiled, nodded, hmmmed, assented, moved or laughed or in any way acknowledged the sheer immensity of what I had just spoken about.

My job is to reveal carefully honed, but intimate details about my life in a safe manner to me, and my job is to connect with consumers/professionals due to my lived experience.  It was like trying to mash a banana through a brick wall.  I did not engage or connect with any of them in that vacuum of silence and disinterest.  I have never had that in all my radio work, public speaking engagements or anything.  I have been told that when I speak I am very seductive (in the entertaining and compelling sense) and I could not seduce them in any way, shape or form.  Even taking account that it was 3pm on a Friday afternoon, they were simply unseduceable.

It reminded me of the anti-climax in the movie “The Truman Show” when Jim Carrey discovers no-one really cares about his life.  Nobody actually cared about my revelation.  But I am so glad I did it, I realise that coming out of the borderline closet will be of major importance, not just to me, but to other BPD diagnosed people, who live under the radioactive umbrella of shame, guilt, embarrassment, self-loathing and who are too afraid to come out of the closet in case they bang their heads on the door-jamb on the way out.

Sonia Neale started therapy writing for post-natal-depression and anxiety. Fifteen years later she is the author of two books, The Bad Mother’s Revenge and Death by Teenager, both published by ABC Books/Harper Collins. She lives in Western Australia, is married with three teenagers, has a certificate in Psychoanalytic Psychotherapy and is studying for a psychology/counselling degree. She is not yet a psychotherapist, and has deferred her academic studies in order to pursue a Certificate IV in Mental Health. She currently works as a Peer Support Worker with the National Tobacco and Mental Illness Project. Her website address is www.sonianeale.com.

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The BRTC is primarily a research clinic, offering treatment to members of the community as part of our clinical trials.  We are not currently recruiting for any clinical trials, but we periodically have openings for new clients in our Treatment Development Clinic (TDC).  Through TDC, clients receive Dialectical Behavior Therapy from doctoral students under the supervision of licensed psychologists.

TDC is currently accepting new clients in our FRIENDS AND FAMILY DBT Skills group.  This group is designed for family members, friends, and caregivers of people with chronic mental and physical health problems like borderline personality disorder, bipolar disorder, and Alzheimer’s disease.  For more information on this group, please call 206-543-3765.

I would urge all family members to consider attending this class (or a similar class). These DBT-FST (Dialectical Behavior Therapy Family Skills Training) are invaluable in understanding your family member with borderline personality disorder and creating a healing environment in the home.

Related posts:

1. DBT for the Family?
2. Ask Bon: How do I get my loved one with BPD to go to therapy?
3. Understanding Borderline Personality Disorder from WHYY

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“…BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics,” writes John G. Gunderson, MD, from the Psychosocial and Personality Research Program, McLean Hospital in Belmont, Massachusetts. “Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury. Such episodes result in an average hospital stay of 6.3 days per year and nearly 1 emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder.”

As you can see BPD has a major financial impact on the health care system, not to mention the distress for the patients and their families.

When reviewing the various treatment options, the author says this about mentalization therapy:

Mentalization-based therapy is a cognitive or psychodynamic therapy including individual as well as group therapy. While assuming a “not-knowing” stance, the therapist insists that the patient “mentalize,” or examine and label his or her own experiences and those of others. This emphasis on thinking before reacting may be a process central to all effective therapies.

That “not-knowing” stance is what I tell the nons that I know: Be a detective, not a judge.

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Mind Reading: Psychologist Simon Baron-Cohen on Empathy and the Science of Evil
By MAIA SZALAVITZ Monday, May 30, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What stunts the development of empathy in personality disorders?

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

What defines borderline personality disorder?

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

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

So how would you address increasing empathy in these conditions?

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

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

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

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

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

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

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

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

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

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

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

Why does empathy seem especially lacking in the teen years?

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

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

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

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

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

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

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

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

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

Find this article at:

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

You can buy to book here:

See larger image The Science of Evil: On Empathy and the Origins of Cruelty (Hardcover) By (author) Simon Baron-Cohen List Price: $25.99 USD New From: $13.92 In Stock Used from: $9.88 In Stock

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Amy Winehouse was spotted buying a bottle of vodka on her way to treatment at The Priory hospital in Southgate.

The troubled and talent singer, Amy Winehouse, made headlines yet again this week after purchasing a bottle of Vodka from a local retailer. Winehouse who is known for hits including ‘Valerie’ and ‘Rehab’ was spotted entering Meadway Food and Wine in North London’s Southgate area where she bought and downed a bottle of Smirnoff. The star, who has been the focus of considerable media attention following an ongoing battle with drink and drugs, was on her way to The Priory where she is being treated for her addictions.

An onlooker, who saw the events in question, confessed to being stunned by Winehouse who slurred her words as she entered the shop premises at 12.30pm last Wednesday. “I was shocked to see her buy vodka so early in the day”, said a witness, “and even more shocked to see her knock it straight back.” Other customers at the site also reported hearing the singer vomit before walking out of the shop whilst announcing that she had “puked” all over the bathroom. “I felt really sorry for the staff”, said a source.

A spokesman for the 27 year old living legend confirmed that the singer was in the area to undergo a period of rehabilitation at the private mental health institution. A Statement issued on behalf of the star insisted that Winehouse had not been sick but was simply making a “joke”. “Amy’s embarked on treatment at The Priory,” the statement concluded. Fans of the singer will be hoping to see the star on the road to recovery in the very near future.

 

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In my group recently, a non-BPD was questioning his own “sanity” (I put it in quotes because I don’t believe that people with BPD are insane) and speculating that he was the one with BPD. One of our longer-time posters replied:

If you’re not throwing full-blown temper tantrums, freaking out because EVERYONE is out to get you, threatening to hurt or kill yourself, running away from those who love you because you’re afraid they’re going to leave you first, complaining that NOBODY loves or respects you AND popping pills and guzzling alcohol all at the same time… then, I think, you can go ahead and disqualify yourself.

Based on the polls that I have conducted over the past few months, I believe that she is right on the money. Here are the poll results from the last few polls about borderline behavior:

Borderline Behavior Poll Results

As you can see by these polls results, more than 73% responded that their borderlines (or themselves if they have the disorder) indicated that they have engaged in self-injury, suicide attempts and/or substance abuse. While these polls are certainly not scientific and it’s pretty much impossible for me to understand the profile of a person that responded, they results are, for me, striking. If 7 out of 10 (or more) individuals engage in these “low functioning” or ineffective borderline behaviors at some point in their lives, what should that tell us?

I believe that it tells us that the “typical” profile of someone with BPD is the “low functioning” or “classic” borderline. While I am sure there are others out there that operate in pretend mode (and pretend everything is ok while they “white-knuckle” their way through life), the vast majority of people with BPD seem to be caught in a spiral of ineffective and often dangerous behavior. They seem to me to be sending the message that they are in a great deal of emotional pain and are suffering greatly – that they will do anything to stop the pain that they feel. It also indicates to me that it is vital for parents of child with borderline-like traits and feelings do their best to get the child into appropriate treatment before their teenage years.

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1. The great tree of behavior modification
2. A Must-Read Interview with a recovered Borderline
3. Does the mode of “failure to mentalize” determine the ineffective behavior of the borderline?

