Note that these are from the viewpoint of the observer/person being impacted by the disorder
Add biological info– place in brain—what can be symbol of?
Add biological info– place in brain—what can be symbol of?
Add biological info– place in brain—what can be symbol of?
A Borderline Personality Disorder Primer by Kiera Van Gelder, MFA
Borderline Personality Disorder 101 Kiera Van Gelder, MFA
is an ILLNESS of impulsivity and dysregulation. Borderline Personality Disorder <ul><ul><li>It influences how a person perceives, relates to , and thinks about the environment and oneself . </li></ul></ul>It is considered a personality disorder because
BPD is highly stigmatized and misunderstood. The typical portrayal of BPD is Glen Close as Alex Forrest in “Fatal Attraction”
Chaotic Childish Clingy Cranky Demanding Desultory Going to Extremes Adoring and Contemptuous Fickle Flighty Fragile Hostile Importunate Inconstant Irritable Manipulative Mercurial Moody Possessive Reckless Seductive Shallow Unpredictable Unreasonable Vehement Volatile Clinicians historically have describe BPD traits as being willfully imposed on others , rather than symptoms of an illness --Michael H. Stone, MD
Helpless Unlovable Alone A failure Defective Misunderstood Incompetent Hopeless Out of control Unsafe However , this is how people with BPD see themselves: Neglected
We need to understand the extreme pain of having BPD in order to make sense of why people behave as they do: <ul><li>“ Feeling overwhelmed, worthless, very angry, empty, abandoned, furious, enraged” </li></ul><ul><li>“ Feeling misunderstood, thinking that no one cares about them or that they are bad, thinking about killing themselves, believing they are evil, feeling like a small child, and believing they are damaged.” </li></ul>“ the overall ‘amplitude’ of this pain may be a particularly good marker for the borderline diagnosis.” <ul><ul><ul><li>Zanarini, et al. Harv Rev Psychiatry. 1998 Nov-Dec;6(4):201-7. </li></ul></ul></ul>Dr. Mary Zanarini and colleagues identified “BPD Pain” as involving:
<ul><li>Frantic efforts to avoid real and imagined abandonment. </li></ul><ul><li>A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation </li></ul><ul><li>Identity disturbance, persistently and markedly unstable self-image or sense of self. </li></ul><ul><li>Impulsivity in at least two areas that are potentially self damaging (e.g. substance abuse, sex, binge eating, spending, reckless driving). </li></ul><ul><li>5. Recurrent suicidal behavior, gestures or threats; or self-mutilating behavior. </li></ul><ul><li>6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and rarely more than a few days). </li></ul><ul><li>Chronic feelings of emptiness. </li></ul><ul><li>Inappropriate, intense anger or lack of control of anger (e.g. frequent displays of temper, constant anger, recurrent physical fights). </li></ul><ul><li>9. Transient stress related paranoid ideation or severe dissociative symptoms.” </li></ul>The American Psychiatric Association’s manual of diagnoses (the DSM IV TR) defines nine BPD symptoms. These symptoms, you’ll note, are also basic human experiences, and so, the disorder is best defined by the severity of symptoms and their duration. “ A pervasive pattern of instability of interpersonal relationships, self-image, affects and control over impulses beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following criteria: (5 out of 9) American Psychiatric Association Dialogistic and Statistic Manual IV TR
How to make sense of BPD when everyone experiences the symptoms to one degree or another? <ul><li>Clinicians and researchers continue to struggle with refining the diagnosis to accurately reflect the experience of those who suffer from it. The variety of forms it takes, and the way it borders on average human experience, makes understanding the disorder difficult. </li></ul>And there are so many of them! Additionally, since you only need 5 out of 9 symptoms to qualify, there are a total of 256 different combinations of BPD. Valarie Porr, MA, often uses the parable of the blind man touching an elephant when showing people in her workshops how many ways BPD can be perceived. Here are just some of the ways clinicians explain the core symptoms: <ul><li>Dr. John Gunderson: “Phenotypes” that can be traced to genetic markers </li></ul><ul><li>Dr. Aaron Beck: “Schema” </li></ul><ul><li>Dr. Judith Herman: Complex Post Traumatic Stress Disorder </li></ul><ul><li>Dr. Marsha Linehan: Multiple areas of “Dysregualtion” </li></ul><ul><li>Dr. Otto Kernberg: Disordered “Attachments” and “Defence Mechanisms” </li></ul>
Emotion Dysregulation Disorder Chemical Imbalance Willful Asshole… Just needs to change Reactive Attachment Disorder I’m screwed Complex Post Traumatic Stress Disorder Faulty Schema Primitive defenses As you can see, doctors have many theories and ways of defining BPD No! Screw you! Thanks to Valarie Porr for the inspirationfor this slide!
