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Bpd 101


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Bpd 101

  1. 1. Borderline Personality Disorder 101 Kiera Van Gelder, MFA
  2. 2. Borderline Personality Disorder is an ILLNESS of impulsivity and dysregulation. It is considered a personality disorder because It influences how a person perceives, relates to, and thinks about the environment and oneself.Kiera Van Gelder © 2009
  3. 3. BPD is highly stigmatized and misunderstood. The typical portrayal of BPD is Glen Close as Alex Forrest in “Fatal Attraction”Kiera Van Gelder © 2009
  4. 4. Clinicians historically have describe BPD traits as being willfully imposed on others, rather than symptoms of an illness Fickle Moody Chaotic Flighty Possessive Childish Fragile Reckless Clingy Hostile Seductive Cranky Importunate Shallow Demanding Inconstant Unpredictable Desultory Irritable Unreasonable Going to Extremes Manipulative Vehement Adoring and Contemptuous Mercurial VolatileKiera Van Gelder © 2009 --Michael H. Stone, MD
  5. 5. However, this is how people with BPD see themselves: Helpless Misunderstood A failure Incompetent Unlovable Hopeless Alone Unsafe Out of control Defective NeglectedKiera Van Gelder © 2009
  6. 6. We need to understand the extreme pain of having BPD in order to make sense of why people behave as they do: Dr. Mary Zanarini and colleagues identified “BPD Pain” as involving:  “Feeling misunderstood, thinking that no one cares  “Feeling about them or that they are overwhelmed, bad, thinking about killing worthless, very themselves, believing they angry, empty, are evil, feeling like a small abandoned, child, and believing they are furious, enraged” damaged.” “the overall ‘amplitude’ of this pain may be a particularly good marker for the borderline diagnosis.” Zanarini, et al. Harv Rev Psychiatry. 1998 Nov-Dec;6(4):201-7.
  7. 7. 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)1. Frantic ef forts to avoid real and 5. Recurrent suicidal behavior, gestures or imagined abandonment. threats; or self-mutilating behavior.2. A pattern of unstable and intense 6. Af fective instability due to a marked reactivity of mo od (e.g. intense episodic interpersonal relationships dysphoria, irritability or anxiety usually characterized by alternating between lasting a few hours and rarely more than a extremes of idealization and few days). devaluation 7. Chronic feelings of emptiness.3. Identity disturbance, persistently and markedly unstable self-image or sense of self. 8. Inappropriate, intense anger or lack of control of anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).4. Impulsivity in at least two areas that are potentially self damaging (e.g. substance abuse, sex, binge eating, 9. Transient stress related paranoid ideation or spending, reckless driving). severe dissociative symptoms.” American Psychiatric Association Dialogistic and Statistic Manual IV TR
  8. 8. How to make sense of BPD when everyone experiences the symptoms to one degree or another? And there are so many of them! 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. 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: • Dr. John Gunderson: • Dr. Marsha Linehan: Multiple areas “Phenotypes” that can be traced to of “Dysregualtion” genetic markers • Dr. Otto Kernberg: Disordered • Dr. Aaron Beck: “Schema” “Attachments” and “Defence Mechanisms” •Dr. Judith Herman: Complex PostKiera Van Gelder © 2009 Traumatic Stress Disorder
  9. 9. As you can see, doctors have many theories and ways of defining BPD Chemical Imbalance Faulty Schema Emotion Dysregulation Disorder I’m screwed Complex Post Traumatic Reactive Stress Disorder Attachment Disorder Willful Asshole… Just needs to change No! Screw Primitive Thanks to Valarie Porr for you! defenses the inspirationfor this slide!Kiera Van Gelder © 2009
  10. 10. 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…. 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. PTSD Generalized Anxiety Disorder Is there “Ragaholic” anything I don’t have? Depression Bipolar & Bipolar II Eating Disorders Substance Abuse Obsessive Compulsive Disorder Agoraphobia Kleptomania Co-dependence Sex Addiction I’m certain you don’tPanic Disorder have BPD! Personality Disorder Not Otherwise Specified
  11. 11. So what is BPD (minus the confusion, stigma, denial, misinformation and horrible media portrayals?Kiera Van Gelder © 2009
  12. 12. First, an understanding of what we call “Psychiatric Disorders” Mental illness or psychiatric disorder refers to difficulties (impairments) a person experiences with thoughts, emotions, behaviors, perceptions and relationships. 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. A psychiatric condition is not WHO we are: no matter if it’s biologically-based or involves our personality! However, our language and thinking often reinforces that concept. ie “He is a schizophrenic; I am an alcoholic;Kiera Van Gelder © 2009 she is a borderline.”