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IATROGENESIS, PSYCHOTHERAPY AND BORDERLINE PERSONALITY DISORDER

Pharmacological studies routinely explore the potential harm that a well-intentioned treatment may cause. In the case of psychosocial treatments we all too readily assume that at worst such treatments are inert. However, there may be particular disorders where psychotherapy represents a significant risk to the patient. Whatever the mechanisms of therapeutic change might be, traditional psychotherapeutic approaches depend for their effectiveness on the capacity of the individual to consider their experience of their own mental state alongside its re-presentation by the psychotherapist. The appreciation of the difference between one’s own experience of one’s mind and that presented by another person is key. It is the integration of one’s current experience of mind with the alternative view presented by the psychotherapist that must be at the foundation of a change process. The capacity to understand behaviour in terms of the associated mental states in self and other (the capacity to mentalise) is essential for the achievement of this integration.

Most individuals with no major psychological problems are in a relatively strong position to make productive use of an alternative perspective presented by the psychotherapist. However, those who have a very poor appreciation of their own and others’ perception of mind are unlikely to be able to benefit from traditional (particularly insight-oriented) psychological therapies. We have argued that persons with borderline personality disorder have an impoverished model of their own and others’ mental function (Bateman & Fonagy, 2004). Their schematic, rigid, sometimes extreme ideas about their own and others’ states of mind make them vulnerable to powerful emotional storms and apparently impulsive actions, and create profound problems of behavioural and affect regulation. The weaker an individual’s sense of their own subjectivity, the harder it is for them to compare the validity of their own perceptions of the way their mind works with that which a ‘mind expert’ presents. When presented with a coherent view of mental function in the context of psychotherapy, they are not able to compare the picture offered to them with a self-generated model and may all too often accept alternative perspectives uncritically or reject them wholesale.

Any psychological therapy can generate these divergent responses. Both cognitively based and dynamically orientated therapies offer causal explanations for underlying mental states. These can give ready-made answers and provide illusory stability by inducing a process of pseudo-mentalisation in which the patient takes on the explanations without question and makes them his/her own. Conversely, both types of perspective can be summarily and angrily dismissed as overly simplistic and patronising, which in turn fuels a sense of abandonment, feelings of isolation and desperation. Even focusing on how the patient feels can have its dangers. A person who has little capacity to discern the subjective state associated with anger cannot benefit from being told both that they are feeling angry and the underlying cause of that anger. Such an assertion addresses nothing that is known or can be integrated. It can only be accepted as true or rejected outright, but in neither case is it helpful. The dissonance between the patient’s inner experience and the perspective given by the therapist, in the context of feelings of attachment to the therapist, leads to bewilderment which in turn leads to instability as the patient attempts to integrate the different views and experiences. Unsurprisingly, this results in more rather than less mental and behavioural disturbance.

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1. Are Borderlines Evil?
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Before I go into this, however, I would like to note something about my (unscientific) polls. I have been told that by certain “experts” in the non-BPD area that this “quiet”, “invisible” or “high functioning” borderline is much MORE common than the (presumably) “loud”, “visible” or “low functioning” borderline. Except… my poll numbers don’t bear that out. I really assumed that these poll numbers would reflect that the “invisible” borderline was more common. However, what my numbers show is that around 75% of borderlines report suicide attempts, substance abuse and self-injury. There seems to be an assumption that there are many, many invisible borderlines, suffering in quiet desperation and known only to their loved ones (and themselves – maybe). I’m not even going to bother to go into the assumption that there are also a large percentage of borderlines with NPD too. Personally, I think this is a fallacy (that there is a large %) and, although there are some for sure (even though my comments reflect that the borderlines feel that these ways of thinking are at opposite spectrums), the skills to effectively interact with someone with BPD and someone with NPD are not the same. I focus on what I think are the vast majority of borderlines – those without NPD.

Now back to the mentalization failures:

Pretend Mode – I believe that this mode is the one in which my commenter was operating often. In pretend mode, you have a sense that you are “faking your way through it” and that you’re pretending “as if” things are ok. This is also the nature of bull-shitting and with BPD, people seem to be able to bullshit their way through about anything, including therapy, relationships, and careers. This mode seems to be the “default state” of the quiet/invisible/high-functioning borderline. However, as evidenced by my commenter, that view of the borderline is from the outside only. From the inside, they feel fake, alien and on the verge of a breakdown and as she says: “I should say the appearance of ‘all is well’ has been going on since then [her in-patient stint]”. It’s all about appearances. For me this can cause the non-BPD to lack compassion for the borderline, because the non-BPD feels that the borderline can “turn it on and off”. What’s missing in the understanding of the non-BPD is the inner view of the borderline which is why in When Hope is Not Enough, I focus on internal features of the disorder (shame, emotional dysregulation and impulsivity).

Psychic Equivalence – this is the “feelings = facts” mode, in which the contents of the borderline’s mind are equivalent with the outside world, other’s thoughts and reality in general. It seems to cause the raging, the paranoid thoughts, the “you’re being mean to me” (on purpose) behavior, and the suspicious behavior, such as stalking, badgering and accusation of affairs, accusations of evilness and “black splitting”. The borderlines that spend a lot of time in psychic equivalence are the aggressive ones (to others). It seems to be the “what if” (in a very negative, “waiting for the other shoe to drop” variety) way of thinking.

Teleological – this is when only physical manifestations of support and soothing matter. Teleological modes seems to manifest in cutting and other forms of self-injury (I bleed so I can stop the hurt), over-deserving behavior (like over-spending, “I deserve a new dress even though I can’t afford it”), and demanding of physical examples of being soothed, such as sex, moving to a new place (“if only I lived in X place, I’d feel better”) and demanding of new things (“if you really loved me, you’d buy me a car”). It causes a very concrete and inflexible way of thinking in which only physical demonstration of self-worth matter.

While each borderline is different and probably spend time in each of these modes, the “default” mode (or conditioned mode) of thinking seems to affect the behavior of the borderline. At least this is what I am postulating regarding the question of “invisible” versus “visible” borderlines. Comments are welcome. For more on modes of thinking (according to me) click here.

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3. Book Review: Overcoming Borderline Personality Disorder

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Stacy on the label Borderline Personality Disorder:

When I first heard of BPD, it was in a magazine article given to me by a college roommate.  That was back in the early ’90s, and the article said BPD couldn’t be cured, so I either had to resign myself to being crazy forever or dismiss the diagnosis as a way of marginalizing women who refused to be meek and subservient.

My initial reservations about the diagnosis, with which I continued to struggle until I found DBT and, therefore, hope, centered around the question of whether you could diagnose any strange, artistic, outspoken girl with the disorder.  I had a lot of legitimate anger over growing up marginalized, and I had a hard time separating that anger from the maladaptive rages that derailed my life for so many years.

Meeting my DBT therapist and reading Marsha Linehan’s work helped me make peace with the diagnosis and to see it as valid.  When I read the DSM criteria and realized I was nine for nine, I had to admit there was some truth there.  It really was like seeing an outline of my life.  By that point, I wanted so desperately to get better, to build a life not punctuated by constant bingeing and purging and starving and suicide attempts, that I was willing to call my illness whatever I had to call it to get treatment.

As for what borderline means to me today, it is an accurate description of a disorder from which I feel mostly recovered.  I encourage anyone who feels the diagnostic criteria ring true to pursue an official diagnosis and seek out the treatment for which they qualify.

Stacy on relationships as triggers (a study by Dr. Paul Links showed that relationship events are the #1 most important trigger for borderlines):

Relationships were my primary triggers. I wanted so desperately to be loved, validated and saved from my loneliness that I latched onto a string of partners who showed intense initial interest, and I promptly scared them off with the depth of my neediness.

I also had a propensity for seeking out emotionally abusive or withholding lovers. Relationship after relationship ended in emotional flameouts and trips to the emergency room for overdoses. When I entered DBT, I realized this was something I had in common with most of the other women in my treatment program, and I was able to let go of some of the shame I felt about it. Learning that this particular brand of self-destruction was a hallmark of my disorder gave me hope that I could use my DBT skills to avoid forming unhealthy attachments in the future.

