Relationships w BPD


http://loveengineer.com/create-maintain-stability-relationships-bpd-partners/

Why Can’t People with BPD Stay Full and Remember That They are Loved?

BPD adults have missed out on two essential developmental experiences that affect all their attachments.

  1. They can’t feel you and hold you as a constant loving being in their mind’s eye. You are either ‘good’, ‘bad’ or ‘absent’!  It’s called a lack of object constancy. So when Jackson went for a walk with Charlene just before they were preparing dinner the night of the threatened attack, she felt him as the good person, present with her. But the moment he wanted to do something else while she was preparing the dinner he became the ‘bad’ person, abandoning her and making her empty again.
  1. They have trouble imagining your intentions and needs. It’s known as trouble mentalizing. According to this theory of BPD, put forward by Bateman and Fonagy in their book, Psychotherapy for BPD, when Charlene gets angry that Jackson wants to do something else as she prepares the dinner, she cannot imagine that he may need the rest room, or need to check messages on his work e-mail, or just need to read a trade magazine. She imagines only that he is tired of her and wants to get away – hence the rage and threats. Mentalization based treatment is very successful in helping people like Charlene control their extreme feelings by learning how to read the intentions of their loved ones.

A good day..


A good day indeed…
We left the city, went to the mountains, visited an ancient Roman gold mine …held hands, had great sex, connected…

I have been reluctant to put my face here…but this picture shows me happy with Friendlover, who’s been more than that (more than a friend, more than just a lover)…and it really has been a great day

I have to say that lately I’ve been feeling a lot of connectedness with him…which of course comes with intense anxiety and a need to pull away…but somehow I think that I am still close..I do really like the feeling of connectedness…there’s a safe and loving emotion attached to it, stronger if I’m in the moment, mindful, than the need to pull away…😄

image

How to make a Borderline Relationship work | Professional Career Advice | Personalized Career and Life Advice by Felicitas Heyne


How to make a Borderline Relationship work | Professional Career Advice | Personalized Career and Life Advice by Felicitas Heyne.

Impulsiveness explained…


Definition:

Impulsiveness – The tendency to act or speak based on current feelings rather than logical reasoning.

It Seemed Like a Good Idea at the Time

Impulsiveness is a normal form of human behavior. All of us make some decisions impulsively, based on “gut-feel”, “instinct”, mood or whim. And life would be very dull we didn’t! 

Impulse can be a tremendous ally. Some people have made the best decisions of their lives impulsively, and many people make big decisions based on “gut feelings” – decisions such as which career to follow, who to marry, where to buy a house or where to invest their savings.

However, in some circumstances, impulse can be a tremendous liability. Some people have made the worst decisions of their lives impulsively based on that same “gut feeling”.

In his groundbreaking book “Emotional Intelligence”, psychologist Daniel Goleman explains how our emotional mind, which is based in the brain’s limbic system, is distinct from our intellectual mind which is based in the brain’s prefrontal cortex. The emotional mind makes lightning-fast decisions about things we like and dislike, hate, love and fear. The intellectual, logical mind makes slower, more deliberate, rational decisions.

Most mature, mentally healthy adults learn how to regulate their impulsive urges with logical reasoning, applying the wisdom of experience to minimize risks and maximize potential rewards.

For example, a married woman who has children may have the urge to have an affair with a co-worker, and then reasons that the consequences of the affair would be devastating to her children and her husband, so she doesn’t. A young man may feel the urge to drive his car at 120 mph, yet restrains the urge because he knows he may wreck his car or may get pulled over by the police. An angry employee may feel the urge to hit a belligerent boss, and hold back because her ability to reason convinces her doing so would probably result in the loss of her job.

Not all impulsive urges are wrong. The impulse to duck and raise your hands to protect your head when an object is hurled at you could save your life. A couple may travel to a vacation in Las Vegas and, knowing the odds are against them, may gamble some of their hard-earned money, knowing they will probably lose but enjoying the thrill of the chance that they just might win a fortune. A young graduate may decide to forego a great job opportunity because he/she wants to head off and “see the world” for a year.

Impulsiveness starts to become dysfunctional when those spur-of-the-moment decisions are insufficiently regulated by rational thought, and chronically harm the decision maker, their immediate family or other innocent bystanders.

The frontal lobe, or prefrontal cortex, is the area of the brain located just behind the forehead. It has been shown by neurologists to be associated with predicting the consequences of actions, ethical decision-making and pattern recognition. In other words, the prefrontal cortex is the risk/reward-calculation zone of the brain. Experiments have shown that, in most people, the prefrontal cortex reaches full development at around the age of 25. The lag between full physical maturity and prefrontal cortex maturity is sometimes used to explain the apparent emotional immaturity in teenagers and young adults, who often make decisions which appear “reckless” to older adults.

In his best-selling book “Blink”, author Malcolm Gladwell gives a very readable overview of how impulsive decision making can, at the same time, be both a powerful asset and a costly liability.
There are four commonly used sub-categories for impulsiveness:

  1. Urgency – A desire to act immediately to avoid a threat or avoid missing a perceived opportunity;
  2. Whimsical – Little or no serious consideration of positive and negative consequences of actions;
  3. Procrastination – Unfettered acceptance of diversions to circumvent an undesirable task;
  4. Thrill-seeking – Experiencing a thrill associated with taking a big risk.

