This blog is my place to vent and share resources with other parents of children of trauma. I try to be open and honest about my feelings in order to help others know they are not alone. Therapeutic parenting of adopted teenagers with RAD and other severe mental illnesses and issues (plus "neurotypical" teens) , is not easy, and there are time when I say what I feel... at the moment. We're all human!

Thursday, January 17, 2013

Books and Methods Review - Borderline Personality Disorder

Borderline Personality Disorder (BPD) affects six million people in North America.  Some people believe that unhealed RAD which is a "childhood" attachment disorder, can become BPD in adulthood.  There are definitely a lot of similarities.

According to the DSM-IV, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible (unlikely to change), is stable over time, and leads to distress or impairment in interpersonal behavior.

DSM-IV-TR (2004) Criteria for Diagnosis of Borderline Personality Disorder

The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts. Individuals with Borderline Personality Disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician's announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this "abandonment" implies they are "bad." These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.

BPD is manifested by 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. Note: Do not include suicidal or self-mutilating behavior covered in (5).
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."
  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 (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.

Most of the following information is paraphrased from the book Stop Walking on Eggshells:

1.  Frantic efforts to avoid real or imagined abandonment. Imagine you are a 7yo lost in the middle of Times Square, your mom was there a second ago, but now you're surrounded by menacing strangers glaring at you.  People with BPD feel isolated, anxious, terrified at the thought of being alone.  Caring, supportive people are like smiling, friendly faces in the crowd, offering smiles, help and warm hugs.  But the moment they do something that suggests an imminent departure (often the trigger is just something the person with BPD interprets that way), the person with BPD panics and reacts - in a variety of way, from raging to begging the person to stay.  If the person was neglected or abandoned as a child then they may have learned to suppress this terror to the extent that they no longer feel or recognize the original emotion.

2.  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called "splitting."  People with BPD look to others to provide things they find difficult to supply for themselves, such as self-esteem, approval and a sense of identity.  Most of all they are searching for a nurturing caregiver whose never-ending love and compassion will fill the black hole of emptiness and despair inside them.  Losing a relationship feels like life or death to them.  At the same time, their self-esteem is so low that they can't believe anyone would want to be with them so they are hypervigilant looking for cues that the person doesn't love them or is about to desert them.  CENTRAL IRONY OF BPD:  People who suffer from it desperately want closeness and intimacy, but the things they do to get it often drive people away from them.
Splitting - fluctuating between extremes of idealization and devaluation, angel on a pedestal or wicked demon.  Often they base these opinions on the last interaction.  Add in major trust issues from childhood abuse....
Marythemom:  We see this a lot as black and white thinking.  Bear loves someone almost instantly - she's "the one" and she "gets me," but the moment they have a slight disagreement, or she has to study, or be with her friends instead of him... it's over.  He's never had a disagreement that didn't almost immediately end the relationship.  That's why we call them Kleenex Girls.  The same is true of jobs and friends/enemies.  We also see the "flipping switch" changes based on the last interaction.  In one phone call with Bear, he spoke of coming home, getting back on his meds, going back to church... The next call starts with us confronting him on a lie, and instantly he's talking about not needing anyone, moving to a place where he knows no one...

3.  Identity disturbance: markedly and persistently unstable self-image or sense of self.
7.  Chronic feelings of emptiness.
By the time people reach their 20s and 30s their self-image is usually fairly consistent - our likes, our dislikes, our religious beliefs, our position on important issues, and our career preferences.  But the person with BPD has no sense of self, just like they lack a consistent sense of others.  They feel empty and chaotic inside and are dependent on others for cues about how to behave, what to think, and how to be.  Being alone leaves them without a sense of who they are, maybe that they don't exist (which is one reason they desperately avoid being alone).  The one consistent thing?  They know they're not enough.  They judge themselves as harshly as they judge others.  They are actors, chameleons, victims of others (even when their own behavior affected the outcome of a particular situation).  Some people with BPD may play the role of victim because it draws sympathetic attention, supplies an identity, and gives them the illusion that they are not responsible for their own actions.  It's important to realize this chameleon-like ability to change personas is real in the moment.  It is not Machiavellian manipulation, it's not even conscious, and there is no real identity to revert back to... how terrifying to not know who you really are?!

Those with abusive backgrounds may be replaying scripts from the past.  They may feel continually victimized because they've been conditioned to expect cruel behavior from people they trust.  They may have come to believe that something about them causes people to act in a heartless or abandoning way.  They interpret normal behavior as cruel or abandoning and react with intense rage, despair or shame (which confuses those around them who see no triggers for the behavior!).

