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I WALK THE LINE Borderline Personality Disorder

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1 I WALK THE LINE Borderline Personality Disorder
Presentation by Summer Brunscheen, Ph.D., LP, HSP, LMHC Central Iowa Psychological Services 319 Lincoln Way Ames, IA 50010 I walk the line: Johnny Cash

2 Personality Disorders
PD’s enduring, pattern of inner experience and behavior that deviates markedly from the expectation’s of an individual’s culture, Pervasive and inflexible Onset in adolescence or early adulthood PD patterns can be dx as young as age 5! (chaotic, disorganized, bizarre, annihilation anxiety) Stable over time, leads to distress or impairment (Axis II “is” vs. Axis I “acts”)

3 Personality Disorders
Cluster B Antisocial, Borderline, Histrionic, Narcissistic (dramatic, emotional, erratic) BPD affects: 2% of the general population 10% of an outpatient population 20% of an inpatient population, 74% of people diagnosed with BPD are female

4 Borderline Personality Disorder
BPD is often comorbid with ADHD, addictive DO’s, and mood disorders People with BPD are often poly-substance abusers/self-medicating (avg 4.5 medications)

5 BPD per DSM-IV-TR (4 of 9) Frantic efforts to avoid real or imagined abandonment Unstable, intense interpersonal relationships, alternating between love and hate Identity disturbance, unstable sense of self

6 BPD per DSM-IV-TR (4 of 9) Impulsiveness in at least 2 areas that are potentially self-damaging spending, sex, substance use, shoplifting, reckless driving, binge eating, cutting

7 BPD per DSM-IV-TR (4 of 9) Recurrent suicidal behavior
least likely to attempt when emotionally upset 8-10% suicide rate Higher among those with SA 400 times the rate of general population 800 times the rate found in women 15-34 5-7 DSM characteristics = 7% suicide rate, 8 = 36% suicide rate so check, document, and increase interventions

8 BPD per DSM-IV-TR (4 of 9) Affective instability (rarely last more than a few hours, even more rarely more than a few days) Chronic feelings of emptiness Inappropriate, intense anger or lack of control of anger, frequent displays of temper, constant anger, recurrent physical fights Transient stress-related paranoid ideation, severe dissociative symptoms

9 Additional Characteristics
Disturbance in Self concept Low Social Functioning/Unstable interpersonal relationships Negative affect/Labile affect Dichotomous thinking

10 Additional Characteristics
Cognitive Disturbances Unrelenting crises Active passivity Expressively Spasmodic

11 Additional Characteristics
Splitting Self-Perpetuating Intrapsychic and Interpersonal Processes Counter Separation Maneuvers Impulsive behaviors

12 Additional Characteristics
Sleep Disorders Intimacy Terror Catastrophic Thinking Manipulative Functional Failures

13 Differential Diagnosis
GET A REALLY COMPLETE ASSESSMENT (including past treatment history) Mood Disorders BPD: Bipolar = QUICK mood changes, when depressed is still impulsive, bipolar shifts are neurological, BPD shifts are environmental (can see what is triggering the mood shifts) BPD: Depressive Suicidality = BPD motivated by wish to gain sympathetic and binding response, depressive motivated by despair and hopelessness

14 Differential Diagnosis
PTSD Eating Disorders Substance Abuse From other PD’s

15 Tools for Assessment Clinical interview: historical patterns,
relationship patterns, suicide attempts/self harm, psychotic symptoms, abuse history

16 Tools for assessment Self-Report (Interview) Instruments:
Diagnostic Interview for Borderline Personality Disorders-Revised, Structured Clinical Interview for DSM-III-R Personality Disorders, PAI, Borderline Personality Inventory, Objective Behavioral Index

17 Assessment Self Harm Inventory Beck Scale for Suicidal Ideation
Suicide Probability Scale MMPI-2 Rorschach MCMI-II

18 Suicide Assessment Previous suicidal attempts, lethal in nature
Specificity Level of commitment Availability of instruments Level of impulsivity Substance use Social support availability