What Chronic Impulsiveness Looks Like

  • • A man spends the family’s monthly budget on a “sure thing” at a gambling institution.
  • • A woman wants to stay married yet still has affairs.
  • • A man repeatedly quits jobs for no adequate reason.
  • • A man starts a brawl while he has his children with him.
  • • An employee berates and insults her boss and co-workers when faced with a minor disappointment.
  • • A woman threatens her husband with a loaded weapon after he returns home late from work.

What it feels like

Depending on your situation, your own psychological make-up and your current mood, you may find episodes of impulsivity thrilling, exhausting, entertaining, frightening or threatening.

However, if you are a mentally healthy adult and you are living with a person who routinely exhibits a dysfunctional impulsiveness, you will likely be very concerned about your own safety and the safety of any children and/or innocent bystanders.

You may feel frustrated at your inability to “talk sense” into such a person. You may also feel torn between a desire to run to safety and a desire to stay and try to help the person who is behaving impulsively.

What NOT to do

  • • Don’t ignore any threats to your own personal safety or the safety of any children or bystanders.
  • • Don’t repeatedly try to talk sense into a routinely impulsive person. If they don’t listen to their own rational thoughts, they are unlikely to pay attention to yours.
  • • Don’t fight or retaliate or fight fire with fire.
  • • Don’t leave precious objects, keepsakes, documents, resources and bank accounts in the custody of a reckless person. Protect your assets.
  • • Don’t take responsibility or blame yourself for the reckless actions of an impulsive person.
  • • Don’t go it alone or keep what you are experiencing a secret.

What TO do

  • • Protect your assets. Move important objects out of the reach of an impulsive person. Make copies of important documents, close joint bank accounts. Move precious items to a safe place.
  • • Hope for the best but plan for the worst. Develop an emergency plan for any scenario that may include violence or abuse being directed towards or your children.
  • • Protect your children and yourself physically from any impulsive acts of violence. Call the police if necessary.
  • • Talk about it! Talk to trusted friends and family about what you are dealing with. A reality check can help enormously in assisting you to make clear decisions for your own wellbeing.

Fear of abandonement explained..


Definition:

Fear of Abandonment – An irrational belief that one is imminent danger of being personally rejected, discarded or replaced.

On the Edge

Fear of abandonment is often partnered with an exaggerated sense of dependency on another individual. People who suffer from Borderline Personality Disorder often live in a chronic sense of fear that their world is about to collapse through the abandonment of those closest to them.

While fear of abandonment may seem to do more harm to the person expressing it, it can become dangerous when someone begins to act on the false belief that you are going to abandon them.

This can result in sabotage of your other relationships, punishment in the form of retribution (“I’ll leave you before you leave me” or “I’ll cheat on you before you cheat on me”); jealous fits of rage (such as destroying property, hitting, threatening – even, in extreme cases, homicide); emotional withdrawal; and self-harm (including suicide attempts).

Fear of abandonment often manifests itself as an irrational form of jealousy. The abuser accuses the victim of being unfaithful or of loving other people in an unbalanced or inappropriate way. Pressure is then applied to the victim to cut off contact with the competing family member, friend or “lover”.

The irony of the fear of abandonment is that those who act on it often behave in ways that frighten their victims and push them further away.

How it looks

  • A spouse assumes their partner is having an affair without any objective evidence.
  • A mother does not allow her teenage child to form romantic or peer relationships.
  • A boyfriend calls or texts repeatedly – 15 or more times in a single day.
  • A girlfriend shows up at an office function to which she has not been invited.
  • A divorcee stalks his ex-wife after the dissolution of the relationship.

Some examples of statements from people who have a fear of abandonment include:

  • “You’ve never loved me.”
  • “I know you are having an affair”
  • “You prefer them to me.”
  • “You never want to spend time with me.”
  • “I know you want to leave me”

Why they do it

One of the root causes of Fear of Abandonment can be Lack of Object Constancy. Another can be deep-seated lack of self-esteem. In the case of some abusive individuals who also feel a strong sense of dependence on their victim and therefore fear losing them, there can be a conviction that the victim will imminently escape. 

Sometimes the accusation “You’re leaving me, aren’t you?” is used to justify an episode of abuse, is used as emotional blackmail or to perpetuate a situation of codependency.

Fear of abandonment can also be used by someone with a Personality Disorder as a justification for abusive behaviors including stalking, isolation, invasions of privacy, and other ways of controlling or monitoring the person they are afraid of losing.

How it feels

It can be a frustrating and deflating experience to live with someone who frequently expresses a fear of abandonment. 

Inwardly, it can be tempting to want to become the person that you are being accused of. You may fantasize about dumping them. You may be tired of their accusations and their dependent attitude. You may feel angry that you are being accused of being unfaithful without being able to act on it.

Outwardly, you may maintain a facade of reasonableness. It’s natural to want to say the “right thing” and assure the other person that you love them and will never leave them. But people who express a fear of abandonment generally make themselves less attractive by doing so. You may feel conflicted, wishing to be kind, yet feeling trapped in a downward spiral, resenting the other person for giving up on improving themselves while putting you in a difficult position.

