Tuesday, March 4, 2014

The Stable Instability of Patients with Borderline Personality Disorder and the Difficulty Clinicians Face Trying to Treat Them

One of the most challenging psychological disorders for a therapist to treat and among the most resistant to therapy, Borderline Personality Disorder features a number of pathological symptoms including suicidal and parasuicidal ideation, impulsivity, aggression, dysphoria, sensitivity to abandonment, identity disturbance, instability, and angry affect (Grube, 2007). These symptoms present themselves with varying degrees of severity depending upon the patient’s type and level of BPD dysfunction. In a 1968 behavioral study of ego functions, clinical psychologists Roy Grinker, Beatrice Werble, and Robert Drye conducted cluster analysis research to identify four distinct types of patients afflicted with Borderline Personality Disorder. According to their findings, these four subgroups comprising BPD appear to occupy a continuum of decreasing severity on the border between psychotic and neurotic psychopathology. Among all four subgroups, leading features of BPD are “stable instability” (Schmideberg, 1959), “panneurosis”’ “pananxiety”, and “pansexuality” (Knight, 1953). Residing nearest the psychotic border, the BPD Type I subgroup displays features such as quasi-psychotic thought, manipulative suicide efforts, and countertransference difficulties (Zanarini et al., 1990). Type II is characterized by a pervasive pattern of instability within interpersonal relationships. Typically, these Type II patients display several dysfunctional behaviors such as self-mutilation, excessive demands/entitlement, and expressions of concern about abandonment/engulfment and annihilation (Zanarini et al., 1990), in their effort to avoid real or imagined abandonment, separation, loss, or rejection. Type III BPD sufferers show a generalized lack of personal identity, appearing to be immensely challenged at maintaining a stable or consistent sense of themselves as individuals, tending to borrow an identity from others. Chessick (1987) noted a “well-hidden poverty of genuine emotional relationships behind an attractive and personable social façade” (p.532). Type IV Borderline patients – exhibiting various traits indicating countertransference difficulties and treatment regressions (Zanarini et al., 1990) – make up the subgroup closest to the neurotic border (Gabbard, 2005). The borderline patient’s suffering is a relatively stable and enduring condition (Chessick, 1979). Often, a BPD sufferer’s emotional dysregulation leads to an uncontrollable outward volatile affect. Such a sudden shift in affect typically reflects disillusionment with a love object, and indicates the patient’s expectation of impending abandonment. Impulsivity is another characteristic signpost of the disorder. Paul, Schroeter, Dahme, and Nutzinger, 2002 found that typical expressions of impulsivity on the part of the BPD patient include binge eating, self-mutilation, substance abuse, unsafe sex and reckless driving (Zanarini et al., 2007). The patient with BPD often dramatically changes career goals, values, sexual identity, and friends (Gabbard, 2005). While in a crisis of instability a patient may inexplicably quit a job, withdraw socially, and isolate entirely. Such an impulsive and chaotic temperamental display leads to anxiety, guilt, and self-loathing for which the patient may choose to engage in high-risk or self-harming behavior in order to feel relief. These patients are known to have chronic suicidal ideation and often engage in self-harm through acts of cutting or burning (Blatt & Levy, 2003; Clarkin, et al., 2006). The BPD patient who uses cutting, burning, food, drugs, alcohol or other self-injurious behavior may obtain at least temporary pseudo-relief from feelings of self-hatred, lassitude, emptiness, and seemingly intolerable loneliness. All too often impulsive marriages and divorces, unexpected pregnancies and abortions, the perpetual starting and stopping of jobs and academic careers, spoiled successes, and blighted relationships coalesce and contribute to the failure of a promising life and even suicide (Blatt & Levy, 2003; Clarkin, et al., 2006; Lilienfeld, 2012; Linehan, et al., 2006; Wenzel, et al., 2006). Inappropriate or out of proportion expressions of anger are a distinguishing feature of BPD. Although the patient may be high functioning, efficient, and display socially acceptable conduct most of the time, the inevitable outbreak of a regressed or childlike state of helpless anger -- observed clinically by Knight (1953) and, later, Kernberg, (1975) -- devastates interpersonal interactions (Clarkin, Yeomans, & Kernberg, 2006; Gabbard, 2001, 2005; Grinker et al., 1968). At times, inappropriate anger can escalate into physical confrontations, explosive rages, and violence. BPD is widely known to interfere with interpersonal relationships. Patients’ unrealistic relational expectations with others lead to devaluation following initial idealization. The patient’s behavior often has a profoundly negative impact on family members (Hoffman et al., 2005). For example, the patient’s inability to exhibit self-control may lead him or her to take a vindictive and rageful reproach (Linehan, 1993) for perceived slights. Family members may be witness to out-of the-blue tantrums with pronounced volatility (Hoffman et al., 2005). Family and loved ones of the patient feel unable to stop or help the patient who appears to explode outwardly and implode inwardly. Commonly, such a patient struggles with a life descending into chaos and a desire to die resulting from feelings of ineptitude, subservience, and self-loathing for his or her perceived inability to self-actualize (van Reekum, et al., 1993; Wenzel, et al., 2006). Koenigsberg & Siever (2000) found evidence that BPD patients may enter a dissociative state and attempt to gain relief through self-harming behavior in order to expiate feelings of non-existence. This finding was consistent with Marsha Linehan’s research (1993). Although deeply unhappy, it is usually only during a time of crisis that the BPD patient is most likely to seek clinical intervention and treatment (Linehan, 1993). The patient with a BPD diagnosis who is in crisis is usually suffering from actual or perceived rejection or separation (Clarkin, et al., 2006). The patient’s intense dysphoria, irritability, and anxiety may vacillate in a noticeably reactive mood -- shifting in intensity, duration and frequency within hours, and on occasion can last for several days (Blatt & Levy, 2003). Depersonalization is known to occur (Zanarini and Frankenburg, 2008) during times of transient paranoid ideation and extreme stress. These feelings of depersonalization usually last from a few minutes to a few hours, and the real or imagined return of a caregiver’s affection and attention may allow the symptoms to spontaneously remit (Clarkin, Levy, et al., 2007; Hallquist & Pilkonis, 2012; Kreisman & Straus, 2010; Watson & Sinha, 1998; Westen, Gabbard, & Blagov, 2006). Patients diagnosed with BPD notoriously pose challenges to therapists seeing them in clinical practice (Adler, 1979; Gabbard, 2000; Levy, Clarkin, Yeomans, Scott, Wasserman, & Kernberg, 2006). Marsha Linehan (1993) reported that it is not uncommon for those with the disorder to storm out of sessions, make frequent calls to therapists between scheduled sessions, and blame therapists for hurting their feelings. Linehan further states that a patient’s fear of rejection by the therapist often leads to noncompliance, a decreased probability of establishing a sound therapeutic alliance, a negative outlook on the therapy process, premature discontinuation of treatment, and a poor prognosis. The rapid cycling of alternating moods and the tendency of BPD patients to inappropriately cross personal boundaries (Gabbard, 2005) can prove challenging and frustrating for a therapist. Patients entering into therapy at the height of crisis often awaken the therapist’s counter-transference response to protect and rescue. However, the patient’s characteristic tendency to idealize and, subsequently, despise others typically triggers some therapists’ intense feelings of disappointment and anger. The volatile dynamic that these patients create is likely to stem from increased sensitivity to criticism and perceived slights (Clarkin, Yeoman, & Kernberg, 2006), which heightens the patient’s instability in sense of self. Compounding these problems further is the sufferer’s chaotic use of medical and psychiatric services (Bateman & Fonagy, 2003), refusal to comply with taking prescribed medications (Gabbard, 2005), and overall noncompliance resulting in the reputation of the patient with BPD as being difficult to treat. The life threatening and debilitating effects of the disorder represent a serious public health and clinical concern (Bateman & Fonagy, 2003). That said, this group is not so much defined by therapists for their symptoms, but rather the characteristic problems underlying the symptoms, as well as the ramifications of their behavior upon others (Clarkin, Yeoman, & Kernberg, 2006). Although no single factor is known to cause the disorder, research conducted by Skodol et al. (2002) suggests contributing factors that may amalgamate, leading to the etiology and onset. Zanarini and Frankenburg (1997) propose that an inherited vulnerability (Masterson and Rinsley, 1975), a particular temperamental constellation (Cloniger et al., 1993), early childhood trauma (Paris, 1998), subtle changes in the patient’s neurobiology (Coccaro and Kavoussi, 1997; Coccaro et al., 1989; Siever and Davis, 1991), and disruptions to hormonal balance (Gabbard, 2005) may coalesce, resulting in BPD. Inconsistent and unstable patterns from caregivers during childhood (Zanarini and Frankenburg, 1997) may result in a “limited behavioral repertoire” and result in dysfunctional compensatory strategies aimed at affect regulation and emotional containment.

