Celiac- Look Closely at What You Cannot See

FICTION- by: Dr. Desiree Jabin She is a psychologist familiar with how divorce affects children. Surely, her doctorate combined with her "mom card" meant that she knew how to stave off the descent of psychological problems that accumulate along the horizon like a foul and ominous storm. The advanced degrees and certificates that adorn her office walls like wallpaper announce this fact to all who see them. Her diplomas served to warn any "fates" away from tightening the ropes around her children in a way that squeezes out all that is joyous and otherwise fondly memorable about early childhood. With the unison of a symphonic cacophony in Latin, her diplomas blazed a warning declaration that she is a mommy whose own children’s lives shall never resemble the statistics describing the tattered lives of other folks' children from broken homes. Gina was determined to actively monitor her kids' developing psyches for any of the text book, tell-tale signs of emotional distress. She spent most hours of the day with them or near them, volunteering daily in their school classrooms, accompanying them on field trips, even going grocery shopping together. She fully participated in her role as mother as the three sought to carve out new meaning, definition and enjoyment despite the obviousness of the missing family member. Wes’s empty place at the table begged explanation far beyond the tender years of the kids’ experiences and too convoluted for Gina to easily explain away. The more Gina feared the Fates were plotting to destabilize her family the more she dug in to provide stability, reassurance, and reinvent a comfortable new normality. Gina detested cooking. During her marriage to Wes she almost always managed to avoid cooking by penciling this chore under her now ex-husband's detailed job description. This “trifecta reconstitution”--- Gina, her seven year old son, James, and nine year old daughter, Rose -- put cooking back on her own list of "to-do's." Gina would simply reinvent the dinner-hour post divorce. No more eating at the table where Wes’s abandoned chair taunted the three of them with memories of happier and simpler times. Sometimes the chair seemed to invite a guess as to Wes’s whereabouts. Occasionally, the chair seemed to grow larger and take up more floor space than any other piece of furniture in the dining room. Gina soon realized the kids and she could eat out more often together without losing the “value” of the dinner hour -- the family meal that experts say matters most to those desirous of raising emotionally healthy children. Four or more days or nights a week Gina took the children out for Italian food. They ordered heavily breaded appetizers, pasta, pizza, garlic bread. Dessert was always in store for the kids if they ate their entire dinner -- the three of them especially savored good Tiramisu and chocolate chip cookies. She found herself buying more frozen foods to make after school snack time easier on her and more enjoyable for them. On most weekdays during their school year Gina skipped eating lunch apart from them in favor of joining them at home for snack time after school. To her credit, Gina was wholly committed to providing them consistency during meal times with extended hours of hands-on, “mommy time.” This time was spent by debriefing each other on the day's high and low points. Rose would say, "Mom, high and low -- go!" Gina would start first by detailing the best part of her day -- the high, and then finish with the worst part of the day -- the low. James would go next and Rose would finish by filling in the events from her day in similar fashion, completing the game. Gina played this simple game with them because it cleverly accomplished several things. First, it gave her a window to crawl through and learn about their internal experiences and mental inner workings during encounters with others as they navigated the features of their external environments. Second, listening to the kids decompress from their school days drew Gina into their lives with a weighted importance that she cherished. It proved to her that they were still young and innocent enough to allow her to play such a contributory part in their day to day affairs and musings. Kids grow up so quickly, and kids from divorced parents are often catapulted into taking on more grown- up roles earlier than preferable in an altruistic perfect world. Professionally, Gina refers to children who are thrust into roles they are ill-equipped or unprepared for, without a buffer or proper role-modeling, as becoming “parentified.” Kids such as these become “mommy’s helper” and “mommy’s big boy” far before they can embrace the magnitude of the shift. Personally, her efforts were designed to bridge communication and connect them in structured and healthy ways. By staying actively engaged and emotionally available to her children, Gina was able to prevent the “parentification” that befalls too many children who