19 Self Harm Behaviors: Attempts to “kill the pain”
Cutting: e.g. arms, legs, stomach (80%) Bruising (24%) Burning (20%) Head banging (15%) Biting (7%) Spending Gambling Substance Abuse Promiscuity Shoplifting Reckless driving Binge eating

20 Self harm behaviors Gestures, threats, attempts, parasuicidal acts, self-mutilation As a way to communicate distress 90% show self-destructive behavior in the broad sense 75% have at least 1 self-damaging act, 75% of acts occur b/n years old

21 Self harm behaviors We have three pain systems
Sharp Hot/cold Blunt Can find out what the “just right” sensation is and then do cognitive construction of WHY do it

22 Self harm behaviors Presence of self-injurious behaviors doubles the likelihood of suicide Suicidal behavior NOT necessarily related to comorbid depression Self harm acts often start as self-punitive measures or ways to control affect then take on increasing awareness and purpose of controlling others

23 Research into the Cause of BPD
Psychoanalytic/Psychological/Developmental Models Trauma (Abuse) Model Interpersonal/family psychological models Genetic/biological models

24 Therapeutic Approaches

25 Management context Interventions done TO the client
Competency desired (not designed to create self internal change) Reduce chaos, avoid worsening, manage crises, try to correct distorted relations with helping systems Use when history of: failed tx, worsening in tx, abusing the system, no motivation for tx Use when the individual is not your psychotherapy client

26 Therapeutic Approaches
Dialectical Behavior Therapy Medications: MAOI’s, SSRI’s, TCA’s, Neuroleptics, Lithium Bicarbonate, Anticonvulsants, Opiate Antagonists, Benzodiazepines Psychodynamic Approach Interpersonal Psychotherapy Cognitive Psychotherapy

27 Therapeutic approaches
Psychoanalytic Approach Cognitive Analytic Therapy Relapse Prevention Group Psychotherapy Psycho-Educational Therapy Family Therapy

28 Dialectical Behavior Therapy
developed by Marsha M. Linehan

29 DBT Developed in the 1970’s by Marsha Linehan and colleagues Developed in the 1970’s by Marsha Linehan and colleagues Originally designed to treat suicidal behaviors The only currently Empirically Validated Treatment for BPD Long term therapy not short term: best if in both individual and group DBT therapy

30 Goals of Skills Training in DBT
Behaviors to Increase (Skills) Mindfulness Distress tolerance Emotion Regulation Interpersonal Effectiveness Walking the Middle Path/Finding the Balance

31 Goals of Skills Training in DBT
Behaviors to Decrease (Problems) Confusion about yourself Impulsivity Emotional Instability Interpersonal Problems Adolescent & Family Dilemmas

32 DBT Assumptions You are doing the best you can. You want to improve.
You need to do better, try harder, and be more motivated to change.

33 DBT Assumptions You may not have caused all of your own problems but you need to solve them anyway. The lives of suicidal & depressed adolescents are painful as they are currently being lived. It will generally be more effective for you to learn new behaviors in all the important situations in your life.

34 DBT Assumptions There is no absolute truth.
It will generally be more effective if you and your family would take things in a well meaning way rather than assuming the worst. You cannot fail in DBT.

35 DBT Skills Dialectics Finding the middle path Validation

36 Dialectics Acceptance AND Change = Middle Path Acceptance Change

37 Dialectics: Finding the Middle Path- Balance

38 Learning to think dialectically: Practice
ID the dialectic statement: a) No one ever listens to me. b) People are always available to me and listen to whatever I feel. c) Sometimes I do not feel listened to and it is very frustrating.

39 Learning to think dialectically: Practice
ID the dialectic statement: a) I may not have caused all of my problems, but I need to solve them anyway. b) It is not my fault that I have these problems so I am not going to even try. c) All of my problems are my own fault.

40 Validation What is validation?
Validation communicates to another person that his or her responses (feelings, thoughts, actions) make sense and are understandable to you in a particular situation. Acknowledgement (observing & describing nonjudgmentally) “I can see that you are really upset now” Acceptance: “I know you are upset.” “I am upset”.


