I WALK THE LINE Borderline Personality Disorder

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I WALK THE LINEBorderline Personality Disorder

• Presentation by
• Summer Brunscheen, Ph.D.,
• LP, HSP, LMHC
• Central Iowa Psychological Services
• 319 Lincoln Way
• Ames, IA 50010
• 515-233-1122
• skb_at_iowacounseling.com

I walk the line Johnny Cash
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Personality Disorders

• PDs enduring, pattern of inner experience and
  behavior that deviates markedly from the
  expectations of an individuals 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)

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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

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Borderline Personality Disorder

• BPD is often comorbid with ADHD, addictive DOs,
  and mood disorders
• People with BPD are often poly-substance
  abusers/self-medicating (avg 4.5 medications)

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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

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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

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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

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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

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Additional Characteristics

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

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Additional Characteristics

• Cognitive Disturbances
• Unrelenting crises
• Active passivity
• Expressively Spasmodic

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Additional Characteristics

• Splitting
• Self-Perpetuating Intrapsychic and Interpersonal
  Processes
• Counter Separation Maneuvers
• Impulsive behaviors

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Additional Characteristics

• Sleep Disorders
• Intimacy Terror
• Catastrophic Thinking
• Manipulative
• Functional Failures

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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

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Differential Diagnosis

• PTSD
• Eating Disorders
• Substance Abuse
• From other PDs

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Tools for Assessment

• Clinical interview
• historical patterns,
• relationship patterns,
• suicide attempts/self harm,
• psychotic symptoms,
• abuse history

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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

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Assessment

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

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Suicide Assessment

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

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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

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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 18-45 years old

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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

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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

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Research into the Cause of BPD

• Psychoanalytic/Psychological/Developmental Models
• Trauma (Abuse) Model
• Interpersonal/family psychological models
• Genetic/biological models

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Therapeutic Approaches
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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

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Therapeutic Approaches

• Dialectical Behavior Therapy
• Medications
• MAOIs, SSRIs, TCAs, Neuroleptics, Lithium
  Bicarbonate, Anticonvulsants, Opiate Antagonists,
  Benzodiazepines
• Psychodynamic Approach
• Interpersonal Psychotherapy
• Cognitive Psychotherapy

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Therapeutic approaches

• Psychoanalytic Approach
• Cognitive Analytic Therapy
• Relapse Prevention
• Group Psychotherapy
• Psycho-Educational Therapy
• Family Therapy

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Dialectical Behavior Therapy

• developed by Marsha M. Linehan

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DBT
faculty.washington.edu/linehan

• Developed in the 1970s 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

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Goals of Skills Training in DBT

• Behaviors to Increase (Skills)
• Mindfulness
• Distress tolerance
• Emotion Regulation
• Interpersonal Effectiveness
• Walking the Middle Path/Finding the Balance

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Goals of Skills Training in DBT

• Behaviors to Decrease (Problems)
• Confusion about yourself
• Impulsivity
• Emotional Instability
• Interpersonal Problems
• Adolescent Family Dilemmas

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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.

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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.

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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.

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DBT Skills

• Dialectics
• Finding the middle path
• Validation

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Dialectics
Acceptance AND Change Middle Path
Acceptance
Change
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DialecticsFinding the Middle Path- Balance
Holding on too tight
Forcing independence
GIVING YOURSELF/YOUR ADOLESCENT GUIDANCE,
SUPPORT, AND RULES TO HELP YOURSELF/YOUR
ADOLESCENT FIGURE OUT HOW TO BE RESPONSIBLE WITH
YOUR/THEIR INCREASED FREEDOM And at the same
time SLOWLY GIVING YOURSELF/YOUR ADOLESCENT
GREATER AMOUNTS OF FREEDOM AND INDEPENDENCE WHILE
ALLOWING AN APPROPRIATE AMOUNT OF RELIANCE ON
OTHERS
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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.

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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.

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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.

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Validation

• REMEMBER
• VALIDATING IS NOT NECESSARILY AGREEING
• VALIDATING DOES NOT MEAN THAT YOU LIKE WHAT THE
  OTHER PERSON IS DOING, SAYING, OR FEELING

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Validation/Invalidation Levels and Types

• Validation
• Basic attention, listening, ordinary non-verbals
• Reflecting or acknowledging the others
  disclosures what she/he is thinking/feeling/wanti
  ng 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.

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Validation/Invalidation Levels and Types

• Validation
• Recontextualizing the others behavior putting
  more positive spin on it acceptance because of
  history reducing the negative valence.
• Normalizing others 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 others vulnerability, the focus
  stays on the other person

• Invalidation
• Agreeing with other persons self-invalidation
  when behavior makes sense in terms of history
  could be spun differently increasing it negative
  valence
• Criticizing others 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.

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Mindfulness Handout 1

• Taking Hold of Your Mind

States of Mind
Reasonable Mind
Wise Mind
Emotional Mind
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DBT Skills

• Mindfulness
• Emotional Mind
• Analytical Mind
• Wise Mind
• HOW skills
• WHAT skills

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DBT skills

• Distress Tolerance
• Crisis Survival
• ACCEPTS
• Self-Soothing
• IMPROVE the moment
• Thinking of Pros and Cons (ST and LT)

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Remember

• ACCEPTANCE OF REALITY IS NOT EQUIVALENT TO THE
  APPROVAL OF REALITY

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Coping with Urges FeelingsWhy Bother

• Coping with emotional pain is important for three
  main reasons
• Pain is a part of life cant always be avoided.
• If you cant deal with your pain, you may act
  impulsively.
• When you act impulsively, you may end up hurting
  yourself or not getting what you want.

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Radical Acceptance

• Suffering is not accepting pain
• Acceptance is
• Letting go of fighting reality
• Turning suffering you cant cope with into pain
  you can cope with
• Acceptance is NOT approval

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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

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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

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(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.

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DBT Skills

• Emotion Regulation
• Reducing vulnerability STRONG skills
• Increase positive emotions
• Opposite Action

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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
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The Interaction of Emotions With Thoughts
Behaviors
Thoughts about the event
Emotions about event
Actions
Event
Body Reactions
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Taking Charge of Your EmotionsWhy 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.

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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

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Opposite Action

• Step 1
• 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.

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

• Step 3
• 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 emotions opposite action.
• Step 5
• This involves actually doing Opposite Action all
  the way.

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

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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

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What Stops You From Achieving Your Goal?

• Lack of skill
• You actually dont 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
• Cant Decide
• Environment

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Questions? Comments?

• skb_at_iowacounseling.com
• 515-233-1122
• Thank you for coming!

66
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67
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