are rudely ejected from the softness of childhood and coldly immersed in the unpleasantries that await them in “the real world.” Always calculating to thwart the “fates,” Gina used this time to reinforce how much she loved her two children. When answering the questions her daughter posed to her during their nightly game her response was unwavering. Gina always answered that her high was seeing them after school or being in the present moment with them. Eventually, the game’s consistent reinforcement of her love for them evolved from the planting of seeds to the eruption of thick and viable roots occupying the darkest recesses in their developing minds. The day arrived when Gina’s kids would recite her answer with her in sing-song rhythm. During this post divorce “check” point, Gina felt being a single parent was coming along better than is typically seen amongst the "broken home" demographic. Gina congratulated herself on her own brand of the “care and feeding” of a high emotional IQ. So much so that professionally she decided she could no longer counsel couples because she, like a pendulum, had swung so far as to become pro-divorce. At the very least, she seriously contemplated putting a warning label on her forehead that read, “Anti marriage, pro-divorce” to serve as a cautionary descriptor for couples teetering on the edge between separating and rekindling. When it came to an after school “quickie meal” for the kids, Gina’s favorite ready to eat snack after two minutes in the microwave was dinosaur nuggets. Basically, these breaded and frozen chicken "treats" allowed her the freedom from cooking while at the same time supporting her desire to become a doting and kitchen-capable mother. An additional perk to Gina was that these “gourmet” breaded chicken dinosaurs allowed her to maintain cognitive dissonance from actual fast food places. Wheat thins, sliced gourmet cheese, cashews, and different combinations of fresh fruit provided quick and healthful snacks for the three of them. James and Rose knew less fortunate children whose mom’s took them to the types of drive-through chains that have become memorialized as part of the fabric Americana. The divorce had not been Gina’s decision. True, she threatened it often but she was never the one who actually pulled the marriage off life support and wrote Do Not Resuscitate. The years of tumult had eroded the marriage, reducing it to a loveless facade. Gina and Wes were merely a cardboard cutout of a couple versus being warm-blooded, passionate lovers. Staying trapped in a marriage devoid of happiness is thought my many experts to be better “for the sake of the kids” than divorcing. Television and radio talk show psychologists berate callers who discuss filing for divorce when young children are involved. “WAIT until the children are 18 years old before you leave!” they shout with venom and hostile aggression at unsuspecting callers for all of America to hear and take heed. During one of Gina’s regular meditations she allowed her mind to play free association with the word "divorce." One time, while in a near hypnotic state she conjured up the following adjectives, modifiers and descriptors: failure, poverty, damaged, stepparents, suicidal, laughingstock, broken heart, lawyers, bills, custody, visitation, traumatized, and many others equal to or exceedingly negative in value. The threats of divorce were meant to more closely resemble a Defibrillator, shocking the ailing marriage back into a romantic rhythm. It was Wes who dealt their marriage the death blow. Rose, James and Gina had their own equivalent of a "honeymoon" phase shortly after Wes moved out. The kids received her full attention, completely uninterrupted by the "cold war" that characterized the dynamic between their warring parental units. Gina was happier, more emotionally available to Rose and James, and even more approachable than she had previously been when arguing and hostile thinking towards Wes consumed her mentally, physically, spiritually and emotionally. Gina was freed up to play, cuddle, and read bedtime stories. As the newness of divorced life settled to take a shape of its own, it ushered in new routines, traditions, and expectations. The warm fuzziness of familiarity was reborn and the three members of the trifecta had perfectly renegotiated the family's group dynamic and roles therein. The only hiccups in this seamless configuration occurring when her daughter, Rose, failed to stay within the confines of her purview. Gina knew that little girls go through a "bossy pants" phase, so she added extra latitude and widened the parameters of the "lanes" Rose was to stay in. When Rose’s tone with her littler sibling, James, was particularly harsh Gina gently reminded her to "stay in her own lane" and not get too far into "the mommy lane." Gina let her know that she appreciated Rose’s “thoughtful input,” but at the same time she told her not to "take my mommy job from me or I won't have any job to do." As if it