  13. 13. Why is BPD called a “Personality” Disorder?Unlike many mood disorders, a personality disorder involves one’s sense of selfand perception of the world. For some of us, our experience of self and other, ourways of behaving and reacting, become harmful and rigid. It takes great courageand insight to go beyond our habitual ways to grasp that our personality might beimpaired. Of course, everyone’s personality is disordered to some extent. But with“Personality Disorder,” it is sever, destructive, incapacitating and often hellish forourselves and those who know us. Personality Development involves the interaction of Biological pre-dispositions (nature) External Environments (nurture) A Personality Disorder occurs when personality traits are inflexible and maladaptive and cause functional impairment or subjective distress.
  14. 14. Dr. Marsha Linehan suggests that people develop BPD due to a “biological vulnerability” in combination with a specific environment: Those with BPD typically have three vulnerabilities 1) High Quick to emotional heat up sensitivity Slow to 2) High cool down emotional reactivity 3) A Slow return to emotional baseline = Symptoms ofKiera Van Gelder © 2009 Impulsivity and
  15. 15. A little Acronym for BPD: RISE REACTIVITY  impulsive, out-of-control, overly aggressive, acting without thinking INTENSITY  psychic bleeding, hemorrhaging pain, unable to calm down SENSITIVITY  emotional burn victims; thin-skinned; easily disturbed by small slights EMOTIONALITY  Overwhelmed by feelings / dissociated from feelings; thoughts easily distorted; difficulty seeing beyond present emotional stateKiera Van Gelder © 2009
  16. 16. Before lo oking 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. 5 Areas of Emotions Dysregulation: Behavior Relationships Self-Image CognitionKiera Van Gelder © 2009
  17. 17. Emotions 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. Rages Chronic anxiety Despair Low tolerance to stress Easily frustrated Rapidly changing emotions Overwhelming passion / desire Extreme sensitivity Dissociation, being “shut down” BoredomKiera Van Gelder © 2009 Loneliness
  18. 18. People with BPD typically use impulsive, self- Behavior destructive behaviors as a way to regulate intense, negative emotions and cope with life. Binging and purging Drug & Alcohol Abuse Vandalism Picking fights Self- harm: cutting & burning Impulsive Spending Thrill-seeking Suicide Attempts and threats Shoplifting Geographical cures Unsafe SexKiera Van Gelder © 2009
  19. 19. People with BPD have difficulty tolerating separationRelationships or perceived rejection from those they are closest too, and can live in constant fear of abandonment. Intolerance of Rejection Intense Fear of Abandonment Other person becomes focal point for self Unstable “Stormy” Conflicts with others Relationships difficult to tolerate Need for constant assurance Difficulty internalizing Trust is given love or remembering indiscriminately or positive connections not at all Need for closeness pushes Frantic AttemptsKiera Van Gelder © 2009 others’ boundaries to Avoid Being Left
  20. 20. Cognition People with BPD can have impaired and distorted thinking, especially under stress or when triggered. Black and White Thinking Paranoia when under stress Difficulty holding onto positives Inability to recognize consequences of behavior “Emotional information Hyper-vigilant to processing” impairment possible threats Interprets neutral faces as hostile Alternately see others as all good or all bad Overly Jealous or SuspiciousKiera Van Gelder © 2009
  21. 21. People with BPD have a fragile and shifting sense of self. A suddenSelf-Image change, even a good one, can destabilize a person’s sense of themselves and their place in the world. Sense of being bad or wrong Emptiness Deep Insecurity Rapidly Changing Identity Confused sexual orientation Depersonalization / feeling unreal Annihilation of self by others through abandonment or engulfment Sense of self dependant on others Environment determines self-worth Shifting and contradictoryKiera Van Gelder © 2009 goals or values
  22. 22. Common beliefs researchers discovered those with BPD have about themselves and the world, in addition to “dysregulation”  I am endangered  The world is dangerous and malevolent  I am like a small child  I am powerless and vulnerable  I am uncared for  Zanarini, (1988)  I am inherently unacceptable  Beck and Freeman (1990) These very much contribute to our personality and how we interact with ourselves and the world!