Terrible Therapists: Bad Marriage Counseling Hurts People with Borderline Personality Disorder

I am an expert on Borderline Personality Disorder (BPD) and write extensively on the subject. I became familiar with it in the 1980’s, wrote a 175 page doctoral dissertation on it, presently blog about it on Patch, and have numerous clients affected by it (either themselves or through a friend or loved one). I gave up the practice of psychotherapy because I think it serves no good purpose to label, diagnose and talk to people year after year about their problems. Although I do not diagnose my clients with this, or any, disorder I do not dispute the fact that the term is widely used within the mental health field. It typically denotes a chronic and persistent pattern of maladaptive behavior that includes harmful “acting out” (suicide attempts, high-risk sex, etc.), and harmful “acting in” (alcohol and drug abuse, eating disorders, etc.). I do not approve of the pharmaceutical industries’ agenda to have doctors label, diagnose and prescribe dangerous and addictive pills to hook unsuspecting consumers. Also, I do not agree with how people are labeled and treated in therapy – especially women and minorities. It is all a scam, in my humble opinion. I became a certified life coach to avoid the pitfalls I see in the current, mental-health zeitgeist (read: DSM5). If you are unsure as to what BPD means exactly, I encourage you to read other posts I have written that describe it in depth. Also, there is no shortage of good literature about BPD in the DSM-IV-TR, DSM5, and various trusted websites. A recent client and I had the following exchange: Client: A therapist my wife and I were seeing diagnosed my wife with BPD and I want to know if I should leave my wife and get custody of the children? Dr. Jabin: Why would you do that? Client: The therapist said BPD is a severe mental illness that is not curable. I am starting to see signs of BPD in my toddler and nine-year old daughter. Dr Jabin: I disagree that BPD is a “non-curable disorder.” My personal experience with clients is tells me otherwise. I have coached people so successfully that they can no longer be considered BPD by therapists who diagnose. Aside from my success with my clients, there is new longitudinal research that suggests the most troubling symptoms remit by the fourth decade. I do not believe you are actually seeing BPD in your toddler, nor do I think you should contextualize your nine-year old’s behavior as occurring along a BPD continuum. What I found the most troubling was that this man was part of a “couple” who had gone to marriage therapy for help. Instead, the therapist aligned him or herself to my client and together they conspired to triangulate against the wife. So perverse is this, yet so common too, that I am moved to write about it. The therapist even had the audacity to suggest to my client that he leave this country and return to his country of origin where he could successfully wrestle away his wife’s parenting abilities due to a power and money imbalance. I was trained in graduate school that American psychologists should not rush to label foreigners with western diagnoses – especially a stigmatizing, “non-curable” diagnosis. Did this therapist understand that he or she was in a trusted position to point out resources? It does not appear to be the case. No wonder so many couples do not get the help they need and deserve when they go to marriage therapy. Despite the fact that couples go to counseling they do not get the tools, learn the skills, or find the resources that they need to repair the marriage. I believe this is because too many marriage counselors are horrible at their job. God help the unsuspecting clients who end up in the throes of a therapist with a secret agenda -- such as "acting out" his or her own traumas under the guise of "therapy." My client’s wife may have some valid reasons for her inappropriate behavior towards her husband that could be respectfully and competently looked at in a more empathic way. A good therapist could gently persuade her to try new and different things to get better results. This woman did nothing to deserve a therapist misusing her position of power to wrestle her husband and children away from her. She did deserve compassion, empathy, hope, and a chance to heal herself and her marriage. Why else would this woman leave the comfort of her home to attend marital therapy, put her children in the paid care of another and agree to attend counseling with her husband? Not for this trickery, I assure you. Therapists with unresolved personal problems that negatively color their therapeutic outlook pose a danger to society. Our society puts doctors and therapists on pedestals to be the gatekeepers of morality and virtue. Doctors get to decide what behavior is “normal” and what behavior gets labeled “disordered.” Judges depend on therapists’ input to help them rule in favor of leniency or harsh sentences. Therapists persuade judges and juries every day about which parents are more fit and which offenders are deserving of second chances. Being a doctor carries a lot of weight in society. Therapists who can’t manage their own healthy relationships should not be able to advise clients on what they should or should not do. Every therapist should be in therapy in order to be accountable and to know what it feels like to be the client. I advised my client to get his wife to a medical doctor for a complete physical that includes blood and urine work. I reminded him that as women age our hormone levels change and that all his wife may need are vitamins and whatever appropriate pharmacology would help her feel better . This may or may not mean antidepressant medication. One of my favorite sayings, and my mantra, is this: If you hear hooves approaching, expect to see horses and not zebras. This reminds me that the cause is usually something fairly more obvious (depleted hormone levels and specific life event stressors) rather than the exotic (an incurable, mental-disorder dreamed up by the gatekeepers of moral society). Another favorite saying of mine speaks about the Art of Detachment. It goes like this: "Detach with love, not with an axe." I seriously doubt the couple's first therapist is correct to advise my client that he should relocate his family to their far away country of origin, lawyer up and rip away the young children from their mother forever. Did I mention that this couple had an arranged marriage and their religion tells them they are married for life and eternity? Psychological Ethics 101 tells American therapists to respect other cultures, learn about client cultures that are markedly different from our own, seek out knowledgeable colleagues for help, and do not pathologize these people because they are not displaying typical American values and norms. Hopefully, my readers know better than to agree with the advice of a terrible therapist.