42 Validation/Invalidation Levels and Types
Basic attention, listening, ordinary non-verbals Reflecting or acknowledging the other’s disclosures; what she/he is thinking/feeling/wanting; or functionally responding to her/him by answering or problem-solving Articulating/offering ideas about what the other might want/feel/think, etc., in an empathic way; helping the other clarify; asking questions to help clarify Invalidation Not paying attention, distractible, changes, changes subject, anxious to leave or to end the conversation Not participating actively, missing ordinary conversational validation opportunities, not providing evidence of tracking the other person; functionally unresponsive Telling the other person what she/he DOES feel/think/ want, etc. even when the other provides contradictory statements; or telling what she/he SHOULD feel/etc.

43 Validation/Invalidation Levels and Types
Recontextualizing the other’s behavior; putting more positive spin on it; acceptance because of history; reducing the negative valence. Normalizing other’s behavior given present circumstances Empathy, acceptance of the person in general; acting from balance about the relationship; not treating the other as fragile or incompetent, but rather as equal & competent. Reciprocal vulnerability/ self-disclosure in context of the other’s vulnerability, & the focus stays on the other person Invalidation Agreeing with other person’s self-invalidation when behavior makes sense in terms of history & could be spun differently; increasing it negative valence Criticizing other’s behavior when it is reasonable or normative in present circumstances Patronizing, condescending, &/or contemptuous behavior toward the other; treating the other as not equal or incompetent; character assaults/ over-generalizing negatives. Leaving the other person hanging out to dry; not responding to his/her vulnerable self-disclosures, thereby assuming a more powerful position.

44 Taking Hold of Your Mind:
Mindfulness Handout 1 Taking Hold of Your Mind: States of Mind Reasonable Mind Wise Mind Emotional Mind Penny exercise

45 DBT Skills Mindfulness Emotional Mind Analytical Mind Wise Mind
HOW skills WHAT skills

46 DBT skills Distress Tolerance Crisis Survival ACCEPTS Self-Soothing
IMPROVE the moment Thinking of Pro’s and Con’s (ST and LT)


48 Coping with Urges & Feelings: Why Bother
Coping with emotional pain is important for three main reasons: Pain is a part of life & can’t always be avoided. If you can’t deal with your pain, you may act impulsively. When you act impulsively, you may end up hurting yourself or not getting what you want.

49 Radical Acceptance Suffering is not accepting pain Acceptance is:
Letting go of fighting reality Turning suffering you can’t cope with into pain you can cope with Acceptance is NOT approval

50 Acceptance Myths Three myths about acceptance:
If you refuse to accept something, it will magically change. If you accept your painful situation, you will become soft & just give up (or give in) If you accept your painful situation, you are accepting a life of pain

51 Willingness Cultivate a willing response to each situation
Willingness is doing just what is needed in each situation. It is focusing on effectiveness. Willingness is listening very carefully to your wise mind, acting from your inner self

52 (Over) Willfulness Replace willfulness with willingness
Willfulness is sitting on your hands when action is needed, refusing to make changes that are needed. Willfulness is giving up. Willfulness is the opposite of “doing what works”, or being effective. Willfulness is trying to fix every situation. Willfulness is refusing to tolerate the moment.

53 DBT Skills Emotion Regulation Reducing vulnerability: STRONG skills
Increase positive emotions Opposite Action

54 Short List of Emotions Love Hate Fear Joy Shame Guilt Anxiety
Loneliness Anger Frustration Sadness Shyness Boredom Surprise Numbness Confusion Curiosity Suspiciousness Rage Interest Depression Worry Hopelessness Irritability Panic Jealousy Optimism Embarrassment Pain Sympathy Research suggests all emotions can be categorized by the 7 basic emotions

55 The Interaction of Emotions With Thoughts & Behaviors
Thoughts about the event Emotions about event Event Actions Body Reactions

56 Taking Charge of Your Emotions: Why Bother?
Taking charge of your emotions is important because: Suicidal & depressed adolescents often have intense emotions, such as anger, frustration, depression or anxiety. Difficulties controlling these emotions often lead to suicidal & other self-destructive behaviors. Suicidal & other self-destructive actions are often behavioral solutions to intensely painful emotions.