How to cope

When faced with fear of abandonment it can be tempting to try to tackle the root cause by addressing the person’s feelings in an attempt to convince them they are not accurate. However, when you tell someone their feelings are inaccurate they are likely to find it invalidating

What NOT to do

  • Don’t try to argue or reason with a person who is experiencing fear of abandonment. Fear of abandonment is a primal emotion they are expressing, like a hungry baby crying for milk. You would have as much success trying to persuade a baby that crying doesn’t help.
  • Don’t go out of your way to try to prove you aren’t having an affair, or plotting to leave a person who has a fear of abandonment. Their fear is irrational and is unlikely to be resolved by a rational argument.
  • Don’t cave in to the demands of a person who is expressing fear of abandonment, when what they are demanding is not healthy for you or them. Just like a responsible parent, you sometimes have to say “no” to an unreasonable demand.
  • Don’t stay in the same room with anyone who threatens to hurt you, any children or themselves. Call the police immediately.
  • Don’t allow yourself to become isolated, or sacrifice things which are good for you in order to try to “prove” your love to someone else. Someone who truly loves you will never require you to prove your love for them. Keep your friends, your job and your support network intact.

What TO do

  • Put safety first – for children, yourself, property and for the person with the abandonment issues.
  • Take stock of the truth and separate what is real from what is not. You will have to do this for yourself as it will not be easy to convince the person expressing abandonment. Remember that even people with Personality Disorders get it right some of the time so don’t always discard their concerns just because they have cried wolf too often in the past.
  • Consider what is good and healthy for all parties concerned. It does no good to sacrifice your own needs to serve another person’s fear of abandonment – especially if it is not based on reality. You need to consider what is good for you AND what is good for the person with the disorder. For example, it isn’t good for you to give up your friends or family relationships to try to convince a person with abandonment that you love them. Neither is it good for you to retaliate in anger – you will just find yourself in a position of having to apologize later and you will just have handed the accusing person evidence that supports their abandonment theory. Consider what is best for both of you – if you can.
  • Follow through on your good judgment of what is appropriate. You will have the satisfaction of knowing you are picking your battles and fixing what you can fix and leaving alone what you can’t. You can’t fix other people’s feelings. Instead you can make good choices for your own life and your children’s lives – and reap long term rewards by doing so.

A BPD BRIEF by John G. Gunderson, MD


Diagnosis

*DSM-IV-TR Diagnostic Criteria

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1)  Frantic efforts to avoid real or imagined abandonment.

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

(3)  Identity disturbance: markedly and persistently unstable self-image or sense of self.

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

(5)  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

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

(7)  Chronic feelings of emptiness.

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

(9)  Transient, stress-related paranoid ideation or severe dissociative symptoms.

Overview of the Borderline Personality Disorder Diagnosis

Every person has a personality: longstanding ways of perceiving, relating to, and thinking about the environment and oneself. However, when these traits are inflexible, maladaptive and cause significant functional impairment or subjective distress, they constitute a personality disorder.

There are 10 classified personality disorders and of those, Borderline Personality Disorder (BPD) is the most common, most complex, most studied, and certainly one of the most devastating, with up to 10% of those diagnosed committing suicide. BPD exists in approximately 2-4% of the general population; up to 20% of all psychiatric inpatients and 15% of all outpatients. Females predominate (about 75%) within psychiatric settings while males are more common in substance abuse or forensic settings.

As a result of clinical observations since the 1930’s and scientific studies done in the 1970’s, psychiatrists determined that people characterized by intense emotions, self-destructive acts, and stormy interpersonal relationships constituted a type of personality disorder. The term “Borderline” was used because these patients were originally thought to exist as atypical (“borderline”) variants of other diagnoses and also because these patients tested the borders of whatever limits were set upon them. The diagnosis became “official” in 1980. While there has been much progress in the past 25 years in understanding and treating BPD, the diagnosis is underused. This owes mainly to the fact that BPD patients are difficult to treat and often evoke feelings of anger and frustration in the people trying to help. Such negative associations have caused many professionals to be unwilling to make the diagnosis. Many give precedence to co-occurring conditions such as depression, bipolar disorder, substance abuse, anxiety disorders and eating disorders. This problem has been aggravated by the lack of appropriate insurance coverage for the extended psychosocial treatments that BPD usually requires.

An Explanation of the DSM-IV TR Criteria

For a patient to be diagnosed with Borderline Personality Disorder, he or she must experience 5 out of the 9 criteria (see page 2) as set forth in the DSM-IV TR. Establishing the diagnosis is complicated by the fact that the presence of many of these criteria fluctuate. Here is a more detailed explanation of these symptoms:

  1. Abandonment Fears. These fears should be distinguished from the more common and less severe phenomena of separation anxiety. The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in the BPD patient’s self-image, affect, cognition, and behavior. Individuals with BPD are interpersonally hypersensitive and may experience intense abandonment fears and inappropriate anger even when faced with criticisms or time-limited separations. These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Frantic efforts to avoid abandonment may include impulsive actions such as self-injurious or suicidal behaviors. It was originally postulated that fear of abandonment developed as a result of failures in a child’s development during the rapprochement phase (from age one-and-a-half to two-and-a-half). However, empirical evidence has not borne this out.
  2. Unstable, Intense Relationships. Individuals with BPD are frequently unable to see significant others (i.e., potential sources of care or protection) as other than idealized (if gratifying), or devalued (if not gratifying). This is often referred to as “black and white thinking,” and in psychological terms, reflects the construct of “splitting.” When anger initially intended toward a loved one is experienced as dangerous, it gets “split” off to preserve the loved one’s goodness. Relationship instability is thought to be a symptom of early insecure attachment characterized by both fearful distrust and needy dependency.
  3. Identity Disturbance. The disorder of self which is specific to borderline patients is characterized by a distorted, unstable or weak self-image. Borderline patients often have values, habits, and attitudes which are dominated by whomever they are with. The interpersonal context in which these identity problems get magnified is thought to begin with not learning to identify one’s feeling states and the motives behind one’s behaviors.
  4. Impulsivity. The impulsivity of the borderline individual is frequently self-damaging, in its effects if not in its intentions. This differs from impulsivity found in other disorders such as manic/hypomanic or antisocial disorders. Common forms of impulsive behavior for borderline patients are substance or alcohol abuse, bulimia, unprotected sex, promiscuity, and reckless driving.
  5. Suicidal or Self-injurious Behaviors. Recurrent suicidal attempts, gestures, threats, or self-injurious behaviors are the hallmark of the borderline patient. The criterion is so prototypical of persons with BPD that the diagnosis rightly comes to mind whenever recurrent self-destructive behaviors are encountered. Self-destructive acts often start in early adolescence and are usually precipitated by threats of separation or rejection or by expectations that the BPD patient assume unwanted responsibilities. The presence of this pattern assists the diagnosis of concurrent BPD in patients whose presenting symptoms are depression or anxiety.
  1. Affective (Emotional) Instability. Early clinical observers noted the intensity, volatility and range of the borderline patient’s emotions. It was originally proposed that borderline emotional instability involved the same problems of affective irregularity found in persons with mood disorders, particularly depression and bipolar disorder. It is now known that although individuals with BPD display marked affective instability (i.e., intense episodic depression, unrest, anger, panic, or despair), these mood changes usually last only a few hours, and that the underlying dysphoric mood is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity to stresses, particularly interpersonal ones and a neurobiologically-based inability to regulate emotions.
  2. Emptiness. Chronic emptiness, described as a visceral feeling, usually felt in the abdomen or chest, plagues the borderline patient. It is not boredom, nor is it a feeling of existential anguish. This feeling state is associated with loneliness and neediness. Sometimes their experience is considered an emotional state and sometimes it is considered a state of deprivation.
  3. Anger. The anger of the borderline patient may be due to temperamental excess (a genetic vulnerability) or a longstanding response to excessive frustration (an environmental cause). Whether the cause is genetic or environmental, many individuals with BPD report feeling angry much of the time, even when the anger is not expressed overtly. Anger is often elicited when an intimate or caregiver is seen as neglectful, withholding, uncaring, or abandoning. Expressions of anger are often followed by shame and contribute to a sense of being evil.
  4. Psychotic-like Perpetual Distortions (Lapses in Reality Testing). Borderline patients can experience dissociation symptoms: feeling unreal or that the world is unreal. These symptoms are associated with other disorders, such as schizophrenia and Post Traumatic Stress Disorder (PTSD), but in those with BPD the symptoms generally are of short duration, at most, a few days, and often occur during situations of extreme stress. Borderline patients also can be unrealistically self-conscious, believing that others are critically looking at or talking about them. These lapses of reality in the BPD patient may also be distinguished from other pathologies in that generally the ability to correct their distortions of reality with feedback remains intact.

The borderline traits are usefully subdivided into four factors, each of which represents an underlying temperament (aka “phenotype”):

  1. Interpersonal hypersensitivity (criteria 1, 2 and 7)
  2. Affect (emotional) dysregulation (criteria 6, 8 and 7)
  3. Behavioral dyscontrol (Impulsivity) (criteria 4 and 5)
  4. Disturbed self (criteria 3 and 9)

The Origins of BPD

Borderline Personality Disorder, like all other major psychiatric disorders, is caused by a complex combination of genetic, social, and psychological factors. All modern theories now agree that multiple causes must interact with one another in order for the disorder to become manifest.

There are, however, known risk factors for the development of BPD. The risk factors include those present at birth, called temperaments; experiences occurring in childhood; and sustained environmental influences.

A. Inborn Biogenetic Temperaments

The degree in which Borderline Personality Disorder is caused by inborn factors, called the “level of heritability” is estimated to be 52-68%. This is about the same as for bipolar disorder. What is believed to be inherited are the biogenetic dispositions, i.e., temperaments, (or, as noted above, phenotypes), for Affective Dysregulation, Impulsivity, and Interpersonal Hypersensitivity. For children with these inborn dispositions, environmental factors can then significantly delimit or exacerbate them into adult BPD. But, in addition, some more BPD- specific disposition is inherited that glues these phenotypes together.

Many studies have shown that disorders of emotional regulation, interpersonal hypersensitivity, or impulsivity are disproportionately higher in relatives of BPD patients. The affect/emotion temperament predisposes individuals to being easily upset, angry, depressed, and anxious. The impulsivity temperament predisposes individuals to act without thinking of the consequences, or even to purposefully seek dangerous activities. The interpersonal hypersensitivity temperament probably starts with extreme sensitivity to separations or rejections. Another theory has proposed that patients with BPD are born with excessive aggression which is genetically based (as opposed to being environmental in origin). A child born with a cheerful, warm, placid or passive temperament would be unlikely to develop BPD.

Normal neurological function is needed for such complex tasks as impulse control, regulation of emotions, and perception of social cues. Studies of BPD patients have identified an increased incidence of neurological dysfunctions, often subtle that are discernible on close examination. The largest portion of the brain is the cerebrum, where information is interpreted coming in from the senses, and from which conscious thoughts and planned behavior emanate. Preliminary studies have found that individuals with BPD have a diminished response to emotionally intense stimulation in the planning/organizing areas of the cerebrum and that the lower levels of brain activity may promote impulsive behavior. The limbic system, located at the center of the brain, is sometimes thought of as “the emotional brain”, and consists of the amygdala, hippocampus, thalamus, hypothalamus and parts of the brain stem. There is evidence that in response to emotional arousal, the amygdale is particularly active in persons with BPD.