How To End a Relationship When Your Partner Has Borderline Personality Disorder (BPD)

It is hard enough to be in a relationship when both people are emotionally stable. When someone has an emotionally-crippling mental disorder, such as BPD, things get exponentially more volatile, and even potentially dangerous. “Emotional Vampire” is a term I have heard patients use to describe a partner who acts erratically, overly-demanding and needy to a point it becomes draining and energy-sucking. Healthy, stable people without a taxing emotional deficit, such as BPD, cannot truly understand the depths of anguish and discomfort a partner with the disorder sinks to. Simply, the person with BPD lacks an emotional skin and cannot contain the overwhelming emotions that cause him or her to “emotionally-bleed-out.” It is heart-wrenchingly tragic to witness the unbearable torment the sufferer deals with. However, this does not mean the healthy partner should continue to stay in the relationship-- unless the suffering partner gets outside help. If you want to get off the roller-coaster and end it with the emotionally dysregulated person in your life, here is what you may want to consider: 1) Do not become unkind to them by yelling at them. Even though your anger would likely be a justified reaction to the “interpersonal-terrorism” they have waged upon you, a person with BPD will become more hurt, feel more victimized, become more isolated and likely to strike-out further. 2) Do not abandon your partner with BPD—if possible—rather, slowly disengage and detach with love and compassion. “Quitting” your partner suddenly can lead to his or her self-harming behavior—or worse. Try to transition from intimate partner to “supporting other” whenever possible. This is usually easier to do when there is autonomy between the partners (i.e., not married or living together, no children, etc.) 3) Be clear with the person you are breaking away from. Do not tip-toe around your plans to put distance between you both. Do not lead them on, give them false hope, or be wishy-washy. Be firm, be gentle, and clear that there will not be a reconciliation. 4) If your partner threatens suicide or to harm you must take these threats seriously. Sometimes a partner with BPD can pull the “suicide-card” as a form of manipulating you or holding you “emotionally-hostage.” You will need outside help when you are being threatened or stalked.

An Outpatient Approach to Treating Mothers with Borderline Personality Disorder and When Hospitalization May be Necessary