were a business meeting, Gina gave the kids a revamped "job description" list. Her aim was to help the kids see their appropriate roles within the family system, identify inappropriate roles (such as Rose parenting her brother, or little James trying to be the man of the house), and reassert her own power over the rest of the triad. Due to Rose’s natural inclination as a leader she stepped on Gina’s toes no matter how much Rose was gently directed not to, and finally demanded, she not continue to do so. As the honeymoon phase was ending, it became like a worn-out blanket no longer able to keep out the biting cold. This newer phase that Gina, Rose and James entered allowed the harsher light of day to pour in too quickly -- flooding and pooling in an unkindly way that illuminated all the cracks, holes and flaws which the blanket had been absorbent enough to swallow up. Life’s messiness was no longer easily contained or promptly cleaned up. Gina sensed an emotional tsunami lurking not too far off the immediate radar, threatening to unleash a downpour that would summon the “fates” upon the trifecta. James was now eight years old and Rose was ten. Gina’s best efforts at staving off Rose’s parentification failed miserably. Rose thrived happily in her own eked-out niche as James’s second mother. Rose’s aggressive behavior created an antagonistic relational dynamic between mother and daughter. The implication for Gina was that her own authority was being usurped due to Rose finding her unfit to mother on some level. Gina expected this type of tension when Rose was older -- say around 15 or 16 years old -- but Rose became an enemy combatant far earlier and reminded Gina of tormentors she had known previously in life’s earlier decades. Rose’s refusal to “stand down” and just be a kid on equal footing with James, versus an equal to her mother --or superior -- unraveled Gina, who now had to place herself in time outs before correcting Rose’s behavior. Eventually, while meditating, Gina realized that there was an underlying personal issue fueling the increasingly bad chemistry she and Rose were encountering. As the youngest child in her own family of origin, Gina realized some enmeshment issues existed between herself and her youngest child, James. This meant that when Gina suspected Rose (the oldest child) was treating James (the youngest child) unfairly, Gina became anxious -- scanning the environment with the type of hyper-vigilance usually reserved for PTSD symptomology. Gina noticed James becoming more irritable and quick to tears. He began having night terrors, his thinking was “foggy,” he had painful gas, stomach cramping, diarrhea, bloating and complained of feeling nauseous. The broad spectrum of his symptoms was increasing in chronicity and severity. Gina’s work experience led her to conclude that James was exhibiting behavioral and physical symptoms as a result of stress from the divorce. There are two very important things Gina learned about being a mother and about being a psychologist. The first thing she learned is that she should never be her own kids’ therapist. Attempting to be her kids’ therapist would be an inappropriate dual role spawning adverse ethical outcomes for all involved. The second thing she learned is that a psychological diagnosis should never be given before, or until after, a physician has ruled out a physiological diagnosis. These two caveats would prove to be the most important things of Gina’s career as a psychologist, and more importantly, her “mommy” career. James was screaming so horrifically on the toilet one particular evening after dinner that Gina decided to schedule a medical appointment for him the next morning -- keeping him out of school to accomplish this. With a doctor’s note the absence wouldn’t count anyway and she felt his need for an MD outweighed whatever he would miss in class that day. By 10:00 o’clock the next morning he had developed new physical symptoms which, to the physician, were “red flags” for appendicitis -- however, he lacked the usually present constellation of appendicitis symptoms, such as vomiting and fever. James gave blood and urine samples after which, mother and son were sent over to the hospital lab for MRI scans to rule out the direst of possibilities. After the primary care visit, Gina and James spent an additional five hours that day having a battery of tests run, thanks to the great health insurance she carried for him. The two went home and waited. A week later, Gina was checking the mail when she noticed a postcard from James’s doctor’s office. On the back of the postcard, the lab tests stood out for all to view -- like the post office, postal carrier, and any of Gina’s neighbors who could have mistakenly received the postcard in their own box! The ominous results publically declared that James had tested positive for Celiac Disease. This was in 2009 and Gina had never heard of Celiac Disease. She was certain it meant he had a lethal and advanced form of