B. Psychological Factors

Like most other mental illnesses, Borderline Personality Disorder does not appear to originate during a specific, discrete phase of development. Recent studies have suggested that pre-borderline children fail to learn accurate ways to identify feelings or to accurately attribute motives in themselves and others (often called failures of “mentalization”). Such children fail to develop basic mental capacities that constitute a stable sense of self and make themselves or others understandable or predictable. One important theory has emphasized the critical role of an invalidating environment. This occurs when a child is led to believe that his or her feelings, thoughts and perceptions are not real or do not matter.

About 70% of people with BPD report a history of physical and/or sexual abuse. Childhood traumas may contribute to symptoms such as alienation, the desperate search for protective relationships, and the eruption of intense feeling that characterize BPD. Still, since relatively few people who are physically or sexually abused develop the borderline disorder (or any other psychiatric disorder) it is essential to consider temperamental disposition. Since BPD can develop without such experiences, these traumas are not sufficient or enough by themselves to explain the illness. Still, sexual or other abuse can be the “ultimate” invalidating environment. Indeed, when the abuser is a caretaker, the child may need to engage in splitting (denying feelings of hatred and revulsion in order to preserve the idea of being loved). Approximately 30% of people with BPD have experienced early parental loss or prolonged separation from their parents, experiences believed to contribute to the borderline patient’s fears of abandonment. People with BPD frequently report feeling neglected during their childhood. Sometimes the sources for this sense of neglect are not obvious and might be due to a sense of not being sufficiently understood. Patients often report feeling alienated or disconnected from their families. Often they attribute the difficulties in communication to their parents. However, the BPD individual’s impaired ability to describe and communicate feelings or needs, or resistance to self-disclosure may be a significant cause of the feelings of neglect and alienation.

C. Social and Cultural Factors

Evidence shows that borderline personality is found in about 2-4% of the population. There may be societal and cultural factors which contribute to variations in its prevalence. A society which is fast- paced; highly mobile, and where family situations may be unstable due to divorce, economic factors or other pressures on the caregivers, may encourage development of this disorder.

The Course of Borderline Personality Disorder

Borderline Personality Disorder usually manifests itself in early adulthood, but symptoms of it (e.g., self-harm) can be found in early adolescence. As individuals with BPD age, their symptoms and/or the severity of the illness usually diminish. Indeed, about 40-50% of borderline patients remit within two years and this rate rises to 85% by 10 years. Unlike most other major psychiatric disorders, those who do remit from BPD don’t usually relapse! Studies of the course of BPD have indicated that the first five years of treatment are usually the most crisis-ridden. A series of intense, unstable relationships that end angrily with subsequent self-destructive or suicidal behaviors are characteristic. Although such crises may persist for years, a decrease in the frequency and seriousness of self-destructive behaviors and suicidal ideation and acts and a decline in both the number of hospitalizations and days in hospital are early indications of improvement. Whereas about 60% of hospitalized BPD patients are readmitted in the first six months, this rate declines to about 35% in the eighteen months to two-year period following an initial hospitalization. In general, psychiatric care utilization gradually diminishes and increasingly involves briefer, less intensive interventions.

Improvements in social functioning proceed more slowly and less completely than do the symptom remissions. Only about 25% of the patients diagnosed with BPD eventually achieve relative stability through close relationships or successful work. Many more have lives that include only limited vocational success and become more avoidant of close relationships. While stabilization is common, and life satisfaction is usually improved, the persisting impairment of social role functioning of the patients is often disappointing.

Suicidality and Self-Harm Behavior

The most dangerous and fear-inducing features of Borderline Personality Disorder are the self-harm behavior and potential for suicide. While 8-10% of the individuals with Borderline Personality Disorder commit suicide, suicidal ideation (thinking and fantasizing about suicide) is pervasive in the borderline population. Deliberate self-harm behaviors (sometimes referred to as parasuicidal acts) are a common feature of BPD, occurring in approximately 75% of patients having the diagnosis and in an even higher percentage for those who have been hospitalized. These behaviors can result in physical scarring, and even disabling physical handicaps.

Self-harm behavior takes many forms. Patients with BPD often will self-injure without suicidal intent. Most often, the self-injury involves cutting, but can involve burning, hitting, head banging, and hair pulling. Some self-destructive acts are unintentional, or at least are not perceived by the patient as self-destructive, such as unprotected sex, driving under the influence, or binging and purging. Tattoos or pornography with retrospective shame are new variations of this.

The motivations for self-injurious behaviors are complex, vary from individual to individual, and may serve different purposes at different times. About 40% of self-harming acts done by borderline patients occur during dissociative experiences, times when numbness and emptiness prevail. For these patients self-injury may be the only way to experience feelings at all. Patients report that causing themselves physical pain generates relief which temporarily alleviates excruciating psychic pain. Sometimes people with BPD make suicide attempts when they feel alone and unloved, or when life feels so excruciatingly painful as to feel unbearable. There may be a vaguely conceived plan to be rescued, which represents an attempt to relieve the intolerable feelings of being alone by establishing some connection with others. There may even be a neurochemical basis for some self- harming acts – the physical act may result in a release of certain chemicals (endorphins) which inhibit, at least temporarily, the inner turmoil. Self-destructive behaviors can become addictive, and one of the initial and primary components of treatment is to break this cycle.