Treating Mothers Who Have BPD Extensive empirical evidence supports a psycho-educational intervention for the identified patient as well as the spouse and children (Cohen et al., 2008). Psycho-educational information about childhood developmental stages and milestones from infancy forward would aim to reduce family stressors and risk of relapse (Cohen et al., 2008; Gunderson et al., 1997). A systems-based approach in treating mothers with BPD would encourage the patient to form or join a support network comprised of other mothers with BPD (Cohen et al., 2008). Presently no manualized form of structured treatment exists, although treatment models have been proposed, and at least one peer reviewed article has been written (Stepp et al., 2012) on the efficacy of treating the entire family. In-Patient Hospitalization for Suicidal Patients with BPD Many people with Borderline Personality Disorder cannot afford ongoing psychoanalysis, and may require hospitalization during a crisis. Further, psychoanalysis may prove to be more harmful than beneficial to patients in crisis, because inherent transference and countertransference problems can derail therapy altogether (Gabbard, 2000). In addition, insurance and managed care companies are less likely to pay for long-term psychoanalytic therapy than the more time-limited cognitive behavioral treatment (Gabbard, 2000). Therefore, hospitalized care is often a crucial component of a good outcome for patients severely impaired by BPD (Gabbard, 2005). A three-step model has been proposed (Ogden, 1979) for BPD patients who have been admitted to a hospital in-patient treatment program, based on the following concepts of projective identification (Gabbard, 1990; Goldstein, 1991; Sandler, 1987): (1) the self-or object representation is unconsciously projected from the patient onto the treater, (2) the treater unconsciously identifies with the patient’s projected self- or object representation, and (3) the treater psychologically processes the projected material, which then becomes modified and re-introjected by the patient. Patients tend to recreate internalized patterns of attachment, perhaps in an attempt to master previously experienced trauma (Gabbard, 1988). Patients with BPD may try to provoke hospital clinicians to gain both the auspice of control and the mastery of similar situations which had eluded them in early childhood (Gabbard 1988). The four forces theorized to contribute to the patients’ perpetuation of transference patterns are: (1) to actively master previous traumatic experiences that he or she was passive in (Pine, 1990), (2) to maintain attachment patterns (Gabbard, 2005), (3) to invite help from others who could protect them (Gabbard, 2005), and (4) to transform their lives (Sandell, et al., 2000). Conflicting and therefore irreconcilable self- and object representations become split off from the patient and projected onto hospital staff members. Rather than merely a defense mechanism, projective identification of fragmented and externalized self- and other material serves as a potent way for patients to communicate, and expresses their hope for a better outcome from a repeated and familiar pattern (Gabbard, 1988). Guntrip (2011) refers to this as “the object and self both being transformed into the fantasy relationship for which the patient longs.” Although unable to verbalize their internal experiences, nevertheless inpatients may be able to evoke similar experiences with hospital staff as an unconscious way of managing affect and primitive anxieties that exert psychical pressure (Gabbard, 1988). There are four identified primary features involved in the phenomenon of splitting that inpatients undergo: (1) the splitting is unconscious; (2) dependent on the patient’s internal object representations, different staff members are perceived differently and, sometimes, these differences are dramatic in their projection; (3) through the process of projective identification staff members react to these projections by taking on the projected aspects; and (4) treaters’ opinions of the same patient can become polarized to the point of causing frictions and falling-out among the staff during discussions (Casement, 1990; Gabbard, 1989a; Ogden, 1987). Corrective measures should include assuring the patient that the treater can tolerate and manage intense feelings without the retaliation or abandonment the patient had experienced in similar situations in the past. Rather than reacting, the treater instead responds to the patient, reducing the patient’s primitive anxieties. This, in turn, stops the patient from having to split, or disavow, painful introjections. Initially, the treater may attempt to contain the patient through a willingness to serve as the patient’s “bad object.” The treater can subsequently vent privately to colleagues to discharge any anger provoked by the patient. Treaters who lack the internal resources to prevent a harsh reaction to the patient may be characterologically unsuited to implement the holding and containing process the patient needs in order to change (Brune, et al., 2010; Carter, 2006).

Dr. Jabin, Does My Girlfriend Have Borderline Personality Disorder?

I have the expressed written permission of my client to write the following blog. Recently a client asked me if I thought his girlfriend has Borderline Personality Disorder (BPD). He told me that he familiarized himself enough with the symptoms online and wanted my professional opinion on the matter. According to my client his girlfriend was moody, says horrible things to him and about him that are plain “evil,” and recently began blocking his calls while in a particularly foul “spell.” After I told him that since I have never met the woman, his girlfriend, that I cannot ethically reach an opinion as to whether or not she has BPD. I told him that while some of the behaviors he described to me seem to resemble some typical borderline pathology that ultimately there is no simple way to know—especially in this instance where I never met her. Where do doctors who diagnose BPD start? I always, and I mean ALWAYS, ask my clients to go see a medical doctor before jumping the gun and rushing into a psychological diagnoses. It is my humble opinion and with all the advanced education, training and real world experience that I tell my clients to please get a physical beforehand. My client was not thrilled with my reluctance (read: refusal) to confirm what he suspects about his girlfriend. He kept insisting, “Okay, I know what you are saying, I hear you, BUT—do you think she could have BPD?” Here is what I told my insistent client about BPD: The symptoms of the disorder are broad, overlap with many other “disorders,” and may just be the result of a physiological problem versus a psychological problem. For example, he said she is very “moody.” Well, doesn’t drug and alcohol addiction make a person tired, irritable, cranky, depressed one minute and elated the next? Of course it does. Guess what else does? A brain tumor. So do diminishing estrogen levels and/or thyroid problems. It could be anything else other than BPD—and that is where one must begin their thorough investigation. I hope I do not offend some folks who diagnose psychological problems with great ease, but Shame on you! How terrible it is to label a person with one of the most severe types of psychopathology---for which the psychological community largely feels there is no cure. After I ran down other possible things it may be other than the most vilified and disliked disorder in the DSM to my client he told me that his girlfriend did in fact have an addiction to Percocet—and alcohol. While BPD does overlap with addiction it does not mean that addicts always have BPD. Often times when people sober up they become free from demons that have played them personally and professionally. However, some people get sober only to find they don’t have an escape from severely debilitating mental health problems. There is definitely correlation between BPD and addiction—but, we need to differentiate correlation from causation. I told my client that even if his girlfriend does seek a therapist to discuss her possible BPD that a well trained, highly knowledgeable therapist will recognize the need to prioritize the addiction problem first. That is, it is first and foremost to help the client find the right resources to get the active addiction under control rather than to spend years discussing her “other” problems. Life endangering problems are to be put at the top of the list and everything else prioritized accordingly. Active alcoholism and drug abuse is a greater “real” problem than anything else a client may present with—such as BPD. After my client and I spent the hour discussing his girlfriend and the problems she may or may not have I asked my client this: “Why would you choose to be with a person whom you describe as horrible to you, abusive and suffering from drug and alcohol abuse?” He sheepishly said, “yeah, I guess we might want to look at that.”