Additionally, many clinicians cannot see the disorder because they focus on the many “Co-Occuring” diagnosis, as BPD “borders” on and combines with numerous other struggles…. Bipolar & Bipolar II Generalized Anxiety Disorder Substance Abuse PTSD Eating Disorders Depression Obsessive Compulsive Disorder Kleptomania Co-dependence Agoraphobia Sex Addiction Often, people with BPD will be given other diagnosis and treated specifically for those, but ultimately the core of our suffering is never healed. This can go on for decades, leading to the conclusion that there are people who are untreatable and incurable. When, in fact, they have not received the right education and treatment. “ Ragaholic” Panic Disorder Personality Disorder Not Otherwise Specified Is there anything I don’t have? I’m certain you don’t have BPD!
So what is BPD (minus the confusion, stigma, denial, misinformation and horrible media portrayals?
First, an understanding of what we call “Psychiatric Disorders” The diagnosis (i.e. depression, addiction, PTSD) acts as a map that allows us to understand symptoms that cause misery and get in the way of good living. <ul><li>A psychiatric condition is not WHO we are: no matter if it’s biologically-based or involves our personality! </li></ul><ul><ul><li>However, our language and thinking often reinforces that concept. </li></ul></ul><ul><ul><li>ie “ He is a schizophrenic; I am an alcoholic; she is a borderline.” </li></ul></ul>Mental illness or psychiatric disorder refers to difficulties (impairments) a person experiences with thoughts, emotions, behaviors, perceptions and relationships.
Why is BPD called a “Personality” Disorder? <ul><li>A Personality Disorder </li></ul><ul><li>occurs when personality traits are </li></ul><ul><li>inflexible and maladaptive and cause </li></ul><ul><li>functional impairment or </li></ul><ul><li>subjective distress. </li></ul>Personality Development involves the interaction of Biological pre-dispositions (nature) External Environments (nurture) Unlike many mood disorders, a personality disorder involves one’s sense of self and perception of the world. For some of us, our experience of self and other, our ways of behaving and reacting, become harmful and rigid. It takes great courage and insight to go beyond our habitual ways to grasp that our personality might be impaired. Of course, everyone’s personality is disordered to some extent. But with “Personality Disorder,” it is sever, destructive, incapacitating and often hellish for ourselves and those who know us.
Dr. Marsha Linehan suggests that people develop BPD due to a “biological vulnerability” in combination with a specific environment: 1) High emotional sensitivity 2) High emotional reactivity 3) A Slow return to emotional baseline Quick to heat up Slow to cool down = Symptoms of Impulsivity and Dysregulation Those with BPD typically have three vulnerabilities
A little Acronym for BPD : RISE <ul><li>REACTIVITY </li></ul><ul><ul><li>impulsive, out-of-control, overly aggressive, acting without thinking </li></ul></ul><ul><li>INTENSITY </li></ul><ul><ul><li>psychic bleeding, hemorrhaging pain, unable to calm down </li></ul></ul><ul><li>SENSITIVITY </li></ul><ul><ul><li>emotional burn victims; thin-skinned; easily disturbed by small slights </li></ul></ul><ul><li>EMOTIONALITY </li></ul><ul><ul><li>Overwhelmed by feelings / dissociated from feelings; thoughts easily distorted; difficulty seeing beyond present emotional state </li></ul></ul>
Before looking at the more “intra-psychic” aspects of BPD (like attachment, rejection sensitivity, and fear of abandonment) let’s focus on the areas of dysregulation Dr. Marsha Linehan lists as being central to BPD. Cognition Behavior Relationships Emotions Self-Image 5 Areas of Dysregulation:
Emotions Chronic anxiety Rapidly changing emotions Overwhelming passion / desire Extreme sensitivity Rages Dissociation, being “shut down” People with BPD have been described as “ emotional burn victims ” due to extreme sensitivity. Their interior world is constantly shifting, unpredictable and difficult to express to others or understand. Low tolerance to stress Easily frustrated Boredom Despair Loneliness I cannot deal with this!