57 Pleasant Activities List
Make a list of fun, SAFE, things you can do to DISTRACT, SELF-SOOTHE, increase positive emotions, lower negative moods, can be opposite actions

58 Opposite Action Step 1 Step 2
Figure out what emotion you are experiencing. You may need to do step 2 first if this is difficult. Step 2 Determine the action urge, in other words, what you feel like doing.

59 Opposite Action Action Urge for the 7 Basic Emotions
Interest Explore Sadness Withdraw Anger Attack Shame Hide Fear Run/Avoid Love Approach Joy Being Active

60 Opposite Action Step 3 Set 4 Step 5
Ask yourself, “Do I want to reduce this emotion?” It is very difficult to actually do Opposite Action if you are not genuinely interested in changing the emotion. In some situations a person might have a negative emotion that he or she would prefer not having, but does not want to change, as in grief at the loss of a loved one. Set 4 Figure out the emotion’s opposite action. Step 5 This involves actually doing Opposite Action all the way.

61 Opposite Action Emotion Action Opposite Action Afraid/Fear Run/Avoid
Approach Anger Attack/Judgmental Thoughts Gently Avoid Sad Withdraw Get Active Shame Hide

62 DBT skills Interpersonal Effectiveness Keeping a good relationship
GIVE skills Getting someone to do what you want DEAR MAN skills Keeping your self-respect FAST skills

63 Ask for Something? Say No to Something? (Cont)
In order to decide whether to ask for or say no to something, the things one needs to consider include: Priorities Capability Timeliness Authority Rights Relationship

64 What Stops You From Achieving Your Goal?
Lack of skill You actually don’t know what to say or how to act. Worry thoughts You have the skill, but your worry thoughts interfere with doing or saying what you want. Emotions Can’t Decide Environment

65 Questions? Comments? Thank you for coming!
Thank you for coming!

66 References American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington D.C.: American Psychiatric Association. Barnes, R. (1985). Women and self-injury. International Journal of Women's Studies, 8(5), Batty, D. (1998). Coping by cutting. Nursing Standards, 12(29), 25-6. Beck, A.T. & Freeman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford.

67 References Bockian, N.R., Villagran, N.E., & Porr, V. (2002). New hope for people with borderline personality disorder: Your friendly, authoritative guide to the latest in traditional and complementary solutions. New York: Three Rivers Press. Brodsky, B. S., Cliotre, M, & Dulit, R. A. (1995). Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. American Journal of Psychiatry, 152, Cauwels, J. (1992). Imbroglio: Rising to the challenges of borderline personality. New York: W.W. Norton.

68 References Clarkin, I.F., Yeomans, F.E., & Kernberg, O.F. (1999). Psychotherapy for borderline personality disorder. New York: John Wiley. Cowdry, R. W. & Gardner, D. L. (1988). Pharmacotherapy of borderline personality disorder: Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Archives of General Psychiatry, 45(2), Crawford, M. J., Turnbull, G., & Wessely, S. (1998). Deliberate self-harm assessment by accident and emergency staff -- an intervention study. Journal of Accident and Emergency Medicine, 15(1),

69 References Dawson, D. & MacMillan, H.L. (1993). Relationship management of the borderline patient: From understanding to treatment. New York: Brunner/Mazel. Favazza, A. R. (1998). The coming of age of self-mutilation. Journal of Nervous and Mental Disease, 186(5), Favazza, A. R. (1996). Bodies under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry, 2nd ed. Baltimore: The Johns Hopkins University Press. Favazza, A. R. (1989). Why patients mutilate themselves. Hospital and Community Psychiatry.

70 References Favazza, A. R. & Rosenthal, R. J. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry. 44(2), Gabbard, G.O. & Wilkinson, S.M. (1994) Management of countertransference with borderline patients. Washington, DC: American Psychiatric Press. Gunderson, J.G. (2001). Borderline personality disorder: A clinical guide. Washington, DC: American Psychiatric Press. Gunderson, J.G. & Gabbard, G.O. (eds.) (2000). Psychotherapy for personality disorders. Washington, DC: American Psychiatric Press.