childhood cancer. Gina almost passed out from hyperventilating as she ran inside to conduct an internet search on how long she and Rose had left with James. Gina’s heart raced wildly inside her chest, loud enough for her to hear it on the outside without a stethoscope. As she pounded the letters --C E L I A C D I S E A S E into her keyboard, Gina cried and ruminated on the inequity of it all. She pondered the “hows” -- how this could be happening to them. Gina learned that Celiac Disease is not Cancer at all. However, a very stringent diet must be adhered to as consuming gluten can lead to intestinal Cancer and other maladies over the course of an entire lifetime. No longer could Gina shop for breaded chicken-dinosaurs, chocolate-chip cookies, or Wheat Thins. Gina would have to learn how to cook, they would never eat in restaurants again, and everything was suddenly very overwhelming and appeared to be too tall of an order -- but, she would do it and she would somehow make it work. At that time there were seemingly few palatable gluten-free options for James. Gina needed to find out if there were other gluten-intolerant sufferers on the planet, how they did it, and how she could manage this for her eight-year old son. The happiest coincidence for Gina’s family occurred when right after James’s Celiac diagnosis a gluten free movement swept California. The gods of fortuitous timing seemed to conspire with the stars in the heavens enabling Gina to get the “memo” that everything would work out after all. She would not be tasked with the Herculean feat of learning to cook nor would James have to die from starvation. Today, in 2014, Gina knows now that many folks do not appreciate the swift marketing ploys that swept across the nation -- similar in scope to the low-carbohydrate movement -- bringing delicious already-prepared and easy to prepare meals to every grocery store chain in America. She reads blogs written by members within the Celiac community who either have the disease themselves or, like her, have loved ones struggling with tough dietary issues. Many such bloggers have become experts themselves who post gluten-free recipes online, share information about restaurants that cater to their special dietary needs, and promote ways of ensuring a gluten-free lifestyle to those who medically require it. Backlash against the corporate-greed -- both bolstering and exploiting an anti-wheat paradigm shift -- has become evident in the blogs. Those suffering from gluten intolerance feel transgressed by manufacturing-ploys marketing to consumers in a way that makes being gluten-free faddish. Junk food campaigns appear to minimize the Celiac sufferer’s lifestyle to pure choice, vanity, or the newest way to lose weight. However, for Gina, being able to give James gluten-free treats like cupcakes and cookies means that he can participate in the birthday parties his classmates have at school. The abundant availability of gluten-free pizzas and pastas to a boy like James means that he can enjoy the end of the season baseball parties with his coaches and teammates -- he can merrily join in the fun that little boys his age deserve to have. He doesn’t have to be ashamed of his intestinal differences that would otherwise force him off to the sidelines or curtail his ability to play baseball altogether! Oftentimes, Gina brings gluten-free dough to the pizza parlors so that special order pizzas can be made just the way James likes it -- with the same toppings his friends are all enjoying. No one has to be the wiser, although most of his friends and all of his coaches and teachers know he has Celiac Disease. There was one teacher who rewarded the efforts of James’s entire class with a school pizza party by ordering them all gluten- free pizza. There have been a few birthday parties at school where the teacher brings gluten-free goodies just so James can be included in the festivities. Holiday celebrations at school are other instances where James’s diet restrictions are at the forefront of a compassionate teacher’s thoughts. Gina is often notified ahead of time so she can supply treats to the whole class, or just to ensure that James has a gluten-free item with him for the party. There was a time when these opportunities did not exist and James would be excluded or feel deprived on some level. Now, when James goes to overnight summer camps Gina can select “special diet restrictions” on the medical forms and waivers without being panic-stricken. Most away camps now offer parents like Gina gluten-free menus so she can circle several meal options for her “special needs” camper. Wes’s chair, all the chairs in the dining room set, and the dining table were all donated to charity. Chairs that no longer taunt or serve as cruel reminders now occupy one of the most lived in rooms of the home. Four friendlier chairs serve this newly reconstituted family of four -- James, Rose, Gina and Alby. The white walls in the dining room always felt too sterile, cold and