Stacy on DBT (and mood stabilizers):

It’s a totally different world!  Life before DBT seemed hopeless, and now it seems exciting and full of possibility.  I trust myself to navigate the storms of day-to-day existence.  Thanks to the DBT distress tolerance and emotion regulation skills, I even weathered a breakup without a suicide attempt, and know that if I ever see my ex again I can hold my head up and feel no shame or guilt over my behavior. I’m really proud of that.

The mood stabilizer Lamictal has also been a godsend.  My moods now swing between happy and sad, not ECSTATIC and SUICIDAL.  Needless to say, I’m a fan.

See larger image Loud in the House of Myself: Memoir of a Strange Girl (Hardcover) By (author) Stacy Pershall List Price: $24.95 USD New From: $12.45 In Stock Used from: $10.51 In Stock

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

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

The text of the article:

Bipolar depression unrecognised in primary care
03 Mar 11

By Christian Duffin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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See larger image Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change (Paperback) By (author) Valerie Porr List Price: $24.95 USD New From: $15.03 In Stock Used from: $11.49 In Stock

Overcoming Borderline Personality Disorder by Valerie Porr is perhaps the most up-to-date and complete book for family members of people with BPD published to date. When I read the book, I couldn’t help but think that Ms. Porr had the therapists and mental health professional more in mind than the family members. It appears as though she is trying to dispel many myths about BPD that exist not only in the family environment but also in the mental health community. This book is steeped in scientific research, including research involving the biological under-pinnings of BPD. It includes many skills for family members from both DBT and mentalization based therapy (MBT). Clearly Ms. Porr is highly respected by the clinical community since many of the leading experts in research and practice in BPD treatment have written blurbs for this book. The book is quite dense and a must read for family members of those with BPD. Yet it might not be the best book to start with because of the complexity of the scientific research, the psychoeducational aspects and the technical details about the various therapies for those with BPD. Still, I highly recommend Overcoming Borderline Personality Disorder.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Many others feel the same way.

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

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

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

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

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

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

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Treatment Poll Results

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coming out of the psycho closet

When Merinda Epstein, a Policy and Law Reform Officer of the Mental Health Legal Centre in Melborne Australia, made the decision to “come out” with borderline personality disorder as a consumer advocate, her therapist was horrified. She asked Epstein, “why would you want to talk about that diagnosis in public for? You’ve got a perfectly good psychotic diagnosis to use in public!”

Such unfortunately is the reaction many of us who self-identify as “borderline” encounter. You can be a drug addict, have depression, OCD, schizophrenia, or any other number of diagnoses and people will shake your hand and congratulate you on your courage and honesty. But if you say you have BPD, everyone—from counselors to well meaning friends to even DBT therapists, will prophesize that you’ve just ruined your chances of ever getting a good job, relationship or credit rating. The last thing you ever want to be in the line-up of mental illnesses is borderline. Even if you have it. Perhaps, especially if you have it.I didn’t know this at first. I came to the diagnosis from the twelve step community, where they say “you can’t save your ass and your face at the same time.” I didn’t care what I had, so long as I knew there’d be a solution to it. And the doctor assured me there was, in the form of a new treatment called dialectical behavior therapy (DBT). I called one of my few remaining friends as soon as I got out of the doctor’s office. “Good news!” I gushed “I have borderline personality disorder! And it makes perfect sense!”

There was a pause on the other end of the phone and then Laura shrieked, “there is no f-ing way you are borderline!!” I pulled the phone away from my ear. “Why not?” “Think fatal attraction.. Knives and stalking. Psychobitch from hell. That’s not you!”

My drug and alcohol counselor had a strikingly similar reaction when I told her during my next session. “You are not one of those!” she exclaimed. Both she and Laura begged me not to accept the borderline diagnosis. It wasn’t yet even an issue of going public, as with Epstein. Just self-identifying, just hitching my little wagon of dysfunction to this wildebeest elicited overwhelming negative reactions from others. (Borderlines, I should say here, don’t do well with negative reactions. Which is probably one of the reasons why so few of us “come out.”)And yet, little by little, the trickle is becoming a stream: Borderlines are coming out, voices gathering: Amanda Wang, AJ Mahari, Tami Green, Amanda Smith, Lisa Johnson, Merinda Epstein, to name just some of the most prominent. Go to Facebook, to Myspace, and other social networking sites, and the focus is shifting from message boards with anonymous sufferers to people with real names who are dedicating themselves to advocacy, building community, educating others, and sharing their experience with recovery. In the last year alone, we’ve seen more videos, books, e-books, blogs and public appearances by self-identified borderlines than we have in the past decade combined. Tami Green calls it BPD 2.0. The Borderline Recovery Movement has truly begun.

The thrill is not just that it’s happening, but how invaluably therapeutic the “coming out” process can be when there is the right support. There is more to recovery than treatment. Life is exposure, and challenging the stigma of BPD by “outing” oneself and connecting to others is a powerful technique in transforming shame and building resilience. It is not easy. But we are learning that in standing up and being open about the illness, we are able to challenge and overcome the deep self-hatred and guilt that fuels so much of our BPD symptoms ; that in facing the stigma and surviving the exposure, we are able to deeply accept all aspects of ourselves and others, positive and negative; that through this, we don’t need saviors or caretakers to fix us, but communities and companions to journey with us; that in risking the rejection and braving the pain of having “outed” ourselves, we discover the deep freedom of no longer having to hide; that as we stop fearing the diagnosis, we are no longer controlled by it.

With BPD 2.0 now a reality, a central question becomes: how can treatments and supports help people with BPD navigate the process– should they want to “come out” and connect with others in the recovery process? The answer is actually quite simple. Help us. Stop telling people with this diagnosis that it’s bad or shameful to have BPD. Affirm that when it’s time, it can be a good thing to “come out.” Just look at all the wild and wonderful people who’ve done it so far! Begin to harbor a conviction that borderline personality is not a curse but an opportunity for growth—both for those who have it, and those near and dear. Catch yourself if you start to think of Borderlines as “them”—the incurable, the lepers of psychiatry, the untreatable. If we continue down that route of condemnation, the river will dry up. Those of us who are finally emerging will retreat back into shame and despair. We will cry, why can’t people recover? And then there will be no recovery. We will never hear the voices of those who’ve passed through the fire, or gained the wisdom of transforming these painful symptoms into strengths. We’ll be right back where we started. Without hope.

And yet, that is the furthest thing from the truth. There is actually much more than hope. There is our experience, a serum of courage and strength that we’ll spoon to each other so long as there are mouths willing to open and hands willing to reach out.guest blogger Kiera Van Gelder, MFA, is the author of The Buddha and the Borderline:My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating. You can visit her at www.kieravangelder.com.

Related posts:

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Anti-depressants and Depression

I believe that it has. Why? Well, there are a number of reasons that depression is a catch-all diagnosis. One certainly is the influence of the pharmaceutical industry given that billions of dollars are spent on anti-depressants each year. Also, doctors who are not mental health professionals (like GP’s) are prescribing anti-depressants if their patients are “depressed”.

Unfortunately, sometimes depression is not accurate. Many times when people say “I’m feeling depressed” they are really expressing that they are feeling emotional pain. Sometimes emotional pain is normal, sometimes a great deal of emotional pain is not normal and becomes problematic. When someone is feeling too much emotionally, it is not depression.