In addition to substance abuse, major depression can contribute to the risk of suicide. Approximately 50% of people with BPD are experiencing an episode of major depression when they seek treatment, and about 80% have had a major depressive episode in their lifetimes. When depression coexists with the inability to tolerate intense emotion, the urge to act impulsively is exacerbated. It is imperative that treaters evaluate the patient’s mood carefully, appreciate the severity of the patient’s unhappiness, but also recognize that antidepressant medications usually have only modest effects.

Family members are, understandably, tormented by the threat and/or carrying out of such acts. Reactions, naturally, vary widely, from wanting to protect the patient, to anger at the perceived attention-demanding aspects of the behavior. The risk of suicide incites fear, anger, and helplessness. It is imperative, however, that family members do not assume the primary burden to ensure the patient’s safety. Whenever there is a perceived threat of harm, or the patient has already engaged in self-harm, a professional should be contacted.

The borderline individual may plead to keep communications or behaviors secret, but safety must be the priority. The patient, treaters, and family cannot work together effectively without candor, and the threat or occurrence of self-destructive acts cannot be kept secret. This is for the benefit of all concerned. Family members/friends do not have the capacity to live with the specter of these behaviors in their lives, and patients will not progress in their treatment until these behaviors are eliminated.

Once safety concerns have been addressed, through the intervention of professionals, family members/friends can play an important role in diminishing the likelihood of recurring self-destructive threats by simply being present and listening to their loved one, without criticism, rejection or disapproval.

BPD individuals often misuse alcohol or drugs (both prescribed and illegal). This may diminish social anxiety, distance them from painful ruminations, or minimize the intensity of their negative emotions. Often alcohol or drugs have disinhibiting affects that encourage self-injury and suicide attempts as well as other self-endangering behaviors.

Current Status of Treatment

In the past few decades, treatment for Borderline Personality Disorder has changed radically, and, in turn, the prognosis for improvement and/or recovery has significantly improved.

One of the preliminary questions confronting families/friends is how and when to place confidence in those responsible for treating the patient. Generally speaking, the more clinical experience the treater(s) have working with borderline patients, the better. In the event that several professionals are involved in the care of a borderline individual, it will be important that they are compatible in their approaches and are communicating with one another. Support by family members of treatment is equally important.

A. Hospitalization

Hospitalization in the care of borderline patients is usually restricted to the management of crises (including, but not limited to, situations where the individual’s safety is precarious). Hospitals provide a safe place where the patient has an opportunity to gain distance and perspective on a particular crisis and where professionals can assess the patient’s psychological and social problems and resources. It is not uncommon for medication changes to take place in the context of a hospital stay, where professionals can monitor the impact of new medications in a controlled environment. Hospitalizations are usually short in duration.

B. Psychotherapy

Psychotherapy is the cornerstone of most treatments of borderline patients. Although development of a secure attachment to the therapist is generally essential for the psychotherapy to have useful effects, this does not occur easily with the borderline patient, given his or her intense needs and fears about relationships.

Moreover, many therapists are apprehensive about working with borderline patients. The symptomology of the borderline patient can be as difficult for professionals as it is for family members. The treater may assume the role of protective caretaker, and then experience feelings of anger and fear when the patient engages in dangerous and maladaptive behaviors. Even very able, motivated therapists are sometimes abruptly terminated by borderline patients. Often, however, though experienced as a failure, these brief therapies turn out to have served a valuable role in helping the patient through an otherwise insurmountable situation and in making the patient more amenable to subsequent therapists.

The standard recommendation for individual psychotherapy involves one to two visits a week with an experienced clinician for a period of one to six years. Good therapists need to be active and maintain consistent expectations of change and patient participation. Essential to successful therapy for a borderline patient is the development of feelings of trust and closeness with the therapist (which may have been missing from the patient’s life to that point) with the expectation that this would enhance the ability of the patient to have relationships of this nature with others. Validation, including being listened to, helps individuals develop recognition and acceptance of their self as unique and worthy.

Multiple forms of psychotherapy have been shown by research to be effective. All of them decrease self-harm, suicidality, and use of hospitals, emergency rooms, and medications. The best known and most widely practiced of the empirically validated therapies is Dialectical Behavior Therapy (DBT). It combines individual and group therapy modalities and is directed at teaching the borderline patient skills to regulate intense emotional states and to diminish self-destructive behaviors. DBT includes the concept of mindfulness, including self-awareness and balancing cognitive and emotional states, resulting in “wise mind.” DBT also emphasizes regulating emotions; distress tolerance skills and effective interpersonal skills. This therapy’s proactive, problem-solving approach readily engages borderline patients who are motivated to change.

Two of the effective therapies for BPD are psychodynamic (aka psychoanalytic). Transference focused psychotherapy (TFP) is a twice-weekly individual psychotherapy that emphasizes the interpretation of the meaning for the patient’s behaviors within relationships, most notably the relationship with the therapist. TFP also emphasizes the importance of experiences of anger. Mentalization based therapy (MBT) combines individual and group therapy. It emphasizes learning to recognize one’s own mental states (feelings/attitudes) and those of others as ways of explaining behaviors. This capability is called mentalizing, and is a capacity that all effective therapies try to enhance.

General Psychiatric Management (GPM) is a once-weekly therapy that can include prescribing medications and family interventions as needed. The therapy tries to create a “containing environment” within which patients can learn to trust and feel. This therapy requires clinical experience, but is the least theory-bound and easiest to learn of the empirically validated therapies.