Mom is not Really a Monster or a Psycho, She Just Has Borderline Personality Disorder

Attachment Theory: What it is Attachment theory is a useful framework by which to understand BPD, because problematic attachments or pathological attachment styles often serve as the basis for BPD (Bowlby, 1973; Mahler et al., 1975). Attachment theory recognizes four categories that exist between child and caregiver: 1) Secure, 2) Ambivalent/ Resistant, 3) Avoidant, and 4) Disorganized (Fonagy, 2001). When a caregiver is sensitive to an infant’s signals and appropriately responds to the infant’s needs, the child feels secure, having come to “possess a representational model of attachment figures as being available, responsive, and helpful” (Bowlby, 1980, p.242). Infants who do not develop feelings of security from a caregiver tend to become distressed in novel surroundings. These children typically exhibit clingy behavior, are difficult to soothe, and are not comforted through interactions with the attachment figure (Ainsworth, 1970). Children who are avoidant often experience the caregiver as insensitive or rejecting of their needs (Ainsworth, 1979). Such a caregiver may withdraw from helping behavior during difficult tasks and become emotionally unavailable during times of emotional distress (Stevenson-Hinde, & Verschueren, 2002). Rather than orientating to their attachment figures when exploring new surroundings, these avoidant children exhibit independent behavior. When the caregiver mistreats the child, is intrusive, or exhibits frightening behavior (all forms of child abuse) the child develops a contradictory attachment strategy, lacking in coherence. For example, such a child characteristically may approach the attachment figure with eyes averted and facing away (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1986). Emotional distress may result when affectional bonds are threatened by loss or disruption, leading to sadness and anxiety (Fonagy, 2001). Hence, when a caregiver is either insensitive or unavailable to the infant, certain pathogenic self-deficits may result (Gabbard, 2005; Goldfried & Wolfe, 1996; Gratz & Gunderson, 2006; Ogden, 1986; Pos, Greenberg, Goldman, & Korman, 2003; Mulder, Joyce, & Luty, 2003; Pynoos, 1993; Vocisano, Klein, Arnow, Rivera, Blalock, Rothbaum, & Thase, 2004). Bowlby (1973, 1977) wrote that both psychopathological and normal development are rooted in attachment processes. Well-adjusted, “healthy” individuals have a balanced and seemingly realistic and coherent narrative about early relationships. People free of psychopathology describe attachment-related experiences as having been influential to their emotionally-sound development and later wellness (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Conversely, Bowlby (1973, 1977) wrote that early difficulties in attachment may predispose a person to vulnerabilities and resultant psychopathology. Bowlby (1973, 1977) postulated that attachment difficulties lead to the specific psychological deficits of BPD. Disturbed attachment styles give rise to emotional distress that manifests in personality disturbances, rage, anxiety, anger, self-destructive, para-suicidal and suicidal ideology, depression, and emotional detachment (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Bowlby further theorized that problems with attachment during early childhood may lead to problems with later close relationships and child rearing. Moreover, according to Bowlby (1973, 1977), attachment patterns persist with potentially long-lasting negative reverberations throughout a person’s lifespan (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Treating Mothers Who Have BPD Extensive empirical evidence supports a psycho-educational intervention for the identified patient as well as the spouse and children (Cohen et al., 2008). Psycho-educational information about childhood developmental stages and milestones from infancy forward would aim to reduce family stressors and risk of relapse (Cohen et al., 2008; Gunderson et al., 1997). A systems-based approach in treating mothers with BPD would encourage the patient to form or join a support network comprised of other mothers with BPD (Cohen et al., 2008). Presently no manualized form of structured treatment exists, although treatment models have been proposed, and at least one peer reviewed article has been written (Stepp et al., 2012) on the efficacy of treating the entire family. A pilot program called Multiple Family Group (MFG) (Gunderson et al., 1997) advocates for a psycho-educational approach to wellness for BPD sufferers. MFG is comprised of three forms of treatment: (1) Family Connections (FC) (Fruzzetti & Hoffman, 2004), (2) Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Blum, Pfohl, St. John, Monahan, & Black, 2002), and (3) Multigroup Family Skills Training (MFST) (Miller, Rathus, & Linehan, 2006). FC and STEPPS focus on the sufferer within the context of the family system, while MFST focuses on the entire family. Gunderson et al (1997) furnish empirical evidence that MFG improves family communication and lessens family burden after 6 months of treatment.

Can a Shrink Really Help Patients Who Have Borderline Personality Disorder?

Psychoanalysis as a Clinical Treatment for BPD Freud’s observation that individuals are often unaware of their own causal factors affecting emotions and behavior led to his development of psychoanalysis. According to Freud’s psychodynamic perspective, the intrapsychic drives influencing human behavior are primarily unconscious. His theory of personality focuses on unconscious forces, psychic determinism, anxieties, and internal conflicts which coalesce to manifest as intellectual and emotional difficulties (Brenner, 2001; Friedman, 1975; Gabbard, 2004; Gaston, et al., 1998; Greenberg & Mitchell, 1983; Ogden, 1986). Seven features distinguish psychodynamic therapy from other therapies (Shedler, 2010). These features are (1) focus on affect and expression of emotion; (2) exploration of attempts to void distressing thoughts and feelings; (3) identification of recurring themes and patterns; (4) discussion of past experience (developmental focus); (5) focus on interpersonal relations; (6) focus on the therapeutic relationship; and, (7) exploration of fantasy life (Blagys & Hilsenroth, 2002; Burum & Goldfried, 2007; Shedler, 2010). The determination of these distinguishing features was made through empirical examination of session recordings and from transcripts of therapy sessions (Shedler, 2010). Psychodynamic therapists explore reoccurring themes and disruptive thought patterns that negatively affect concepts of self, interpersonal relationships, and the ability to enjoy life. Although aware of painful or self-defeating patterns, some patients are not able to manage these patterns (Gabbard, 2004). Often, patients are drawn to emotionally unavailable romantic partners and even abusive partners (Dutton, et al., 2006). For patients who are unaware of the ways they sabotage themselves, work with a psychodynamic psychotherapist can help them become more emotionally aware and thus, able to change (McWilliams, 2011; Sachse, et al., 2011; Shedler, 2010; Wampold, et al., 2002; Waters, et al., 2000 ).