Depression is usually a problem when someone is feeling a strong lack of emotions – causing a lack of interest in the usual activities (including sex) that once gave us pleasure. Although many configurations of “depression” exist (because it is a non-specific term nowadays), the configuration in which one lacks emotions is alexythimia, although if one lives without pleasure it’s called anhedonia. I suspect that most people, when they describe being “depressed” are really describing a combination of anhedonia (where they can’t enjoy anything anymore) and social anxiety.

As I said above, another configuration that is referred to as “depression” is when the emotional pain becomes too overwhelming. In this case the person is feeling too much and would possibly beg for anhedonia because, while the pleasure would not be present, at least the pain would go away. I think that BPD probably involves more of this kind of “depression” than other disorders. The constant emotional pain leads people to doing anything to stop it (thus, this site’s name), including substance abuse, sexual promiscuity, risk-taking, self-injury and other seemingly self-defeating behaviors.

How can this be explained? How can someone be in such emotional pain all the time? One explanation comes from the study of u-opiods in the brain. A recent study by Stanley and Siever showed that people with BPD have too few u-opiods (the precursor for natural pain-killing neuro-chemicals) AND have over-active u-opiod receptors. This combination provides a baseline of pain and, when opiods are added, the brain feasts on these pain-killing substances with the over-active receptors. This is why some people with BPD can ingest large quantities of pain killers to seemingly little effect (or less effect than those without the disorder). I have heard people with BPD say they only feel “normal” while taking pain killers.

So, the question here is two-fold: First, are anti-depressants an appropriate treatment for emotional pain that is not really “depression”? And secondly, if not, what is? Low-dose pain-killers?

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Director’s Blog
April 19, 2010
What’s in a Name? — The Outlook for Borderline Personality Disorder

Thomas Insel

In Shakespeare’s “Romeo and Juliet,” the question is posed to illustrate that a name doesn’t define a person’s feelings or intent. In psychiatry, the same may be said of that which we call borderline personality disorder. Noted primarily for symptoms such as impaired mood regulation, unstable relationships with others, and self-harming behaviors, the name “borderline personality disorder,” fails to capture the essence of this serious mental illness.

As currently defined, borderline personality disorder is considered a reflection of an essential aspect of a person’s character that influences his or her way of seeing and being seen in the world. Recent research, however, has shown that symptoms of the disorder aren’t constant and may not always be as enduring as some researchers and clinicians may think. Yet fluctuating moods and behavior also happen to define another mental illness, bipolar disorder, with which borderline personality disorder may be confused….

He concludes with this:

…Whatever the outcome of reclassification efforts, however, we must keep in mind the essence of the question — that “borderline personality disorder” by any other name would still be as real, as disabling, and as necessary to treat, as other serious mental illnesses.

Read the whole post here.

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Remission Common in BPD, but Good Functioning Lags

A substantial majority of patients with borderline personality disorder (BPD) experience remission of symptoms, and their remission tends to be stable over time compared with other mental disorders—but only half of patients also achieve good social and vocational functioning.

Those were among the findings of a 10-year study of remission and recovery in BPD patients. The study was published online in AJP in Advance on April 15 and will appear in the June print edition of the American Journal of Psychiatry.

“Symptomatically, this is a good prognosis,” said Mary Zanarini, Ed.D., lead author of the study, in an interview with Psychiatric News. “The idea that people with BPD never get better isn’t true. But as much as they get better symptomatically, it’s clear that we need to pay attention to psychosocial and vocational functioning. Just to talk about symptoms isn’t enough.”

In the study, 290 inpatients at McLean Hospital in Belmont, Mass., who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for BPD were assessed at admission using a series of semi-structured interviews and self-report measures. The same instruments were readministered every two years for 10 years.

At the 10-year mark, 249 patients remained in the study. (Of the 41 patients who were no longer in the study, 12 had committed suicide, seven died of other causes, nine discontinued their participation, and 13 were lost to follow-up.)

Recovery was defined as not only remission of symptoms, but being able to function both socially and vocationally. Social functioning was defined as having at least one emotionally sustainable relationship with a friend, spouse, partner, or other non-blood-related individual. Vocational functioning was defined as the ability to perform full-time work competently and consistently.

Study results showed that 93 percent of the patients achieved remission of symptoms lasting at least two years, and 86 percent achieved remission lasting at least four years. However, only 50 percent achieved the full definition of recovery including social and vocational functioning (see chart).

Zanarini speculated that many patients may have temperamental problems—anger and/or extreme abandonment issues—that persist after the remission of symptoms and that hold them back socially and vocationally. “All of our manualized treatments for BPD are aimed at acute symptoms—self-mutiliation and suicidality—and those are the symptoms that remit the most quickly,” she told Psychiatric News.

She said that a rehabilitation model of treatment incorporating training in life skills—use of public transportion, budgeting, personal care, and vocational training—is key to fully addressing the recovery needs of patients who achieve remission of BPD symptoms.

The study’s other notable finding was that despite the difficulty many patients have in achieving full recovery, both remission of symptoms and full recovery, when they do occur, tend to be stable over time. Of those who achieved recovery, only 34 percent relapsed. Of those who achieved a two-year remission of symptoms, 30 percent had a symptomatic recurrence, and of those who achieved a sustained remission at four years, only 15 percent experienced a recurrence.

Zanarini and colleagues noted in their report that those rates compare favorably with remission and recurrence rates for common Axis I disorders studied longitudinally, such as major depression and dysthymic disorder. “[T]he high rate of sustained symptomatic remission and the low rate of symptomatic recurrence after sustained remission are among the most optimistic findings about borderline personality disorder reported to date,” they said.

In an interview with Psychiatric News, Zanarini said, “Depression and bipolar disorder tend to remit quickly but recur much more often. Recovery from BPD is more akin to the process of maturation. It occurs slowly, but once you achieve a certain level, you stay there, and it takes some enormous stressor to push you back.”

Joel Paris, M.D., an expert in BPD, reviewed the study for Psychiatric News. He said that it confirms and extends findings from the Collaborative Longitudinal Personality Disorders Study and the McLean Study of Adult Development. This study found that while symptomatic improvement is sufficient for many patients to stop meeting criteria for the disorder—such as no longer cutting themselves or overdosing—functional improvement is much slower.

“The study suggests that while BPD is by no means incurable, many patients continue to function at a low level for years,” Paris said. “So what are the clinical implications? On the one hand, when we thought that BPD was a life sentence, we avoided treating patients who can in fact be helped. And some people do make a full recovery, going on to live normal lives. On the other hand, other cases are more chronic. If we become too optimistic, we may mislead our patients into expecting the impossible and not provide the supportive and rehabilitative services they need.”

“Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-Year Prospective Follow-Up Study” is posted at <http://ajp.psychiatryonline.org/pap.dtl>.

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Study shows long-term success in recovery from borderline personality disorder
April 15, 2010 |  6:00 am

Borderline Borderline personality disorder has long been considered one of the toughest psychiatric disorders to resolve. There have been many questions about how to best treat the condition, which is marked by unstable relationships, unhappiness, mood changes, impulsive behavior and poor decision-making.

Advances in understanding and treating the condition have been made in recent years, however. And a new study offers hope that recovery, although challenging, can be long-lasting.

Many Zanarini of McLean Hospital in Massachusetts studied 290 hospitalized patients with BPD over 10 years. Half of the patients recovered from the disorder after 10 years of follow-up. Recovery was defined as at least two years without symptoms and both social and vocational functioning. Overall, 93% of patients achieved a remission of symptoms lasting at least two years and 86% for at least four years.

The research suggests that while it may be difficult to achieve recovery, once recovery has been attained it appears to last. While many treatments focus on symptoms, therapy should include work on improving relationships and functioning in the workplace, areas that vastly boost the odds of long-term recovery, the authors said.

