Presentation on theme: "I WALK THE LINE Borderline Personality Disorder"— Presentation transcript:
1 I WALK THE LINE Borderline Personality Disorder Presentation bySummer Brunscheen, Ph.D.,LP, HSP, LMHCCentral Iowa Psychological Services319 Lincoln WayAmes, IA 50010I 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 inflexibleOnset in adolescence or early adulthoodPD 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 BAntisocial, Borderline, Histrionic, Narcissistic (dramatic, emotional, erratic)BPD affects:2% of the general population10% of an outpatient population20% 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 disordersPeople 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 abandonmentUnstable, intense interpersonal relationships, alternating between love and hateIdentity disturbance, unstable sense of self
6 BPD per DSM-IV-TR (4 of 9)Impulsiveness in at least 2 areas that are potentially self-damagingspending,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 upset8-10% suicide rateHigher among those with SA400 times the rate of general population800 times the rate found in women 15-345-7 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 emptinessInappropriate, intense anger or lack of control of anger, frequent displays of temper, constant anger, recurrent physical fightsTransient stress-related paranoid ideation, severe dissociative symptoms
9 Additional Characteristics Disturbance in Self conceptLow Social Functioning/Unstable interpersonal relationshipsNegative affect/Labile affectDichotomous thinking
13 Differential Diagnosis GET A REALLY COMPLETE ASSESSMENT (including past treatment history)Mood DisordersBPD: 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 PTSDEating DisordersSubstance AbuseFrom 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 ScaleMMPI-2RorschachMCMI-II
18 Suicide Assessment Previous suicidal attempts, lethal in nature SpecificityLevel of commitmentAvailability of instrumentsLevel of impulsivitySubstance useSocial 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%)SpendingGamblingSubstance AbusePromiscuityShopliftingReckless drivingBinge eating
20 Self harm behaviorsGestures, threats, attempts, parasuicidal acts, self-mutilationAs a way to communicate distress90% show self-destructive behavior in the broad sense75% have at least 1 self-damaging act,75% of acts occur b/n years old
21 Self harm behaviors We have three pain systems SharpHot/coldBluntCan find out what the “just right” sensation is and then do cognitive construction of WHY do it
22 Self harm behaviorsPresence of self-injurious behaviors doubles the likelihood of suicideSuicidal behavior NOT necessarily related to comorbid depressionSelf 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 ModelsTrauma (Abuse) ModelInterpersonal/family psychological modelsGenetic/biological models
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 systemsUse when history of: failed tx, worsening in tx, abusing the system, no motivation for txUse when the individual is not your psychotherapy client
28 Dialectical Behavior Therapy developed by Marsha M. Linehan
29 DBT Developed in the 1970’s by Marsha Linehan and colleagues faculty.washington.edu/linehanDeveloped in the 1970’s by Marsha Linehan and colleaguesOriginally designed to treat suicidal behaviorsThe only currently Empirically Validated Treatment for BPDLong 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)MindfulnessDistress toleranceEmotion RegulationInterpersonal EffectivenessWalking the Middle Path/Finding the Balance
31 Goals of Skills Training in DBT Behaviors to Decrease (Problems)Confusion about yourselfImpulsivityEmotional InstabilityInterpersonal ProblemsAdolescent & 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 AssumptionsYou 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 SkillsDialecticsFinding the middle pathValidation
37 Dialectics: Finding the Middle Path- Balance Holding on too tightForcing independenceGIVING YOURSELF/YOUR ADOLESCENT GUIDANCE, SUPPORT,AND RULES TO HELP YOURSELF/YOUR ADOLESCENT FIGUREOUT HOW TO BE RESPONSIBLE WITH YOUR/THEIR INCREASEDFREEDOMAnd at the same timeSLOWLY GIVING YOURSELF/YOUR ADOLESCENT GREATERAMOUNTS OF FREEDOM AND INDEPENDENCE WHILE ALLOWINGAN APPROPRIATE AMOUNT OF RELIANCE ON OTHERS
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”.
41 VALIDATING IS NOT NECESSARILY AGREEING ValidationREMEMBER:VALIDATING IS NOT NECESSARILY AGREEINGVALIDATING DOES NOT MEAN THAT YOU LIKE WHAT THE OTHER PERSON IS DOING, SAYING, OR FEELING
42 Validation/Invalidation Levels and Types Basic attention, listening, ordinary non-verbalsReflecting or acknowledging the other’s disclosures; what she/he is thinking/feeling/wanting; or functionally responding to her/him by answering or problem-solvingArticulating/offering ideas about what the other might want/feel/think, etc., in an empathic way; helping the other clarify; asking questions to help clarifyInvalidationNot paying attention, distractible, changes, changes subject, anxious to leave or to end the conversationNot participating actively, missing ordinary conversational validation opportunities, not providing evidence of tracking the other person; functionally unresponsiveTelling 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 circumstancesEmpathy, 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 personInvalidationAgreeing with other person’s self-invalidation when behavior makes sense in terms of history & could be spun differently; increasing it negative valenceCriticizing other’s behavior when it is reasonable or normative in present circumstancesPatronizing, 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 1Taking Hold of Your Mind:States of MindReasonable MindWise MindEmotional MindPenny exercise
45 DBT Skills Mindfulness Emotional Mind Analytical Mind Wise Mind HOW skillsWHAT skills
46 DBT skills Distress Tolerance Crisis Survival ACCEPTS Self-Soothing IMPROVE the momentThinking of Pro’s and Con’s (ST and LT)
47 ACCEPTANCE OF REALITY IS NOT EQUIVALENT TO THE APPROVAL OF REALITY Remember…ACCEPTANCE OF REALITY IS NOT EQUIVALENT TO THE APPROVAL OF REALITY
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 realityTurning suffering you can’t cope with into pain you can cope withAcceptance 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.
54 Short List of Emotions Love Hate Fear Joy Shame Guilt Anxiety LonelinessAngerFrustrationSadnessShynessBoredomSurpriseNumbnessConfusionCuriositySuspiciousnessRageInterestDepressionWorryHopelessnessIrritabilityPanicJealousyOptimismEmbarrassmentPainSympathyResearch suggests all emotions can be categorized by the 7 basic emotions
55 The Interaction of Emotions With Thoughts & Behaviors Thoughts about the eventEmotions about eventEventActionsBody 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 2Determine the action urge, in other words, what you feel like doing.
59 Opposite Action Action Urge for the 7 Basic Emotions InterestExploreSadnessWithdrawAngerAttackShameHideFearRun/AvoidLoveApproachJoyBeing 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 4Figure out the emotion’s opposite action.Step 5This involves actually doing Opposite Action all the way.
62 DBT skills Interpersonal Effectiveness Keeping a good relationship GIVE skillsGetting someone to do what you wantDEAR MAN skillsKeeping your self-respectFAST 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:PrioritiesCapabilityTimelinessAuthorityRightsRelationship
64 What Stops You From Achieving Your Goal? Lack of skillYou actually don’t know what to say or how to act.Worry thoughtsYou have the skill, but your worry thoughts interfere with doing or saying what you want.EmotionsCan’t DecideEnvironment
65 Questions? Comments? Thank you for coming! firstname.lastname@example.org Thank you for coming!
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