4.  Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).  Some people with BPD find it very hard to resist or control impulses and delay immediate gratification, and may be trying to fill the emptiness and create an identity through impulsive behaviors.  About 23% (Links et al. 1988) of people with BPD had a dual diagnosis of substance abuse.  Borderline Substance Abusers are likely to abuse more than one drug (often alcohol), are more likely to be depressed, have more frequent suicide attempts and accidents, have less impulse control and seem to have more antisocial tendencies (Nance et al. 1983).

5.  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.  About 8-10% of all people with BPD commit suicide.  This does not include those who engage in risky behavior that results in death.  Suicide (and other impulsive, dysfunctional behaviors) are seen as solutions to overwhelming, uncontrollable emotional pain.  Self-injury is a coping mechanism  that may release chemicals that lead to a general feeling of well-being.  There are many reasons for self-injury, and it may be done intentionally or unconsciously (unaware and in a haze).  An intellectual understanding of they they do it, doesn't make it any easier to stop.  There is a misperception that all people with BPD harm themselves or are suicidal.  Many high functioning people with BPD do not, but those that do, however, may seek professional help more often than those who don't.

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).  When most people feel bad they can take steps to feel better, and control how much their moods affect their relationships with others.  People with BPD have a hard time doing this.

8.  Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).  Borderline rage is usually intense, unpredictable, and unaffected by logical argument.  It can disappear as quickly as it appears.  Some people with BPD have the opposite problem and feel unable to express their anger at all for fear of losing control or that the target of even minor anger expression will retaliate.  Some specialists believe that people with BPD feel ALL emotions intensely, but that anger is highlighted by the DSM criteria because anger is typically the feeling that causes the most problems for people close to them.  "People with BPD are like people with third degree burns over 90% of their body.  Lacking emotional skin, they feel agony at the slightest touch or movement." ~Marsha M. Linehan (1993).

9,  Transient, stress-related paranoid ideation or severe dissociative symptoms.  People who are severely dissociating feel unreal, strange, numb, or detached. They may or may not remember exactly what happened while they were "gone."  This can be mild or severe (like Dissociative Identity Disorder - formerly known as Multiple Personality Disorder.)  The more stressful or painful the feelings or situations, the more likely that the person will dissociate.

Additional Traits Common to BPD

  • Pervasive Shame - Toxic shame is the all-pervasive sense that I am flawed and defective as a human being.  A shame-based person will guard against exposing his inner self to others, but more significantly, he will guard against exposing himself to himself.  John Bradshaw, Healing the Shame That Binds You, sees shame as the root of issues such as rage, criticism and blame, caretaking and helping, codependency, addictive behavior, excessive people pleasing, and eating disorders.  In their typical all-or-nothing way, people with BPD may either become consumed by their shame or deny to themselves and others that it even exists.  
  • Undefined Boundaries - People with BPD may need to feel in control of other people because they feel so out of control with themselves.  They may be trying to make their own world more predictable and manageable.  They may unconsciously try to control others by putting them in no-win situations, creating chaos that no one else can figure out, or accusing others of they to control them.  Conversely some people with BPD may cope with feeling out of control by giving up their own power, possibly by choosing a lifestyle where all choices are made for them (military, cult, abusive people who control through fear...).  Control is the ultimate villain in destroying intimacy.  We cannot share freely unless we are equal.
  • Lack of Object Constancy - Some people with BPD find it difficult to evoke an image of an absent loved one to soothe them when they feel upset or anxious.  If that person is not physically present, they don't exist on an emotional level.  The person with BPD may call their significant other frequently just to make sure they're still there and still care about them.  Letters, pictures, scents that remind them of the person they care about, may reduce their anxieties or fears and clinginess.
  • Interpersonal Sensitivity - Some people with BPD have an amazing ability to read people and uncover their triggers and vulnerabilities, like a social and emotional antennae.  Many adults who were repeatedly physically and/or sexually abused as children developed these skills to help them predict and therefore protect themselves (usually by dissociating).
  • Situational Competence - The ability to have competence in difficult situations while being incompetent in seemingly equal or easier tasks.  Possible explanation - they know deep within that they are defective so they try hard to act "normal" because they want so much to please everybody and keep the people in their lives from abandoning them.
  • Narcissistic Demands - Frequently bringing the focus of attention on themselves (can include complaints of illness and acting up in public) and reacting to most things based solely on how it affects them.  Limited to no understanding of how these actions affect others.