People with BPD typically use impulsive, self-destructive behaviors as a way to regulate intense, negative emotions and cope with life. Behavior Self- harm: cutting & burning Suicide Attempts and threats Drug & Alcohol Abuse Impulsive Spending Unsafe Sex Vandalism Thrill-seeking Picking fights Shoplifting Binging and purging Geographical cures I can't stop!
Relationships Intolerance of Rejection Unstable “Stormy” Relationships Intense Fear of Abandonment Frantic Attempts to Avoid Being Left Other person becomes focal point for self Conflicts with others difficult to tolerate Need for constant assurance Trust is given indiscriminately or not at all Need for closeness pushes others’ boundaries People with BPD have difficulty tolerating separation or perceived rejection from those they are closest too, and can live in constant fear of abandonment. Difficulty internalizing love or remembering positive connections I need you to survive!
Cognition Overly Jealous or Suspicious Black and White Thinking Alternately see others as all good or all bad Difficulty holding onto positives Paranoia when under stress People with BPD can have impaired and distorted thinking, especially under stress or when triggered. Inability to recognize consequences of behavior Hyper-vigilant to possible threats Interprets neutral faces as hostile “ Emotional information processing” impairment Nothing is safe!
People with BPD have a fragile and shifting sense of self. A sudden change, even a good one, can destabilize a person’s sense of themselves and their place in the world. Self-Image Rapidly Changing Identity Deep Insecurity Depersonalization / feeling unreal Emptiness Confused sexual orientation Sense of self dependant on others Annihilation of self by others through abandonment or engulfment Environment determines self-worth Sense of being bad or wrong Shifting and contradictory goals or values I don't know who I am!
Common beliefs researchers discovered those with BPD have about themselves and the world, in addition to “dysregulation” <ul><li>I am endangered </li></ul><ul><li>I am like a small child </li></ul><ul><li>I am uncared for </li></ul><ul><ul><ul><li>Zanarini, (1988) </li></ul></ul></ul><ul><li>The world is dangerous and malevolent </li></ul><ul><li>I am powerless and vulnerable </li></ul><ul><li>I am inherently unacceptable </li></ul><ul><ul><ul><li>Beck and Freeman (1990) </li></ul></ul></ul>These very much contribute to our personality and how we interact with ourselves and the world!
There are recognized biological components to BPD Research shows abnormalities in the neural systems that regulate emotions, impulsivity and thinking Emotions Regulation is impaired Amygdala system Impulsivity control problems Anterior Cingulate Orbitomedial Prefrontal Systems Perception and Reasoning disortions Dorsolateral prefrontal system The Best and Most Up to Date information on this is found in Valarie Porr’s Book: Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change
How biological vulnerabilities and environment interact: Linehan’s Bio-social model of BPD Development 1. High emotional sensitivity 2. High emotional reactivity 3. Slow return to emotional baseline 1. Indiscriminately rejects private experience 2. Punishes emotional displays while intermittently reinforcing emotional escalation 3. Oversimplifies ease of problem solving and meeting goals Invalidating Environment: Biological Vulnerability Dr. Marsha Linehan proposes that it’s within a specific “person/environment” interaction that BPD develops
So what is an Invalidating Environment? Negates Dismisses Disregards Criticizes Punishes An Invalidating Environment A person’s communication and behavior (Feelings, thoughts, preferences, beliefs, sensations) * * Linehan, 1991 An invalidating environment can be anything from highly abusive to a simple mismatch between caretakers and the person who is vulnerable.