  23. 23. There are recognized biological components to BPD Research shows abnormalities in the neural systems that regulate emotions, impulsivity and thinking Emotions Perception andRegulation is Reasoning disortions impaired Dorsolateral prefrontal systemAmygdala system Impulsivity control problems Anterior Cingulate Orbitomedial Prefrontal Systems 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
  24. 24. How biological vulnerabilities and environment interact: Linehan’s Bio-social model of BPD Development Dr. Marsha Linehan proposes that it’s within a specific “person/environment” interaction that BPD develops Biological Invalidating Vulnerability Environment: 1. High emotional 1. Indiscriminately sensitivity rejects private experience 2. High emotional 2. Punishes emotional reactivity displays while intermittently reinforcing 3. Slow return to emotional escalation emotional baseline 3. Oversimplifies ease of problem solving and meeting goalsKiera Van Gelder © 2009
  25. 25. So what is an Invalidating Environment? An Invalidating Environment Negates An invalidating Dismisses A person’s environment can be communication anything from highly Disregards abusive to a simple and behavior mismatch between Criticizes (Feelings, thoughts, caretakers and the person who is Punishes preferences, beliefs, sensations) * vulnerable. * Linehan, 1991Kiera Van Gelder © 2009
  26. 26. People with BPD and those in relationship to them will encounter challenges specific to the disorder For example, intimate and close relationships are triggering to a person with BPDBeing with and needing others brings up: Emotional reactivity Sense of being threatened Paranoia and jealousy (especially perception of betrayal) Dif ficulty negotiating boundaries (taking on others emotions, issues) Heightened sensitivity to judgment and criticism Polarized thinking / perceptions Dif ficulty seeing others’ perspectives Taking desperate actions in order to manage pain of conflicts and to express feelings. 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.
  27. 27. 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.Kiera Van Gelder © 2009
  28. 28. Treatment for Borderline Personality Disorder is now proven effective and available in many places DBT : Dialectical Behavior Therapy (Marsha Linehan, WA) CBT: Cognitive Therapy (Aaron Beck, PA) SFT: Schema-Focsued Therapy (Jeffrey Young, NY) Mentalization (Andrew Bateman and Peter Fonagey, UK) TFP: Transference-focused Psychotherapy (Otto Kernberg, NY) STEPPS: Systems Training for Emotional Predictability and Problem Solving (Nancy Blum et al, IO)
  29. 29. Dr. Marsha Linehan specifies 4 Stages of Recoveryfrom Borderline Personality Disorder Stage 4: “Incompleteness”  Capacity for Joy and Freedom: Love as inter-dependence, internalized mastery, “having Sense of perspective”, self-management, sense of self is evolving. Self Stage 3: “Problems in Everyday Living”  Ordinary Happiness and Unhappiness: Rebuilding a life, generalizing skills to Interpersonal relationships and work, involved with life. Stage 2: “Overcoming Quiet Desperation”  Emotional Experiencing: Emotional & Dealing with PTSD and trauma, fear of emotions, Cognitive understanding triggers. Stage 1: Severe Behavioral Dyscontrol Behavioral  Behavioral Control: Reducing self-harm, addictions, dissociation, rage, suicide attempts, chronic despair.* Adopted from M.M Linehan, 2004
  30. 30. No matter what kind of treatment is done, healing from BPD involves the cultivation of the following qualities for ALL involved Openness: A willingness to Non-judgment: Mindfulness: Not imposing our experience the symptoms Developing awareness of own viewpoint but without shutting down or body, feelings, thoughts, defending ourselves focusing on facts reactions, & surrounding unnecessarily environment Giving the Benefit of the Validation: Doubt: Not jumping to Recognize what conclusions about other each person is people’s behavior saying and experiencing, even if you Curiosity: disagree. Asking “what is going on” rather than makingPausing and imagining judgments and assumptions what others are feeling: Patience: The pause allows us to Allowing ourselves and Hope:respond rather than react others to go through the Believing that recovery process and accept it won’t be on our schedule is possible
  31. 31. “Abandon what is unskillful…. Cultivate what is good.” --The BuddhaKiera Van Gelder © 2009