Manipulation or desperation?  In most cases the person with BPD's behaviors are not intentionally manipulative.  Rather this behavior can be seen as impulsive, desperate attempts to cope with painful feelings or to get their needs met.

People with BPD vary a great deal in their functionality and ability to live a normal lifestyle, coping with everyday problems, interactions with others....  Low-functioning people with BPD often find themselves living from crisis to crisis.  High-functioning people with BPD act normal on the outside, but it's important to remember that they feel the same way inside as their lower functioning counterparts.  People in relationships with high-functioning people with BPD frequently need more validation - their perceptions and feelings confirmed - as most outsiders don't see the rages and verbal abuse.

Myth 1:  People with BPD never get better.
Reality:  Many people with BPD report success with proper treatment (which is relatively new so some mental health professionals are not aware of it).  Many professionals find working with patients with BPD so arduous and exhausting, that feel they are too difficult to work with and therefore do not follow the research about the latest treatment approaches.

Myth 2:  BPD is a "wastebasket definition" given when clinicians can't figure out what's wrong with them.
Reality:  BPD should be diagnosed only when patients meet the specific clinical criteria.  The fact that it is used as a "wastebasket definition" doesn't make it a "wastebasket definition."

Myth 3:  Women have BPD, men have Antisocial Personality Disorder.
Reality:  Although BPD is diagnosed in women much more frequently (about 75%), men have it as well.

Females with BPD are in the mental health system, males with BPD are in jail.

Males are more likely to be treated only for their alcoholism or substance abuse; their borderline symptoms tend to go unnoticed because BPD is assumed to be a women's disorder.

Wikipedia:  Borderline personality disorder (BPD) (called emotionally unstable personality disorder, borderline type in the ICD-10) is a personality disorder marked by a prolonged disturbance of personality function, characterized by unusual variability and depth of moods. These moods may secondarily affect cognition and interpersonal relations.[n 1]
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline,[4] and some have suggested that this disorder should be renamed.[5] The ICD-10 manual has an alternative definition and terminology to this disorder, called Emotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes people and supports discriminatory practices.[6]  


Dialectical Behavioral Therapy (DBT)
Currently the best treatment for Borderline Personality Disorder is DBT - Dialectical Behavior Therapy - here's my post reviewing DBT.
DBT Peer Connections - Episode 0 - Introduction to DBT Skills Training - by Rachel Gill

Marythemom: Kitty is diagnosed with emerging BPD.  I believe this is a pretty accurate diagnosis, although it makes me scared for her, sad, and frustrated.  

I was so happy to finally get Kitty into a residential treatment center that specializes in treating trauma and Borderline Personality Disorder through DBT,  but when she got there, they found she was too young emotionally (~6 years old on a good day) and the combination of low IQ, immaturity, reasoning/ processing deficits, memory issues, severe emotional issues, and inability to cope with her trauma… meant that Kitty could not work their program (which includes DBT therapy and trauma work).   

To date, DBT is the ONLY therapy that is known to help with her issues!  The Center was my last best hope.   Now that they are no longer an option, I’ve lost that hope and I’m stuck.  I don’t know where to go from here.  

Books about Borderline Personality Disorder

*****Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul Mason MSRandi Kreger
Do you feel manipulated, controlled, or lied to? Are you the focus of intense, violent, and irrational rages? Do you feel you are 'walking on eggshells' to avoid the next confrontation?
If the answer is 'yes,' someone you care about may have borderline personality disorder (BPD). Stop Walking on Eggshells has already helped nearly half a million people with friends and family members suffering from BPD understand this destructive disorder, set boundaries, and help their loved ones stop relying on dangerous BPD behaviors. This fully revised edition has been updated with the very latest BPD research and includes coping and communication skills you can use to stabilize your relationship with the BPD sufferer in your life. This compassionate guide will enable you to:
  • Make sense out of the chaos
  • Stand up for yourself and assert your needs
  • Defuse arguments and conflicts
  • Protect yourself and others from violent behavior

Marythemom:  This is an excellent book written for family members of people with BPD, but I feel it can also help parents of RAD teens. The first half of the book explains how the person with BPD feels.  The second half addresses how to live with a person with BPD.  The book assumes that the person with BPD is an adult and that we cannot change the person with BPD - treatment is their choice.  

This book is NOT written to help the person with BPD.  It is how to cope as a sympathetic family member.  I review this book here.

*****I Hate You--Don't Leave Me: Understanding the Borderline Personality by Jerold J. Kreisman, Hal Straus 
After more than two decades as the essential guide to Borderline Personality Disorder (BPD), this new edition now reflects the most up- to-date research that has opened doors to the neurobiological, genetic, and developmental roots of the disorder as well as connections between BPD and substance abuse, sexual abuse, Post-Traumatic Stress Syndrome, ADHD, and eating disorders.