C. Pharmacotherapy

Selective serotonin reuptake inhibitors and other antidepressants have frequently been prescribed to patients with BPD, but they are only modestly useful. Randomized controlled trials now suggest that atypical antipsychotics or mood stabilizers may be better choices. These studies also show that no type of medication is consistently or dramatically effective. Benzodiazepines are the one class of medications shown to make patients worse, though even here, there are exceptions. Thus medications should be initiated with the full understanding by the borderline patient that they have an adjunctive role to psychotherapy in treatment. In practice, prescribing medications may help to facilitate a positive alliance by concretely demonstrating the physician’s wish to help the borderline patient feel better; but unrealistic expectations of the benefits of medication can undermine work on self-improvement.

Common concerns when prescribing medication to these patients include risks of overdosing and non-compliance, but experience suggests that medications can be used with much reduced risk as long as a patient is regularly seeing and communicating with his or her provider. Another common problem in practice is polypharmacy, which may occur when patients want to continue or add medications despite a lack of demonstrable benefit; eighty percent of borderline patients are taking three or more medications. Consequences include side effects such as obesity (especially with antipsychotic agents) and associated problems such as hypertension and diabetes. When the benefit of a medication is unclear, patients should be urged to discontinue it before initiating a new one.

D. Family Interventions

Parents and spouses often bear a significant burden. They usually feel misjudged and unfairly criticized when the person with BPD blames them for their suffering. Suffice it to say, that for both the borderline patient, and those who love them, living with this disorder is challenging. Family members are usually grateful to be educated about the borderline diagnosis, the likely prognosis, reasonable expectations from treatment, and how they can contribute. Such interventions often improve communication, decrease alienation, and relieve family burdens.

Conjoint sessions with parents and the BPD offspring should be offered both the borderline patient and their parents need to be motivated to participate, to have established an ability to communicate with words (rather than actions) and to willing listen to each other.

E. Group Therapies

Group therapies include those led by professionals, with selected membership, and self-help groups, comprised of people who gather together to discuss common problems. Both are effective treatments.

DBT skills groups are often like classrooms with much focus and direction offered by the group leader and with homework between sessions. MBT groups offer a form for recognizing misattributions and how one affects others. Borderline patients may be resistant to interpersonal or psychodynamic groups which require the expression of strong feelings or the need for personal disclosures. However, such forums may be useful for these very reasons. Moreover, such groups offer an opportunity for borderline patients to learn from persons with similar life experiences, which, in conjunction with the other modalities discussed here, can significantly enhance the treatment course.

Many borderline patients will find it more acceptable to join self-help groups, such as AA, and other groups that are directed to problems such as eating disorders or that have purely supportive functions, such as Survivors of Incest. Such self-help groups that provide a network of supportive peers can be useful ad an adjunct to treatment, but should not be relied on as the sole source of support.

Conclusion

Despite its prevalence in clinical settings and its enormous public health costs, borderline personality disorder has only recently begun to command the attention it requires. This is evident in the emergence of parental advocacy/education/support groups, in the identification of BPD as a priority by the National Institute of Mental Health (NIMH) and by the National Alliance on Mental Illness (NAMI) in 2006. In 2009, the US Congress passed a resolution calling for more awareness of this disorder and more investment into its research and treatment. To date this has not occurred.

Our understanding of the disorder itself is in the process of dramatic change. Where its etiology was once thought to be exclusively environmental, we now know it is heavily genetic. Where it was thought to be a highly chronic, resistant-to-change disorder, we now know it has a remarkably good prognosis. Finally, where once it was thought to require heroic commitments to undertake BPD treatment, we now have a variety of interventions specifically designed for BPD, which can have significant and enduring benefits.

RESOURCES

Behavioral Technology LLC

DBT referral, training and resources

4556 University Way NE, Suite 200
Seattle, Washington 98105
(206) 675-8588 http://www.behavioraltech.com E-mail: information@behavioraltech.org

Borderline Personality Disorder Resource Center

BPD referral to resources and treatment

New York Presbyterian Hospital-Westchester Division
21 Bloomingdale Road
White Plains, New York 10605
(888) 694-2273 http://www.bpdresourcecenter.org E-mail: info@bpdresourcecenter.org

National Education Alliance for Borderline Personality Disorder (NEA-BPD)
BPD conferences, publications, videos and education
Rye, New York 10580

(914) 835-9011 http://www.borderlinepersonalitydisorder.com E-mail: neabpd@aol.com

NEABPD ©Family Connections

12-week course for relatives that provide education, coping skill strategies, and support

(914) 835-9011 http://www.borderlinepersonalitydisorder.com E-mail: neabpd@aol.com

New England Personality Disorder Association (NEPDA)

BPD family workshops, regional conferences, education, advocacy, and support

115 Mill St. Belmont, Massachusetts 02478
(617) 855-2680 http://www.nepda.org E-mail: info@nepda.org

Publication and distribution of A BPD Brief is made possible by the support of the following organizations:

New England Personality Disorder Association (NEPDA)

McLean Hospital
115 Mill Street
Belmont, Massachusetts 02478
(617) 855-2680 E-mail: info@nepda.org http://www.nepda.org

National Education Alliance for Borderline Personality Disorder
(NEA-BPD)
Rye, New York 10580
(914) 835-9011 E-mail: neabpd@aol.com http://www.borderlinepersonalitydisorder.com

Borderline Personality Disorder Resource Center

New York-Presbyterian Hospital-Westchester Division 21 Bloomingdale Road
White Plains, New York 10605
(888) 694-2273 E-mail: info@bpdresourcecenter.org

For copies of A BPD Brief contact:

The Borderline Personality Disorder Resource Center (888) 694-2273 E-mail: info@bpdresourcecenter.org

Damn panic


I can’t shake it off… I had almost a week w/o the kids and was doing so well with exercising the emotions… And now all I’ve been feeling is panic..