71 References Haines, J. & Williams, C. L. (1997). Coping and problem solving of self-mutilators. Journal of Clinical Psychology, 53(2), Haines, J., Williams, C. L., Brain, K. L., Wilson, G. V. (1995). The psychophysiology of self-mutilation. Journal of Abnormal Psychology, 104(3), Hawton, K., Arensman, E., Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazell, P., van Heeringen, K., House, A., Owens, D., Safinosky, I., & Traskman-Bendz, L. (1998). Deliberate self-harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ, 317(7156),

72 References Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Kernberg. O.F. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson. Kernberg, O. F. (1986). Severe personality disorders: Psychotherapeutic strategies. New Haven: Yale University Press. Koenigsberg, H.W., Stone, M.H., Appelbaum, A.H., Yeomans, F.E., & Diamond, D. (2000). Borderline patients: Extending the limits of treatability. New York: Basic Books.

73 References Kreisman, J.J. & Straus, H. (1989). I hate you, don’t leave me: Understanding the borderline personality disorder. New York: Avon Press. Landecker, H. (1992). The role of childhood sexual trauma in the etiology of borderline personality disorder: Considerations for diagnosis and treatment. Psychotherapy, 29, Lester G. W. (2003). Personality disorders in social work and healthcare. Nashville: Cross Country University and Houston: Ashcroft Press. Lester, G.W. (2004). Borderline personality disorder: Treatment and management that works. Nashville, TN: Greg Lester & Cross Country University.

74 References Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: The Guilford Press. Linehan, M. M., Armstrong, H., Suarez, A. Allmon, D. & Heard, H. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, Linehan, M. M., Oldham, J. & Silk, K. (1995). Dx: Personality disorder-- now what? Patient Care, 29(11),

75 References Linehan, M. M., Tutek, D., Heard, H. & Armstrong, H. (1992). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry, 151(12), Magnavita, J.J. (1997). Restructuring personality disorders: A short-term dynamic approach. New York: Guilford. Marziali, E., &Munroe-Blum, H. (1994). Interpersonal group therapy for borderline personality disorder. New York: Basic Books.

76 References Mason, P.T. & Kreger, R. (1998). Stop walking on eggshells: Taking your life back when someone you care about has borderline personality disorder. Oakland, CA: New Harbinger Publications, Inc. Masterson, J.F. (1981). The narcissistic and borderline disorders: An integrated developmental approach. New York: Brunner/Mazel. Masterson, J.F. (2000). The personality disorders: Theory, diagnosis, treatment. Phoenix: Zieg, Tucker.

77 References Miller, D. (1994). Women who hurt themselves: A book of hope and understanding. New York: Basic Books. Millon, T. & Davis, R. (2000). Personality disorders in modern life. New York: John Wiley. Paris, J. (2003). Personality disorders over time: Precursors, course, and outcome. Washington, DC: American Psychiatric Press. Preston, J.D. (1997). Shorter term treatments for borderline personality disorder. Oakland, CA: New Harbinger Publications, Inc.

78 References Reiland, R. (2002). I’m not supposed to be here: My recovery from borderline personality disorder. Milwaukee, WI: Eggshells Press. Roberts, A. R., ed. (1975). Self-destructive behavior. Springfield, IL: Thomas. Santoro, J. (2001) The angry heart: Overcoming borderline and addictive disorders: An interactive self-help guide. New York: MJF Books. Silk, K.R. (ed.) (1998). Biology of personality disorders. Washington, DC: American Psychiatric Press.

79 References Simeon, D., Stanley, B., Frances, A., Mann, J. J., Winchel, R., & Stanley, M. (1992). Self-mutilation in personality disorders: psychological and biological correlates. American Journal of Psychiatry, 149(2), Simpson, E. B., Pistorello, J., Begin, A., Costello, E., Levinson, J., Mulberry, S., Pearlstein, T., Rosen, K., & Stevens, M. (1998). Use of dialectical behavior therapy in a partial hospital program for women with borderline personality disorder. Psychiatric Services, 49(5)

80 References Spradlin, S. (2003). Don’t let emotions run your life: How dialectical behavior therapy can put you in control. Oakland, CA: New Harbinger Publications, Inc. St. John, D. (2000). Relationship management and functional improvement in the care of the BPD patient. Journal of the American Academy of Physicians' Assistants, 13,

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