<ul><li>Being with and needing others brings up: </li></ul><ul><li>Emotional reactivity </li></ul><ul><li>Sense of being threatened </li></ul><ul><li>Paranoia and jealousy (especially perception of betrayal) </li></ul><ul><li>Difficulty negotiating boundaries (taking on others emotions, issues) </li></ul><ul><li>Heightened sensitivity to judgment and criticism </li></ul><ul><li>Polarized thinking / perceptions </li></ul><ul><li>Difficulty seeing others’ perspectives </li></ul><ul><li>Taking desperate actions in order to manage pain of conflicts and to express feelings. </li></ul>People with BPD and those in relationship to them will encounter challenges specific to the disorder We all need to see these behaviors as “maladaptive” rather than “bad”: those with BPD can be triggered constantly by those they are closest to , therefore it may seem impossible to interact with them without getting hurt yourself. For example, intimate and close relationships are triggering to a person with BPD
Despite all this, we now know BPD is treatable! 2 years = 40% Remission 6 years = 68% Remission 10 years = 85% Remission ( Zanarini, 2005, 2006) Remission is defined as “no longer meeting 5 of 9 criteria” However, we must also be aware that remission does not mean “recovery” or having a good quality of life: Recovery involves more than the absence of symptoms.
DBT : Dialectical Behavior Therapy (Marsha Linehan, WA) www.behavioraltech.org CBT: Cognitive Therapy (Aaron Beck, PA) www.academyofct.org SFT: Schema-Focsued Therapy (Jeffrey Young, NY) www.schematherapy.com Mentalization (Andrew Bateman and Peter Fonagey, UK) www.menninger.edu TFP: Transference-focused Psychotherapy (Otto Kernberg, NY) www.borderlinedisorders.com STEPPS: Systems Training for Emotional Predictability and Problem Solving (Nancy Blum et al, IO) www.uihealthcare.com/topics/medicaldepartments/psychiatry/stepps/index.html Treatment for Borderline Personality Disorder is now proven effective and available in many places
Dr. Marsha Linehan specifies 4 Stages of Recovery from Borderline Personality Disorder <ul><li>Stage 4: “Incompleteness” </li></ul><ul><li> Capacity for Joy and Freedom: </li></ul><ul><ul><ul><li>Love as inter-dependence, internalized mastery, “having </li></ul></ul></ul><ul><ul><ul><li>perspective”, self-management, sense of self is evolving. </li></ul></ul></ul><ul><li> </li></ul><ul><li>Stage 1: Severe Behavioral Dyscontrol </li></ul><ul><li>Behavioral Control: </li></ul><ul><li>Reducing self-harm, addictions, dissociation, rage, </li></ul><ul><li>suicide attempts, chronic despair. </li></ul> Stage 2: “Overcoming Quiet Desperation” Emotional Experiencing: Dealing with PTSD and trauma, fear of emotions, understanding triggers. Behavioral Emotional & Cognitive Interpersonal Sense of Self * Adopted from M.M Linehan, 2004 Stage 3: “Problems in Everyday Living” Ordinary Happiness and Unhappiness: Rebuilding a life, generalizing skills to relationships and work, involved with life.
No matter what kind of treatment is done, healing from BPD involves the cultivation of the following qualities for ALL involved Mindfulness: Developing awareness of body, feelings, thoughts, reactions, & surrounding environment Non-judgment: Not imposing our own viewpoint but focusing on facts Validation: Recognize what each person is saying and experiencing, even if you disagree. Pausing and imagining what others are feeling: The pause allows us to respond rather than react Openness: A willingness to experience the symptoms without shutting down or defending ourselves unnecessarily Giving the Benefit of the Doubt: Not jumping to conclusions about other people’s behavior Curiosity: Asking “what is going on” rather than making judgments and assumptions Patience: Allowing ourselves and others to go through the process and accept it won’t be on our schedule Hope: Believing that recovery is possible
“ Abandon what is unskillful…. Cultivate what is good.” --The Buddha