clinical -- mirroring Gina’s earlier hand’s-off approach to cooking. Alby, the general contractor whom Gina ended up marrying is great at cooking nutritious and tasty meals for the family. Alby painted the dining room a periwinkle-blue which adds depth and warmth -- qualities his presence in the family and fondness for cooking impart. The weekends are especially fun because each member of the family helps in the meal preparation and presentation. It is a collective effort and all participate with military precision and finesse. Alby is a reservist in the Air National Guard, a First Sergeant, so there are times when Gina is left to “cook” for the kids. Fortunately for James and Rose, Alby usually leaves Gina with enough food to reheat for the three of them while he is deployed. Occasionally, however, it becomes necessary for Gina to visit high-end, smaller markets that stock “really special” gluten-free frozen food. Gina is able to purchase gluten-free fish sticks, chicken nuggets, corn dogs, pizzas, glazed doughnuts, muffins, and anything else for which there is a non-gluten-free “twin.” Gina has learned so many things about Celiac Disease thanks to this unintended journey. Before James’s Celiac diagnosis, Gina lacked a meaningful context to understand why James broke his collar bone while playing soccer. The extent of his injury was a shock because the fall did not seem too bad. Gina could not assemble the fragmented parts in a way that illuminated the whole picture. It was like trying to put a 10,000 piece puzzle of the sky together -- nothing stood out, everything blurred together and overlapped without borders. No matter how closely she scanned for clues each piece seemed endless as well as finite. Each piece of the puzzle looked like it could belong anywhere -- and nowhere. The closer she looked for cause and effect the more her concentrated efforts failed her. She examined each of the 10,000 pieces closely – still, she could not see his Celiac. Prior to his diagnosis, James caught more colds and had the flu more often than a healthy person ever should -- a puzzle piece. Gina didn’t know that his body was failing to absorb vitamin C because she didn’t yet know anything about Celiac. In fact, it is almost unheard of for a child under two years old to get Strep but James did -- a puzzle piece. More puzzle pieces -- James went to the emergency room by ambulance with a fever of 107.2. In 2002 he caught Scarlet Fever. In early 2009 James caught H1N1, or the “bird flu.” After the Celiac diagnosis the picture came alive in Technicolor clarity. The effect of the diagnosis served to put numbers on each of the 10,000 puzzle pieces. Everything fell into focus and the pieces assembled themselves. She could now clearly see his Celiac. James came down with Chicken Pox even though he had been vaccinated against it -- no longer puzzling. Celiac Disease means that James has a compromised immune system making him more susceptible to everything going around -- 10,000 pieces of the sky all properly placed. Now, Gina understood that James was consuming a gallon of milk every two days because his body was not absorbing the calcium efficiently and would never be able to unless gluten was entirely removed from his diet. Events such as this would now register on Gina’s radar as James’s skeletal system becoming fragile due to his body’s decreased ability to absorb vitamin D properly. Celiac disease weakens bones by making them more brittle -- sufferers have more broken bones than their non-gluten-intolerant peers. Today Gina knows what blips on her radar are the real threats to keep in her cross-hairs as she parents a gluten-free child. Namely, she has to read every ingredient before James can eat something new. It means going to great lengths to avoid cross contamination since gluten is the enemy and can wipe out the health of his gut. His brain seems healthier now too. He never had a psychological problem but “leaky gut syndrome” resulting from an allergy to gluten can imitate psychological problems. Gina is thankful that she never allowed a mental health clinician to slap a diagnostic label or medicate James for ADHD and other psychiatric disorders that leaky gut symptom can appear to be. Still, Gina often wonders about those children whose parents remain unaware of the real culprit behind their own children’s “unwell-ness.” This is especially the case when she reads of the alarming frequency with which newly minted diagnostic labels are assigned to children -- who become mere patient records filed in a quagmire-like labyrinth with little regard for their individuality as people. It should not be so easy for the psychiatric community’s disorder de jour to begin a lifelong journey with a small child. Gina smiles at James who is thriving. Rose pulls out the gluten-free cookie dough that she will bake -- and all will enjoy -- when Alby returns later tonight from a weekend deployed with the Guard.

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.