Borderline Pathology: The Unique Reactivity to Social Rejection Seen in Patients with Borderline Personality Disorder

Research by Dixon-Gordon, Chapman, Lovasz and Walters (2011) suggests social rejection carries the strongest likelihood of negative interpersonal consequences on behavioral functioning for those suffering with BPD. In the study, Dixon-Gordon and colleagues sorted patients with the disorder into categories of high, mid, or low levels of symptoms/features of BPD. The high-BP group showed a compromised ability to find “relevant solutions to social problems” (Dixon-Gordon, et al., 2011, p. 243); whereas the low-BP group showed more appropriate solutions to the same set of social problems. The high-BP group demonstrated an increase in self-reports of negative emotions during attempts to find appropriate solutions to social problems when compared with the low-BP group. Based on the study, Dixon-Gordon and colleagues determined that clinical interventions aimed at improving social problem solving skills among the BPD population is worthy of further examination. Some of the more severe behavioral problems exhibited by BPD patients seeking psychiatric services (self-injury, suicide attempts, behavior dyscontrol) occur during times of interpersonal conflict and the resulting distress. According to Berk, Jeglic, Brown, Henriques, & Beck, 2007, suicide attempters with BPD demonstrate poor social solving skills and heightened physiological emotional reactivity. According to Kuo & Linehan (2009) patients with BPD are very likely uniquely reactive to social rejection stimuli. Findings by Dixon-Gordon and colleagues (2011) support the conceptualization of a negative emotional state leading to consequential social problem-solving deficits in patients with the disorder. Further, rather than this being simply a trait-like symptom of BPD it appears that BPD sufferers have a tendency to experience heightened negative emotional states as well as emotional stressors (Dixon-Gordon et al., 2011). Kuo & Linehan (2009) hypothesize that an increased arousal beyond the threshold of “optimal social problem-solving performance” may account for the tendency of patients with BPD to suffer from “heightened negative emotional states” in response to social-rejection. Moreover, these patients may be more “uniquely reactive” to scenarios of interpersonal distress (Kuo & Linehan, 2009). Rather than a trait-like symptom of BPD, the social problem-solving deficits may be a consequence of a negative emotional state (Bateman & Fonagy, 2008; Dixon-Gordon, et al., 2011). This is especially important for consideration as it relates to DBT (Kuo & Linehan, 2009). For instance, training aimed at reconciling the chaotic emotional states of BPD sufferers may prove to be a potent refinement of and salient therapeutic feature in treating the disorder. Additionally, DBT may allow working memory to become “freed up” by augmenting the patient’s social skills and affording the patient more self-efficacy through increased capacity to problem solve (Linehan, 1993; Linehan, et al., 2002; Lyons-Ruth, 2008; Schmahl et al., 2004; McWilliams, 2011).

My Ex Has Borderline Personality Disorder So Why Do I feel Like the “Crazy” One?

Divorcing someone with Borderline Personality Disorder (BPD) is no easy feat. When children are involved, the non-BPD person will suffer PTSD-like constellations of symptoms including depression, hopelessness, anxiety, panic attacks, angry outburst and more. Your insides are bleeding, hemorrhaging actually, and feel as though they are strewn about before you while life as you hoped it would be is nowhere in sight. You remember the distant memories of the life you thought you had, the life you both promised to work hard for together, and you continue to puke your guts out in the aftermath. Borderlines cannot hold two opposing thoughts in their mind at the same time. Therefore, you (the non BPD) are either ALL GOOD in their mind or you are ALL BAD. There is no grey area whereby you are a mostly good person who has human shortcomings and is prone to make unintentional mistakes. Through the BPD process of “splitting” you are “the bad guy” and the Borderline in your life is “the good guy.” Sexual trauma during childhood is found in more than 75% of BPD sufferers. When the abuse was occurring, he or she began the process of “splitting” that would forever alter the life course trajectory. A sexually abused child is understandably filled with rage over the inherent powerlessness of the situation and the misuse of trust. Many children may feel a sense of “badness” over being sexually abused. The borderline cannot tolerate feeling bad about his or her self so projects all the bad qualities onto the abuser while allowing the “self” to remain “apart FROM” the badness (versus “apart of”). The themes of “good me” and “bad other” repeat throughout the lifespan because those with BPD cannot integrate the simpler fact that a “bad thing” happened to the “self” which isn’t the same thing as the “self” being contaminated by the “bad act” and irreversibly damaged. Not all children who experience sexual abuse develop BPD. There are too many variables to account for properly in this blog as to why some develop BPD while others do not, so I will just say this: Children who get the therapy and help they need to properly contextualize the abuse that happened to them do not develop BPD with the same alarming frequency as those who do not get the help they need to move past the abuse. It may be that children with emotionally available parents are able to safely open up about the abuse and begin the healing process faster. Perhaps traumatized children with avoidant parents who are unavailable emotionally due to substance abuse problems, absenteeism, or mental health problems must fend for themselves via the “splitting” process – which can also be termed the “failure to integrate” process, or the process of “disassociation.” Disassociation means that the mind has left the body. During the abuse this is a life-saving technique whereby the child is not “part of” the badness, but is “apart from,” and still “all good.” The trouble with disassociation and splitting is that it cannot be easily controlled by the BPD sufferer. In times when the person should be able to feel intimacy, closeness, acceptance and other positive emotions they may not be able to. They may feel like they are outside of themselves watching themselves go through the motions but they fail to properly integrate positive emotions experientially. Therefore, the result is a lowered emotional IQ creating a chasm between themselves and their loved ones. If you are a non BPD in love with a BPD or divorcing a BPD sufferer you will share in their suffering, rage, and have “badness” projected onto you and you will only get glimpses of authentic love – this is usually at the height of the relationship and then spotty until “the big end” obliterates it altogether. You will find yourself as one more disenfranchised lover in the borderline’s pattern of volatile relationships. There is help for those with BPD and non BPD partners or exes. There are also measures that can be taken preemptively when children are biologically, genetically, or environmentally at increased risk to developing BPD. My next blog will address some of those things.