The study is published online Thursday in The American Journal of Psychiatry.

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Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder
Anthony Bateman, M.A., F.R.C.Psych., and Peter Fonagy, Ph.D., F.B.A.

Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.

Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.

Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.

Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

http://focus.psychiatryonline.org/cgi/content/abstract/8/1/55

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DSM-5 Type and Trait Cross-Walk

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Mentalizing conference call with Drs. Peter Fonagy & Efrain Bleiberg
At the request of participants and the positive response to this November 2009 presentation on the interactive conference call, we are making this tape availalble.

Download conference call

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Ignored Psych Patient Dies on Hospital Floor

Video Shows Death in NYC Hospital Already Faces a Lawsuit for ‘Squalid’ Psych Care

By DAVID SCHOETZ

July 1, 2008—

Even pared down to a few minutes, the hour-long surveillance video is disturbing.

At 5:32 a.m. June 19, a woman in a hospital gown in the waiting area of the psychiatric emergency room of a New York City hospital topples first to her knees before collapsing on her face.

A full hour passes. Other people stream in and out of the waiting room, including hospital security guards. The woman writes something on the ground before going completely still. Finally, someone takes notice and alerts the staff. But by then, at 6:36 a.m., the woman is already dead.

The woman, 49-year-old Esmin Green, died on the floor of the waiting room at the Kings County Hospital Center Psychiatric Emergency Department. Her exact cause of death has not been released.

The native of Jamaica, who had been waiting for a bed when she collapsed, had been involuntarily admitted the previous day for “agitation and psychosis,” according to the City Health and Hospital Corp., which acknowledged June 20 that Green had been left unattended on the ground for an hour.

Alan Aviles, the president of the Health and Hospital Corp., had already announced that six hospital employees, including staff members who oversee patient care and security, face disciplinary action for their lack of response. Two of the employees were fired, while four unionized staff members must go through termination proceedings.

The hospital, in the Brooklyn borough of New York City, may have a much bigger problem on its hands. In May, Kings County Hospital was targeted in a federal lawsuit by three organizations that described hospital conditions as “inhumane.” Attorneys for the plaintiff released the footage of Green’s death Monday night to illustrate in brutal detail some of the allegations made in the suit.

The Mental Hygiene Legal Service, New York Civil Liberties Union and Kirland & Ellis LLP filed the lawsuit after an investigation at the hospital “showed that Kings County psychiatric facilities are overcrowded and often dangerously unsanitary and that patients — including children and the physically disabled — are routinely ignored and abused,” according to the groups’ May 3 release announcing the suit.

The groups claim that alleged mistreatment of patients at the hospital is a violation of the federal Americans With Disabilities Act as well as several New York State provisions that guarantee the delivery of mental health services in a safe and sanitary manner.

Aviles is named as one of the lead defendants in the 36-page suit, which specifically cites five patients, all with some type of disability, who allege “abusive and neglectful” treatment at Kings County.

One patient, L.D., claimed that she was laughed at when she asked to call her family and was placed in a bed with soiled sheets. Another patient, identified as J.P., said that she had to sleep sitting up in a wheelchair after she got up in the night to use the bathroom and returned to find another patient in her bed.

The New York Daily News reported that in addition to the neglect in Green’s case, staff members entered false information into her medical chart during the hour in which she lay on the ground to cover up the lack of treatment.

At 6 a.m. on the morning of her death, according to the Daily News, Green’s medical chart reportedly listed the patient as “awake, up and about, went to the bathroom.” Green had been in the same spot on the ground for more than a half-hour. At 6:08 a.m., she stopped moving, according to the footage. But her chart described her at 6:20 a.m. as “sitting quietly in the waiting room.” In reality, she may have already been dead.

Ana Marengo, a spokeswoman for the Health and Hospital Corp., would not address the exact entries in Green’s medical chart, but did say, “There appears to be some discrepancies” that have been forwarded, along with the entire case, to various New York City investigative departments.

“It is clear that some of our employees failed to act based on our compassionate standards of care,” administrators wrote in a statement last night that followed the video’s release.

Hospital administrators outlined a series of improvements already made to the Kings County psychiatric program, including the addition of staff and expanding space to cope with overcrowding. They pledged a series of improvements, including the appointment of an “interim administrator” who will report directly to Aviles, and a guarantee that patients in the psychiatric emergency unit will be checked on every 15 minutes.

In June, USA Today reported that nearly 80 percent of hospitals said that mentally ill patients sometimes wait up to four hours or more for emergency care, citing a study by the American College of Emergency Physicians that surveyed 328 emergency medical directors.

Physicians blamed the delayed care on shrinking budgets that have prompted many hospitals to either consolidate mental health services or shut them down completely. Since 2000, the number of psychiatric beds has dropped 12 percent, according to the medical organization’s statistics.

Copyright © 2008 ABC News Internet Ventures

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Admitted for depression

Vicki Salemi

Heather Locklear has checked herself into an in-patient treatment facility in Arizona. The quintessential evening soap opera vixen is on the road to recovery. And no, it’s not for substance abuse.

As for the reason? To deal with issues of anxiety, depression, and to re-evaluate her current condition. We give props to the 46 year-old actress who apparently recently switched doctors and is taking a pro-active stance towards her mental health. The new doc recommended that her condition and medication be re-evaluated.

While her publicist confirmed that Heather’s been dealing with anxiety and depression, it seems she’s taking it head on: by entering the facility she’ll get a proper diagnosis and treatment.

Actually, a few months ago paramedics were called to her home. Her psychiatrist called 9-1-1 and told authorities there was concern for a possible overdose attempt on prescription meds. Well, paramedics left her home extremely quickly after arrival and deemed everything was all right.

As for the back story, last year her ex-husband and Bon Jovi band member Richie Sambora stayed in a treatment facility last year. Their ten year-old daughter Ava is staying with family at the moment.

Best wishes, Heather!

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Mentally ill face extra-long ER waits

By Julie Appleby, USA TODAY

Psychiatric patients who need hospitalization wait for hours in emergency departments for admission because hospitals are dropping mental health units and beds are scarce, a new survey says.

Nearly 80% of hospitals said mentally ill patients sometimes wait four hours or more to be admitted, says the American College of Emergency Physicians, which surveyed 328 emergency medical directors. About 10% said patients wait more than a day on average.

Average admission times for non-psychiatric patients were shorter: Only 30% of directors said those patients waited four hours or more. Yet 84% of the medical directors said ER wait times for all patients would drop if their hospitals had better psychiatric services.

Only half of the hospitals surveyed had psychiatric units. The rest transferred patients, sometimes far from homes and families. Hospitals are closing their units because of inadequate payments from government and insurers, unpaid costs for the uninsured and too few psychiatrists willing to work in hospitals, says James Bentley of the American Hospital Association.

Patients with mental illness “are the ones we hold the longest because there are so few psychiatric services available, and the ones that are available are overwhelmed,” says David Mendelson, of the physicians group.

The long waits can be troublesome for mentally ill patients, says Bruce Schwartz, director of psychiatry at Montefiore Medical Center in the Bronx, N.Y. “For individuals in need of admission because they’re psychotic or severely depressed, it can be a very uncomfortable, scary, disorienting time.”

The survey found 61% of hospitals do not have psychiatry staff caring for ER patients while they wait, although they receive treatment for other medical problems.

The poll comes amid growing concern about wait times and overcrowding in the nation’s ERs, which experienced a 14% jump in visits for all illnesses and injuries from 2001 to 2005.

Since 2000, the number of psychiatric beds in U.S. community hospitals dropped 12%, the association’s statistics show. The number of hospital beds overall fell 4%.

