Ambiguity is the greatest threat

In 2009, I attended the International Society for the Study of Personality Disorders (ISSPD) in New York. Dr. Glen Gabbard, MD, a psychiatrist and clinician that treats people with Borderline Personality Disorder (#BPD). About halfway through his presentation, Dr. Gabbard said: “Ambiguity is the greatest threat.” He was speaking in the context of a clinician treating someone with BPD. Many studies have show that people with BPD react to neutral facial expressions as if the person is angry. People with BPD interpret neutral faces as angry. I once saw a woman with BPD view a picture of a neutral face and she said, “He’s angry with me.” Dr. Gabbard was suggesting to the clinicians treating people with BPD to NOT be neutral, to not use the “blank slate” approach.

The main problem with BPD is that these people are exquisitely emotionally sensitive. Their emotional tolerance is set very, very low.  Dr. Gabbard had a slide in his presentation that read: “Neuroimaging data of adult BPD patients suggest that amygdalar hypersensitivity and emotional dysregulation may be related to specific dyfunctions in the prefrotal cortex and the ACC.” This suggests that emotional (from the amygdala) hypersensitivity (the person is on an emotional hair-trigger) and emotional dysregulation could be due to an inability to integrate information (which is what the prefrontal cortex does) and is personalized (through the ACC).  Basically, the emotional anaphylactic reaction of someone with BPD could be a brain dysfunction. The ambiguity of what could happen is overwhelming.

The other day, I had a coaching session with a husband who has a wife with BPD. He just couldn’t understand why his wife thought that he was “angry with her all the time.” He told me he remained calm during her emotional dysregulation and that she interpreted his reactions as angry. Neutrality in the face of strong emotional reactions will be interpreted as disapproval. The person with BPD will be unable to communicate his/her emotional pain and think “I’m falling apart here and he’s so calm! He doesn’t understand me!” This client’s wife was interpreting his neutral reactions as angry ones. Add the fact that people with BPD have trouble regulating their own emotions such that they typically attach to another person who they expect to regulate the emotions for them. In other words, the internal emotional regulator is externalized and embodied in another person, usually the “attachment person” (like a parent, partner or friend). When the external regulator reacts in a way that is misaligned with their internal state (i.e. is calm when they are not), the person with BPD will feel as if they’ve lost control of a part of themselves. This causes more intense emotional dysregulation. From When Hope is Not Enough:

As a buyer on eBay, you don’t give neutral feedback to a seller when everything about the sale is perfect. You give neutral feedback when something is wrong. A person with BPD will interpret a neutral face as “something wrong.”

When Hope is Not Enough ebook (Kindle Locations 459-461).

Ambiguity about the future and what may come can cause ruminating. Unpredictability of the attachment person can cause fear and that fear often morphs to anger. People with BPD live in with a cloud hanging over their future… they are always waiting for and dreading the other shoe dropping.

So, what are you to do as a supporter, family member or partner of someone with BPD? In When Hope is Not Enough, I suggest this:

Most people believe that remaining calm in the face of strong emotions expressed by their BP loved one is the best and most effective course of action, but in reality, it is not. A study of BPD patients using functional MRI technology “found that the level of amygdala activation to the Fearful, and Neutral faces in BPD patients is significantly correlated with diagnostic measures of emotional lability.”28 What does that mean to you? Well, although clothed in scientific language, what that means is that a person with BPD is more likely to view a “neutral” (or calm) face as a threat and become fearful. If you go “calm” on her, in the face of her emotional dysregulation, she will see you as a threat and, if she sees you as a threat, she will do one of two things: fight or flee. Additionally, the tenor and tone of your voice matters in this area.

The purpose of someone coming to you in an emotionally dysregulated (or close to one) state is to communicate the emotions that she feels. She may have difficulty expressing these emotions and may use other means for expressing them such as blame, sobbing, cutting, raging or other behaviors that are difficult for you to deal with. The underlying point however is one of communication – she is trying to tell you something, but she doesn’t have the language for it. Therefore, if you respond to an emotional communication in either an invalidating fashion (using one of the many, many invalidating phrases above) or in a way that doesn’t match the emotional distress, the BP will feel unable to communicate. She will think “I’m going off the deep end here and you are so calm! You don’t understand anything! You’ll never understand me!”, and not trust you. The tenor of your voice is more effective if you express your emotional identification with emotion in your voice as well, but with slightly less emotion than the BP is feeling. In other words, express distress in the identification, but less emotion than if you are actually in distress yourself.

When Hope is Not Enough ebook (Kindle Locations 1264-1277).