How Mothers "Spread" Borderline Personality Disorder to Children/ Show Me a Patient with BPD and I Will Show You a Patient Whose Mother Had BPD

Multigenerational Transmission of BPD from Mothers to their Children Since women in clinical settings with diagnosis of BPD comprise an estimated 75% of patient population, it is roughly estimated that over 6 million women in the United States are diagnosed with the disorder (Friedel, 2004). Stepp and others (2012) have recently begun to focus on mothers with BPD in order to better understand the impact of generationally transmitted components within the etiology of the disorder. Additionally, only sparse research has been undertaken and therefore few manualized efforts exist to guide the efforts of clinical professionals in developing targeted interventions for the high-risk population of children being raised by mothers with BPD (Skodol & Bender, 2003; Stepp et al., 2012). In the theoretical model, a child who is genetically vulnerable to the disorder and its related psychopathology is at increased risk from the invalidating experiences transacted within the child-parent relationship (Bandelow et al., 2005). This is especially true when the child is highly emotionally reactive (Krause, Mendelson, & Lynch, 2003). Conversely, children who have a lower level of emotionally reactivity may not have as difficult a time soliciting a positive response from caregivers, which in turn moderates their internalizing and externalizing symptoms with less emotional dysregulation (Bandelow et al., 2005). Thus, acceptance and warmth from caregivers can mitigate accumulative damage to children from neglect, abuse, and conflict otherwise present in the social environment (Stepp et al., 2012). Since nothing can be done to change the particular genetic vulnerabilities of children who are born to mothers with BPD, future researchers would be prudent to concentrate on the modification of parenting practices in order to intervene environmentally (Herr, Hammen, & Brennan, 2008). Hobson and colleagues (2009), researching the particular challenges of parents with BPD, find a dysfunctional display in the inter-relatedness of these patients with psychotherapists. The moment-to-moment interactions between patient and therapist may be compared to patients with dysthymia, due to intense and often heated exchanges coupled with idealizing and devaluing “flip-flopping” (Conroy et al., 2009). The ramifications of similar patterns of interacting carrying over into the patient’s exchanges with offspring may have far-reaching and negative, social-emotional consequences developmentally (Stepp et al., 2012). Unresolved trauma from the mother’s childhood tends to lead to a disorganized and unresolved attachment style that causes her parenting style to fluctuate unsteadily between hostile and passive (Paulson & Lejuez, 2006). Bio-social theorists (Linehan, 1993) are finding evidence that when the patient oscillates between hostile control and passive devaluation it has a deleterious effect on the infants’ ability to self regulate (Stepp et al., 2012). Furthermore, these mothers with BPD tend to model the very strategies their own parents used, thereby replicating the same invalidating environments for their children (Stepp et al., 2012). This is indicative of a generational “handing-down” of a dysfunctional parenting template that perpetuates the disorder trans-generationally (Stepp et al., 2012). Recent studies by Fonagy & Luyten (2012) and Schacht, Hammond, Marks, Wood, & Conroy (2012) have attempted to address epidemiological concerns about the heritability of BPD by examining comorbid features of maternal psychopathology and resultant psychosocial outcomes on their offspring. According to Stepp, Whalen, Pilkonios, Hipwell, & Levine (2012), the attentiveness of mothers with BPD was observed during free-play interactions with their infants, and compared with the results of the same interactions between healthy control mothers and their infants. The data collected suggested that infants of the mothers with BPD were less attentive and less interested in interacting with their mothers during the free play than were the infants of the healthy control mothers. One emerging theory from the research is that this dynamic leads to avoidant interaction patterns between mothers with BPD and their offspring. Further research suggests that gaze aversion, “dazed looks” (Hobson et al., 2005; Stepp et al., 2012), and less overall responsiveness occurs in infants whose mothers have BPD, compared with infants of mothers with no evidence of psychopathology (Johnson et al, 2006). Over time the infants of the mothers with psychiatric disorders showed increasing negative affect, more emotional dysregulation, and less satisfaction when reengaged with their mothers (Whalen, Dahl, & Silk, 2009). By the time these same infants were 12 months old, 80% of them (Hobson et al., 2005) had patterned behavior consistent with disorganized attachment style, as well as poor mood toward strangers (Stepp et al., 2012). Negative psychosocial consequential outcomes may include the children of mothers with BPD exhibiting poorer emotional regulation (Steinberg & Morris, 2001), increased fear of abandonment (Bandelow et al., 2005), and more negative parent-child relational expectations. These outcomes, in turn, may engender a shameful and incongruent sense of self, leading to disturbances in identity formation (Conroy et al., 2009; Newman et al., 2007). Children with a shameful and incongruent sense of self are more likely to engage in self injurious behavior and have dissociative symptoms, both of which are correlates of BPD (Hobson et al., 2005). Similarly, childhood internalizing and externalizing disorders have been shown to occur in patients with early deficits in their ability to self regulate (Eisenberg et al., 2001; Ogawa et al., 1997; Stepp et al., 2012; Suveg, Hoffman, Zeman, & Thomassin, 2009; Yates, 2004). Compared with children from healthy control mothers, school aged-adolescent children of mothers with BPD are at an increased risk of disruptive behavioral disorders and attention-deficit hyperactivity disorder (ADHD). These particular children are 6.8 times more likely than controls from healthy mothers to have depressive symptoms (Ghassabian, Herba, Roza, Govaert, Schenk, Jaddoe, & Tiemeier, 2012). Moreover, among this group are higher reported incidences of (Stepp et al., 2012) (1) cognitive and interpersonal vulnerability, (2) negative attributional style, (3) dysfunctional attitudinal behavior, (4) ruminative responsive style, (5) self-critical attitude, (6) insecure style of attachment, and (7) increased reassurance seeking behavior. Further, increased rates of psychiatric disorders are seen in children whose mothers have been diagnosed with BPD when compared with children of control mothers (Stepp et al., 2012). Global ratings of impairment are higher for the children from mothers with BPD. Even when adjusted for contributing factors such as childhood trauma, data found by Hobson and colleagues (2005) shows that maternal BPD continued to be a compelling factor correlating to poor outcomes in offspring. Within this same group of offspring of mothers with BPD, higher rates of anxiety, depression, and low self-esteem were observed than in children from healthy controls (Hobson et al., 2005). Finally, studying the effects of maternal BPD on 15-year old adolescents, Stepp and others (2012) observed lower social self-perception, increased