In March, the closure of Santa Rosa Memorial Hospital’s psychiatric unit left California’s Sonoma County without hospital-based care for mentally ill patients. Now patients must be taken 40 miles or more away to other hospitals.

“It’s not unheard of for people to spend a night or even a couple of nights (in the ER),” says Sonoma County Mental Health Services Director Art Ewart.

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Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up.

Blum N, St John D, Pfohl B, Stuart S, McCormick B, Allen J, Arndt S, Black DW.

Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.

OBJECTIVE: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial. METHOD: Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis. RESULTS: Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups. CONCLUSIONS: STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

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Attorney: Spears not fit enough to take part in probate case

* Story Highlights
* Britney Spears’ attorney says the pop star is not ready to participate in court
* Lawyer told court Thursday that Spears’ medical condition is “fluid”
* Spears’ probate case scheduled to go to trial July 31

LOS ANGELES, California (AP) — Britney Spears is not yet fit to participate in court proceedings in her conservatorship case, her lawyer told a Los Angeles Superior Court commissioner Thursday.

Samuel Ingham, Spears’ court-appointed attorney, and attorneys for the pop star’s father and conservator, James Spears, spent 90 minutes in Commissioner Reva Goetz’ chambers.

Ingham told the court afterward that Spears’ medical condition is “fluid” because her treatment is changing.

Spears’ probate case is scheduled to go to trial July 31, but Ingham said it could be “harmful” for her to participate. Goetz agreed and said Spears’ diagnosis is not complete.

The 26-year-old singer and her estate have been under the conservatorship of her father for four months.

I’d say that’s code for “she’s acting nutty again.” They probably don’t want to release that she’s got BPD. “Some form of bipolar” is likely to come up again. I mean, come on… she started this whole thing in January. How long does it take a team of doctors to diagnose her? Hmm?

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Here’s some information on  Amitriptyline studies:

Amitriptyline (Antidepressant Tricyclic)

Soloff PH, George A, Nathan RS, Schulz PM, Perel JM.
1987 Psychopharmacol Bull.23 – Behavioral dyscontrol in borderline patients treated with amitriptyline.
Amitriptyline was associated with a paradoxical behavioral toxicity in patients with BPD, increasing suicidal ideation, paranoid thinking, and assaultiveness significantly more than among placebo nonresponders

Amitriptyline (Antidepressant Tricyclic) / Haloperidol (neuroleptic)
Soloff PH, George A, Nathan S, Schulz PM,… – Western Psychiatric Institute and Clinic, University of Pittsburgh, Pennsylvania.
J Clin Psychopharmacol. 1989 Aug – Amitriptyline versus haloperidol in borderline: final outcomes and predictors of response.
The authors report the final results of a 4-year study of amitriptyline and haloperidol in 90 symptomatic borderline inpatients. Haloperidol produced significant improvement over placebo in global functioning, depression, hostility, schizotypal symptoms, and impulsive behavior.
Significant effects of amitriptyline were generally limited to measures of depression.

Amitriptyline (Antidepressant Tricyclic) / Haloperidol (neuroleptic)
Arch Gen Psychiatry 1986 Jul – Progress in pharmacotherapy of borderline disorders. A double-blind study of amitriptyline, haloperidol, and placebo.
In symptomatic patients with borderline disorder, we conducted a double-blind, placebo-controlled trial of haloperidol and amitriptyline hydrochloride to test the differential efficacy of medication against the affective and schizotypal symptoms that characterize the disorder.
Haloperidol was superior to both amitriptyline and placebo on a composite measure of overall symptom severity, with no difference between amitriptyline and placebo.
Haloperidol produced significant improvement on a broad spectrum of symptom patterns, including depression, anxiety, hostility, paranoid ideation, and psychoticism. In contrast, amitriptyline was minimally effective, with small gains limited to some areas of depressive content.

Here’s more on that abstract about amitryptiline (Elavil):

Paradoxical effects of amitriptyline on borderline patients

PH Soloff, A George, RS Nathan, PM Schulz and JM Perel

A paradoxical increase in suicide threats, paranoid ideation, and demanding and assaultive behavior occurred among 15 borderline inpatients receiving amitriptyline in a double-blind study. This pattern differed significantly from that of 14 nonresponding patients receiving placebo.

As you can see, if dyscontrol and and increase in  “suicide threats, paranoid ideation, and demanding and assaultive behavior” occurs in people with BPD on Amitriptyline – it’s probably best to stay away from it. Of course, I’m not a doctor. Obviously, you should consult one before stopping meds or beginning new ones.

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Inconsistency also seems like a harbinger of BPD. I think that
with wildly swinging emotions, people with BPD are widely
inconsistent. My wife can be manic and organized and get things done
one moment of one day and then depressed, crying and avoidant the
next. Now, you might think she is bipolar – but her moods last hours
(and sometimes minutes), not days or weeks.

A lot of her moods are governed by her medication schedule. She
recently (last week) switched off Xanax (whew!) and is
now taking Ativan, which she says “doesn’t work”. She of course
takes high doses and mixes it with alcohol, and has periods of
dyscontrol. We went to a neighbor’s birthday party on Saturday and my wife did something embarrassing.
I just took her home and went back to the party. But the
key here is that she is highly unstable in her moods. She uses the
drugs and alcohol to try and quell the pain, but they cause even
more instability.

I think that is why we often make mistakes
in “self-diagnosis”. For all I know, half the people (or more)
viewing the messages in my group are not dealing with BPD at all, but instead
something else. That is one of the reasons that a couple of months
ago, I specifically asked a mother on an email list whether her
daughter was diagnosed with BPD and how old the daughter was -
because the behavior that she described could be attributed to
many “disorders” (including the disorder of being a teenager).

There is a movement within the psychiatric community to change the
name of BPD. Some also want BPD to be classified as an Axis I
disorder. So, it could be that “borderline personality disorder”
will not exist anymore and BPD will not be a “personality” disorder
anymore. The point of saying this is that I think the traits of
which you speak are shared among many different disorders,
personality or otherwise.

In the CBT community, one of the things they talk about
is “cognitive distortions” – basically thinking in a way that
doesn’t match the “objective” facts. At times everyone, disordered or not, does some of these
things. In the case of BPD, many of these distortion can into play.
But these distortions are shared with other disorders and
with “normal” thinking.

Self-harm is sort of a sure sign of BPD (although not all
self-harmers have BPD) versus, say, PTSD. And the basic self-image
thing is also key. In fact, one of the things that many “nons”
don’t “get” about people with BPD is that the borderlines hate
themselves. The nons come to the table saying “this person (the
borderline) is SO selfish!” and they are angry about all the
behavior (which they have every right to be angry, the behavior is
quite frustrating). However, they don’t understand that behind this
maddening behavior is a deep, painful self-loathing. If that self-
loathing (and shame) is NOT there, then it is not BPD. From my
experience, there are not people with BPD that are OK inside. They
are not evil (let’s not bring up Hitler again, please – I’m sticking
with Princess Di as my BPD historical figure), they are
just “broken” inside.

As for impulsiveness and extreme emotional liberation (especially via drugs or alcohol), I have seen
studies that say that those things can be transmitted biologically.
As you know, I have a 9 year old daughter (who has a fraternal twin
sister), who is specifically impulsive and subject to stormy
emotions. Over the weekend, she told me and her twin that she would
not want to run for student counsel because (in her words) she
gets “overtaken by anger” and would be really “furious” if people
didn’t vote for her. She also got angry and pushed my 3 year old son
over and he smacked his head on a bookcase (he’s ok though). When I
came in and spoke to her about it, she lied to me. So here’s a girl
that’s 9 years old and exhibits the signs of emotional unstability
and impulsiveness. But has she been abused? No. Has she been
invalidated? Yes, many times.