I tried sticking with it…but I can’t…mostly because I couldn’t just take “time out ” from the kids to truly feel it till it’s done…when I did tell them that I needed 5 minutes, all I could think of was that I’m a terrible mom… I kept trying to ride it, to figure out exactly what I was feeling and why…

The panic came back again… I don’t like it… I feel that although yeah I know that I have been a pretty good mother I think….now I don’t know what to do…. I’m panicking that I have not explained the divorce well enough that I haven’t helped them process it well enough… And of course I’m panicking about what their dad does and tells them… Like the other day they asked if I loved their dad and I said yes in my own way since he is their father… And they said ok but he doesn’t love you anymore. And then they wanted to know if that makes me sad or something. 
So I’m overwhelmed by panic… Fear that I am screwing my kids up.. Fear that I don’t know how to handle them…fear that I don’t know how to react…fear that although I really have been good with them I might end up screwing my relationship with them … 

I really have to be patient with myself… And I really have to cut myself some slack…. I have offered them validating environment, lots of love, acceptance, support… And I’m seriously trying really hard to help them adjust to the divorce, being positive and encouraging them to like spending time and having fun with their dad and keeping him on a positive light, simply saying that I didn’t get along with him anymore because we didn’t know how to solve our problems…

So I am really trying to be there for them…to avoid what I felt when my parents got divorced and my dad became a “villan” I don’t want my kids to ever hate their dad, no matter what my beef is with him…

Seems like this writing exercise is helping me with the panic… Gotta keep at it… Gotta stick to it…gotta persevere 

Seriously… Damn perfection… I m human… I’m allowed to screw up :p or to at least not do stuff perfectly 

What It’s Like To Live With Borderline Personality Disorder


What It’s Like To Live With Borderline Personality Disorder.

The Dialectical World View and Basic Assumptions


DBT Skills Training Manual

Dialectical perspectives on the nature of reality and human behavior share three primary characteristics.

  1. First, much as dynamic systems perspectives do, dialectics stresses the fundamental interrelatedness or wholeness of reality. This means that a dialectical approach views analyses of individual parts of a system as of limited value unless the analysis clearly relates the parts to the whole. Thus dialectics directs our attention to the individual parts of a system (i.e., one specific behavior), as well as to the interrelatedness of the part to other parts (e.g., other behaviors, the environmental context) and to the larger wholes (e.g., the culture, the state of the world at the time).
  2. Second, reality is not seen as static, but as made up of internal opposing forces (thesis and antithesis) out of whose synthesis evolves a new set of opposing forces. A very important dialectical idea is that all propositions contain within them their own oppositions. As Goldberg put it, “I assume that truth is paradoxical, that each article of wisdom contains within it its own contradictions, that truths stand side by side” (pp. 295–296, emphasis in original).4 Dialectics, in this sense, is compatible with psychodynamic conflict models of psychopathology. Dichotomous and extreme thinking, behavior, and emotions are viewed as dialectical failures. The individual is stuck in polarities, unable to move to syntheses.
  3. A third very important polarity has to do with clients’ maintaining personal integrity and validating their own views of their difficulties versus learning new skills that will help them emerge from their suffering. If clients get better by learning new skills, they validate their view that the problem all along was that they did not have sufficient skills to help themselves. They have not been trying to manipulate people, as others have accused them of doing. They are not motivated to hurt others, and they do not lack positive motivation. But the clients’ learning new skills may also seem to validate others’ opinions in other ways: It may appear to prove that others were right all along (and the client was wrong), or that the client was the problem (not the environment). Dialectics not only focuses the client’s attention on these polarities, but also suggests ways out of them.

10 things you discover about yourself when diagnosed with BPD


1. People will not understand you.

2. What feels right at first is usually wrong, wrong, wrong.

3. Sometimes you’re the villain.

4. You have a love/hate relationship with your diagnosis.

5. You’ve got some extra baggage.

6. It’s not your fault!

7. You’re interesting and exciting to others.

8. You’re crazy in bed.

9. Your best friend/partner is one strong motherfucker.

10. You are also one strong motherfucker.

see full article here (10-things-you-discover-about-yourself-when-youre-diagnosed-with-borderline-personality-disorder/)

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Emotions are like a sixth sense because like sight, sound, taste, touch, and smell, they give us important information about our environment that we need to survive. What makes emotions so special is that they help us to act quickly when logical thought is too slow for us to engage in problem-solving. (See Situations below.) However, for people who may be unusually emotionally reactive, sensitive, or have learned to judge or invalidate their emotional sixth sense from culture, values, gender roles, parents, family, loved ones, etc., emotions may not always cause the expected effective response. Therefore, dialectical behavior therapy came up with the skill checking the facts to help us figure out if our emotional responses fit the facts and intensity of a situation and whether an unwanted or distressing emotion needs skills toward accepting and changing or skills toward accepting and tolerating.

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Adapted from the Linehan Board of Certification by Rachel Cara Gill For DBT Peer Connections Facebook Group Administrators Consultation Team All DBT Connections Facebook Group Administrators are required to complete the FREE DBT Skills Training E-course prior to joining the consultation team Request to join DBT Peer Connections Facebook Skills Support Group as a general […]

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