fearful attachment styles, more chronic stress, and maternal hostility within the mother-adolescent dyad. Bandelow et al (2005) and Bornovalova et al (2006) theorize that parental criticism and invalidation of their children’s emotions causes the transmission and development of BPD. An invalidating home environment is associated with early-childhood social and emotional difficulties, as well as psychological distress later in adulthood (Bandelow et al., 2005; Bornovalova, et al., 2006). It may be that the mother invalidates the child due to her own inaccurate perception of her child’s emotional state. A BPD-afflicted mother who struggles to properly understand and manage her own feelings and emotions, and who herself has a history of parental invalidation from her early childhood, may lack the tools to model strategies for emotional socialization (Bandelow et al., 2005; Bornovalova, et al., 2006). Rather, such a mother would model ineffective ways of coping and managing stressful emotions, possibly even leading to neglect and abuse (Bandelow et al., 2005; Bornovalova, et al., 2006). When caregivers invalidate children’s emotional responses during early childhood, often the child learns to deny his own natural responses, disrupting the development of emotional regulatory and processing systems (Bandelow et al., 2005; Bornovalova, et al., 2006). Consequently, children of mothers with BPD -- who repeat the invalidating atmosphere of their own early childhoods -- grow up emotionally compromised systemically, and are likely to repeat the transgenerational pattern themselves (Bandelow et al., 2005; Bornovalova, et al., 2006). Treatment for children negatively impacted by maternal BPD may thwart the mechanisms of early-childhood transmission of the disorder, as well as the transgenerational repetition (Krause, et al., 2003; Stepp et al., 2012). The following are commonalities in parenting behaviors that typify mothers with Borderline Personality Disorder: (1) they use insensitive forms of communication; (2) are critical and intrusive; (3) use frightening comments and behavioral displays (Hobson et al., 2009); (3) demonstrate role confusion with offspring (Feldman et al., 1995); (4) inappropriately encourage offspring to adopt the parental role (Feldman et al., 1995); (5) put offspring in the role of “friend” or “confidant” (Feldman et al., 1995); (6) report high levels of distress as parents; (Macfie, Fitzpatrick, Rivas, & Cox, 2008); and (7) may turn abusive out of frustration and become despondent (Hobson et al., 2009; Stepp et al., 2012). The role-reversal becomes most apparent during the toddler period for children whose mothers have the disorder (Macfie, Fitzpatrick, Rivas, & Cox, 2008). Hobson et al (2009) theorize that the mother with BPD discourages the development of autonomy in her toddler in order to have her own needs met through an enmeshed closeness. Because such mothers fear abandonment, they are reluctant for the toddler to achieve independence (Stepp et al., 2012). Thus, the mother encourages the toddler to be more adult-like, grooming him in the role of confidant, peer, or even parent. In turn, this leads to disorganized attachment within the mother-child dyad (Stepp et al., 2012). Stepp et al (2012) compared psychiatrically healthy mother-child dyads with dyads of mothers with BPD and their infants, and found differences in parenting. For example, patients reported feeling less satisfied, less competent, and more distressed with their abilities to parent properly than the controls did (Stepp et al., 2012). Also, the mothers with BPD displayed less sensitivity and used fewer opportunities to structure their interactions with their infants than the controls demonstrated (Johnson et al., 2006). Eisenberg et al (1996) and Lunkenheimer, Shields & Cortina (2007) believe that the neglect and emotional under-involvement in the parent-child dyad displayed by caregivers with BPD may lead to feelings of emotional invalidation in their children, thereby increasing the risk to those children of developing BPD, themselves. Moreover, even after controlling for contributing factors such as infant irritability, Feldman et al (1995) found that personality disordered caregivers reserve less time for recommended infant care practices during at-home assessments. Further, data from research by Feldman and colleagues (1995) indicates that children aged 4 -18 are oftentimes exposed to frequent and sudden environmental instabilities such as maternal suicidal ideation, geographic changes to housing and school, and even removal by agencies from the family home (Feldman et al., 1995; Stepp et al., 2012). One complex issue researchers face when creating controlled trials to observe the parenting practices of mothers with BPD is that this group must be carefully disentangled from mothers with other forms of psychopathology instead of, or in addition to BPD (Bezirganian et al., 1993). In solving this issue, researchers selected mothers by the common discordant BPD parenting strategies characterized by “over-involved/intrusive” behaviors and “hostile control/coldness” (Whalen, Dahl, & Silk, 2009). In this way, researchers are able to use select criteria for mothers with BPD, versus mothers with BPD and confounding variables in which data becomes difficult to extrapolate and validate (Johnson et al., 2006; Stepp et al., 2012). When parents are psychiatrically healthy their “emotion related parenting practices” enable children to “emotionally socialize” through proper “emotional modeling” (Bezirganian et al., 1993). By contrast, mothers with a diagnosis of BPD are thought to administer a punishing disciplinary response when their children display strong emotions (Bezirganian et al., 1993). Also, these mothers use negative parenting behaviors that include the following: (1) criticizing (Eisenberg et al., 1996), (2) mocking (Eisenberg et al., 1996), and (3) punishing emotional expression of the child based on inaccurate perceptions about the child’s emotional state (Hobson et al., 2005; Stepp et al., 2012). Children may in turn extinguish, suppress, or conceal their emotions through “aggressive emotion regulation strategies” (Ogawa et al., 1997; Yates, 2004). Such children are left without the ability to effectively manage their own emotions through appropriate models of adaptive strategies (Steinberg & Morris, 2001). Further, they will likely emulate poor parenting strategies later in life with their own children (Stepp et al., 2012). Mothers with BPD are less likely to monitor or supervise their children (Clark, Kirisci, Mezzich, & Chung, 2008; Hoeve et al., 2007), which increases the likelihood of childhood injuries and delinquent behavior persisting into young adulthood (Petrass, Blitvich, & Finch, 2009). Moreover, these mothers frequently vacillate from harshly punishing their children to being overly permissive and failing to set limits or provide proper guidance (Hobson et al., 2005). Interventions aimed at teaching mothers with BPD to promote self-efficacy in their children by maintaining schedules and providing routines with structure have been shown to effectively decrease distress in their children (Lunkenheimer, Sheilds, & Cortina, 2007). Furthermore, mothers who learn to decrease their withdrawing and ignoring behaviors while developing a nurturing and stable environment for their offspring may decrease children’s risk of developing BPD or other psychiatric symptoms (Murphy, et al., 2009; Stepp et al., 2012).