The reason I bring her up is that I think that BPD has a biological
base as well. There was a really interesting article that [a member of the list]
posted about biological and social contributors to BPD. Maybe I can
dig it up.

I brought up an unstable personality because, when mixed
with shame, causes extreme personalization – but it is
not unique to BPD (the unstable personality or the personalization).
The shame, however, IS (I think). I saw a study that showed that
people with BPD reported feeling shame 14 times a day.

SHAME is considered the core emotion
by some psychotherapists. That just tells me that I’m not completely crazy if I
say, “if there’s shame, there’s BPD – if not, it’s probably
something else”. But hiding shame is the natural reaction to it. So,
we nons may not see it initially.

My wife has BOTH BPD and PTSD – because of childhood sexual abuse
(the PTSD). However, as I said before, I think there is also a
biological component to BPD and I’m not sure that you HAVE to have
been abused to have BPD; whereas with PTSD, trauma is necessary
(it’s built into the name for heaven’s sake). On the flip side,
Marsha Linehan said “not everyone who is sexually abused gets BPD”
(I’m paraphrasing) – so it seems to be her belief that there must be
a biological pre-disposition there. So, if we look at her biosocial
model, we see that there are biological components in combo with
an “invalidating enviornment” (not necessarily abuse). So it could
very well be that shame is 1) built into some people (my 9 year old
feels a lot of shame herself BTW) or 2) that the “invalidating
environment” is not strictly abuse or 3) both. If I look at my 9
year old’s shame, it seems awfully unfounded to me. You can
attribute my wife’s shame to her being sexually abused (and a large
portion of BPs have been abused in some way), but my 9 year old, she
feels very shameful about the way she feels. She feels shameful in
her skin. She has already expressed suicidal ideation (at 9!).

As for cutting or “blood letting” – geting something out of your system – that’s quite wise. I don’t
know if you’ve ever read Jim Carroll’s books about his heroin
addiction (“The Basketball Diaries” and “Forced Entries”), but there
is a scene in one of them, Forced Entries I think, in which Carroll
lances and drains his infected needle sight on his arm. I know it
sounds yucky (and it is), but he really translates it in a wonderful
metaphor for getting all the filth out of his system and liberating
himself from the pain he is in.

The suicide gestures are usually impulsive with BPD.

Of course, I could take suicide out of the equation, because I
could make the same statement about cutting (or burning oneself) -
that is, 95%+ of the borderlines I have come into contact with
(through their parents mainly) cut (or burn) themselves. My wife
cuts herself. She also picks her nails until they bleed. My 9 year
old with the emotional “issues” picks her nails until they bleed.
Her twin (and just to clarify, they are fraternal) sister does not.

A trained professional that works with borderlines
every day can diagnose BPD. You might remember the case that happened on another
list (ATSTP) in which the guy’s girlfriend sounded about as borderline as
possible, but when she went to U of Washington to get evaluated,
they said, “No, you have PTSD.” I don’t know how they told the
difference, but I suppose it had something to do with the
distinguishing charactersitics of BPD that are mentioned here: self-
injury, toxic shame and self-loathing, uncontrollable impulsiveness
and “emotional liberation” with mind-altering substances. Still,
those last 2 might show up in other disorders as well.

No related posts.

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When borderline personality disorder makes communication difficult, following the SET method may help. SET stands for support, empathy and truth. It was developed by Jerold J. Kreisman, MD and Hal Straus, the authors of I Hate You, Don’t Leave Me and Sometimes I Act Crazy.

Why SET Works

The symptoms of borderline personality disorder (BPD) can result in the BP asking for conflicting things or being unable to recognize that the another person cares for them, especially during times of stress. A person with BP may be unable to experience conflicting feelings at the same time, and tends to see things in black and white with very little shades of gray.

As a result, the BP experiences her current feelings as being her persistent feelings.

SET allows friends and loved ones of people with BP to honestly and address the person’s demands, assertions, or feelings, while still maintaining appropriate boundaries. It is important to do these steps in order, as each step builds upon the other.

Support

Support refers to an initial statement which indicates the loved one supports the person with borderline personality. It is a statement that begins with “I” and demonstrates concern and a desire to help. It can be anything that establishes a foundation for the relationship or interaction: “I want to try to help you feel better,” “I care about you,” or “I am worried about how you are feeling.”

The support statement is meant to reassure the BP that the relationship is a safe one, and that her needs matter even during this difficult moment.

Empathy

Empathy refers to communicating that the loved one understands what the BP is feeling, and focuses on “you.” It is not a conveyance of pity or sympathy, but instead a true awareness and validation of the feelings of the BP: “I see you are angry, and I understand how you can get mad at me,” “How frustrating this must be for you.”

It is important not to tell the BP how she is feeling, but instead put her demonstrated feelings into words. The goal is to convey a clear understanding of the uncomfortable feelings she is having and that they are OK to have, thus validating her feelings. Without such a statement of empathy, the BP may feel that her feelings are not understood. It is important to use feeling words, as in the examples above.

Truth

Truth refers to a realistic and honest assessment of the situation and the BPs role in solving the problem. It is an objective statement that focuses on the “it” — not on the subjective experience of the BP or Non-BP. Often the BP may seem to be asking, or demanding, something impossible, not taking an active role or responsibility in resolving the issue, or even presenting you with a “no-win” situation. The truth statement is meant to clearly and honestly respond to the difficult demand or behavior of the BP, while placing responsibility appropriately: “This is what I can do…,” “This is what will happen…,” “Remember when this happened before and how you felt so bad about it later.”

It is important to use the support and empathy statements first, so that the BP is better able to hearwhat you are saying, otherwise the truth statement may be experienced as little more than another, and expected, rejection creating even more defensiveness or anger.

Validation and Support Are Not Agreement

When first learning about SET, it can seem that you are being asked to agree with the BP. It important to clarify that validating feelings does not mean that you agree with them, only that you recognize that the BP is feeling them. The supportive communication described in the SET model does not mean that you are letting the BP off the hook, instead you are focusing on honest communication and ensuring that you are being heard, not just reacting to and defending against what is being said.

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No medication should be given without proper medical supervision. This is particularly true for the drugs used to treat the borderline disorder. Some medicines make the symptoms of borderline worse, especially amitryptilline (Elavil) and alprazolam (Xanax). Possibly a third of borderlines may suffer from low thyroid (hypothyroidism) – despite a normal ‘TSH’ blood test. They may need to take thyroid medication.

My BP does take xanax and it makes everything MUCH worse. Also, she has thyroid issues which seemed co-incident with her first really BP-like behavior. Still, it is difficult to separate the meds, hormones and behaviorial aspects.

Benzos and BPD

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Recovery possible for Borderline Patients

Dutch investigators prove effectiveness of new treatment.

For the first time in history it has been proven that Borderline
Personality Disorder can be effectively treated in its full range.
Investigators of Maastricht University, Vrije Universiteit Amsterdam, and Leiden University published in the June 2006 issue of the JAMA journal the Archives of General Psychiatry a study into the effectiveness of two psychotherapies for borderline patients. The study demonstrates that Schema focused therapy leads to complete recovery in about 50% of the patients, and in two-thirds to a significant improvement. The success of the therapies is strongly related to their duration and intensity (two sessions a week for three years). The results clearly contradict common ideas that borderline personality disorder cannot be fully cured, and that prolonged psychotherapy is useless.