Both pharmacological and psychotherapeutic advancements point to real hope for success in the treatment and understanding of BPD.

This expanded and revised edition remains as accessible and useful as its predecessor and will reestablish this book as the go-to source for those diagnosed with BPD, their family, friends, and colleagues, as well as professionals and students in the field.
Patty Pheil of Borderline Personality Disorder Today, "This book, as far as I know is the first book about the BPD written for the consumer. The book in and of itself is excellent and filled with good information. However, many borderlines have felt suicidal after reading this book if this is the first book they read about the BPD. Why? Simply because this book was written awhile back before much was known about how certain medications can be extremely helpful with many of the BPD symptoms such as rage, depression, mood swings, etc. Therefore the book was written with good information but the aspect of hope and recovery is not in this book. One feels hopeless after reading this book. This was the first book I read about the BPD and that is how I felt - more disturbed and hopeless. This is not the author's fault however. He simply wrote the book at a time where there wasn't much known about treatment. It would be great to have this great information along with the new drug treatment in a new edition."

More Books:
More books about Borderline Personality Disorder


Loving a Borderline: The Impossible Connection. Part 1 of 3. BPD Personality Disorder Expert. Part 1, Part 2, Part 3, by Ross Rosenberg author of The Human Magnet Syndrome: Why We Love People Who Hurt Us 

SET Communication Skills

When borderline personality disorder (BPD) makes communicating with your loved one difficult, following the support, empathy and truth (SET) method can help. It can be a way for you to talk with a friend or family member who is struggling with BPD and make her feel heard and understood.
Why SET Works With Borderline Personality Disorder
The symptoms of borderline personality disorder (BPD) can result in a person with BPD asking for conflicting things or being unable to recognize that the another person cares for them, especially during times of stress. 
He or she may be unable to experience conflicting feelings at the same time and may see things in black and white with very little shades of gray.
The SET method allows you to honestly address your loved one's demands, assertions or feelings, while still maintaining appropriate boundaries. Because each step builds on the last, it is important to do these steps in order.
SupportSupport refers to an initial statement which indicates that you support the person with BPD. It is a statement that begins with "I" and demonstrates concern and a desire to help. It can be anything that establishes a foundation for the relationship or interaction: "I want to try to help you feel better," "I care about you" or "I am worried about how you are feeling."
The support statement is meant to reassure the other person that the relationship is a safe one and that her needs matter even during this difficult moment.
EmpathyEmpathy refers to communicating that you understand what the other individual is feeling and focuses on "you." It is not a conveyance of pity or sympathy, but instead a true awareness and validation of the feelings of the other person, such as, "I see you are angry, and I understand how you can get mad at me," or "How frustrating this must be for you."
It is important not to tell the BP how she is feeling, but instead put her demonstrated feelings into words. The goal is to convey a clear understanding of the uncomfortable feelings she is having and that they are OK to have, reassuring her. Without a statement of empathy, she may feel that her feelings are not understood. It is important to use feeling words, as in the examples above.
TruthTruth refers to a realistic and honest assessment of the situation and the other person's role in solving the problem. It is an objective statement that focuses on the "it", not on the subjective experience of the either you or her. She may seem to be asking or demanding something impossible, not taking an active role or responsibility in resolving the issue or even presenting you with a "no-win" situation. The truth statement is meant to clearly and honestly respond to her demand or behavior while placing responsibility where it belongs. Examples include,"This is what I can do…," "This is what will happen…" and "Remember when this happened before and how you felt so bad about it later."
It is important to use the support and empathy statements first, so that she is better able to hear what you are saying, otherwise the truth statement may be experienced as another rejection, creating even more defensiveness or anger.
Validation and Support Are Not AgreementWhen first learning about SET, it can seem that you are being asked to agree with the person with BPD. It important to clarify that validating feelings does not mean that you agree with them, only that you recognize that he or she is feeling them. The supportive communication method does not mean that you are letting the BP off the hook; instead you are focusing on honest communication and ensuring that you are being heard, not just reacting to and defending against what is being said.
By Erin Johnston, LCSW (Updated April 06, 2016)
Source: Kreger, R. "Secrets of S.E.T." Psychology Today, 2013. 

Marythemom:  I hadn't heard of SET, but I use a lot of these techniques and they makes sense, well, as much sense as you can make with someone with a loose grip on reality.

1 comment:

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