Borderline Personality Disorder is generally known as “untreatable” and is quite common in the general population: 1 to 2.5 % of the population suffers from it. Characteristics are chronic instability, emotional dysregulation, self-mutilation, suicidal behaviour, impulsivity, abandonment fears, anger attacks, identity problems, and low stress tolerance. The medical and societal costs are high, and many of these people cannot participate in the labour process, or don’t function at levels that could be expected given their intellectual capacities. Usual care is limited in effectiveness, and even the best treatments so far can only successfully address a minority of the borderline problems.

Dr. Josephine Giesen-Bloo, Dr. Arnoud Arntz (projectleader), Dr. Philip Spinhoven, Dr. Richard van Dyck and other investigators of the universities mentioned above compared in the study two treatments for borderline personality disorder: Schema focused therapy (SFT) and
Transference focused psychotherapy (TFP). 86 patients recruited in 4 mental health institutes in the Netherlands (Maastricht, Amsterdam, The Hague, and Leiden) received two sessions SFT or TFP a week for 3 years. The effects of the treatments were assessed with 4 criteria:
borderline-symptoms (BPDSI-IV-score), general psychopathological symptoms, personality characteristics, and quality of life. During the 3 years assessments were conducted every 3 months. In 24% (TFP) and 46% (SFT) of the patients treatment led to full recovery. One year later the percentages even increased to 52% (SFT) and 29% (TFP). In the SFT condition two-thirds of the patients improved to a significant degree. On the other 3 criteria effects were also positive and in favour of SFT.

Positive effects became apparent after one year, with continuing
improvement in years 2-4. The investigators conclude that both
treatments have positive effects, with a clearly higher effectivity of SFT. Moreover, the lower dropout rate indicates that SFT induces a higher treatment allegiance in the patients than TFP.

SFT is a cognitive-behavioral therapy, in which patients acquire
insights in the patterns that underlie their problems. For borderline personality disorders these are classified into 4 standardized patterns, called schemas. By means of behavioural, cognitive and experiential techniques the disorder is treated. The treatment focuses on the relationship with the therapist, on daily life outside of therapy, and on traumatic childhood experiences (which are very common in this disorder).

TFP is a psychodynamic therapy. At start, a treatment contract is agreed upon, which remains at the centre during treatment. By continuous analysis and interpretation of the mutual relationship a structural change in personality of the patient is brought about.

Thus, both treatments address the problems at the level of the personality, whereas most common treatments are restricted to the reduction of specific symptoms of the disorder (i.e., self-destructive
behaviors).

The investigators plead for the recognition of SFT as an evidenced based treatment of borderline personality disorder. Despite the high number of sessions and the long duration, they observed that the treatment is cost-effective, as it leads to an immediate cost-reduction for society of 4500 Euros per patient per year, already during treatment. The common idea that prolonged psychotherapy is unjustified is, at least in the case of SFT for borderline personality disorder, incorrect.

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There are at least three ways of looking at the universe (and it’s
interaction with our minds). They are basically this:
1) The western way (or the “clockwork universe”). Because rationality,
science and technology is so ingrained in our way of thinking the model
of the universe is that of a giant mechanism. We (or bodies) are also
mechanisms. The mind/spirit/soul/self is some kind of “ghost in the
machine” – living inside it’s machine skin and going on after death to
another realm.
2) The Indian way (or “all the world’s a stage”). Every person and
thing is a hiding place for god – he (or the ultimate spirit – the pure
brahma – ok my spelling will be crappy and I don’t have time to look it
up) is reflected in you (in “your” ultimate spirit called “atman” in
sanskrit). God wears a “you” mask and a “me” mask. Basically, (in
computer terms) we are all particular instances of a class called
“spirit”. That is the “true” reality, the rest is illusion (maya). This
grew out of the society (which, with it’s caste system is very
role-based). However, Buddhist thought shattered that world-view (more
on that later).
3) The Chinese way. (or “organic systems” – in Chinese I think it’s
called Wu-Li). The universe and you are a tightly integrated organic
engery system. You are a natural extension of the world and the world
is a natural extenion of you. You can not exist without the world, it
can not exist without you. Think of the Yin-Yang and that symbol sort
of summarizes this position.

As Buddhism integrated Chinese concepts #2 and #3 sort of merged and
mixed. Buddha, however, pretty much dismissed “atman” (or essential
essence, see below).

OK, on the Buddhist thing. Buddha espoused three core concepts (called
the 3 “marks of existence” – he BTW had a lot of lists of ideas. Why?
because these ideas were not written down for hundreds of years, so the
monk had to remember them.) – they are:
1) Dukkha – suffering. Suffering exists and it exists because of a
basic inability of the mind to accept the state that it is actually in.
We thrist for “other” and cling to what we think we “have” (including,
paradoxically, our own mind).
2) Anicca – impermance. Every thing is in a state of flux, passing in
and out of existence, including ourselves and our minds. There is a
really interesting related concept called “Dependent Arising” (although
there are a number of translations of it). I don’t have time to talk
about that, but it is facisnating (and implies there is no creator of
the universe or beginning at all, BTW).
3) (OK here is the biggy in the Joseph Campbell sense) Anatta means
“no-self”. Buddha didn’t believe that we had a “core”
personality/mind/identity. This concept is that the mind (or self) is
made up of five “bundles”. A quote from the buddhism scripture (written
long after buddha died BTW):

“A chariot is neither asserted to be other than its parts, nor to be
non-other. It does not possess them. It does not depend on the parts,
and the parts do not depend on it. It is neither the mere collection of
the parts, nor it is their shape.:

Basically, we created the “charriot” in our minds and call it “me”. But
it is made up of parts that, on their own, can’t be called a charriot.
It is a concept that we label something with wheels and a seat and a
place for horses to pull (or race in like “Ben-hur”). But it is nothing
more than a label we slap on that concept. Buddha was suggesting that
our identity is the same way. There is no “you” there. Instead there is
a flux of feelings, thoughts, memories, sensory perceptions (or
“cognitions” – mental floral and fauna) that you throw together, slap
your name on it and say “hey that’s me!” However, are you the same you
as you were at 9 years old?

What does any of this have to do with BPD? Actually, probably a LOT. If
they feel that they have no core – they, according to the Buddha
anyway, might be experiencing reality as is really is. But it scares
the living sh*t out of them. Like doing acid? I think
it is probably a whole lot like doing acid. Nothing to stand on,
nothing to build on. You can’t build a castle on top of a river.

So, DBT borrowed more from Buddhism than mindfulness – it also borrowed
the concept of radical acceptance – deep acceptance and knowing of the
way things REALLY are. If you can’t accept it, if you cling to that
illusion, if you feel that your mental afflictions are real, then you
are in for a whole lot of suffering (see “mark of existence #1″). But
the interesting things is: what if our BP’s are actually MORE sensitive
to the “actual” reality than we are? Sure, it’s scary, but it might be
more “real”? That, of course, only applies to their sense of “self”,
not the impulsiveness and the emotional dysregulation. I think there
was a psychologist that called schizophrenics “the hyper-sane” (but I
think he became a Scientologist and disavowed psychiatric meds and
stuff). Something to think about.

Anyway, that was fun. As you know I find Buddhist thought/philosophy
very interesting.

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The most important thing is, Do not hospitalize a person with borderline personality disorder for any more than 48 hours. My self-destructive episodes – one leading right into another – came out only after my first and subsequent hospital admissions, after I learned the system was usually obligated to respond. Nothing that had happened to me before being admitted to a psychiatric unit for the first time could even approach the severity of the episodes that followed.

Should you hospitalize your BP? Maybe not.

http://ps.psychiatryonline.org/cgi/content/full/49/2/173

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