This is an introduction to borderline personality disorder in for those who

1. Borderline Personality Disorder 101 Kiera Van Gelder, MFA

3. BPD is highly stigmatized and misunderstood. The typical portrayal of BPD is Glen Close as Alex Forrest in “Fatal Attraction”

4. Chaotic Childish Clingy Cranky Demanding Desultory Going to Extremes Adoring and Contemptuous Fickle Flighty Fragile Hostile Importunate Inconstant Irritable Manipulative Mercurial Moody Possessive Reckless Seductive Shallow Unpredictable Unreasonable Vehement Volatile Clinicians historically have describe BPD traits as being willfully imposed on others , rather than symptoms of an illness --Michael H. Stone, MD

5. Helpless Unlovable Alone A failure Defective Misunderstood Incompetent Hopeless Out of control Unsafe However , this is how people with BPD see themselves: Neglected

9. Emotion Dysregulation Disorder Chemical Imbalance Willful Asshole… Just needs to change Reactive Attachment Disorder I’m screwed Complex Post Traumatic Stress Disorder Faulty Schema Primitive defenses As you can see, doctors have many theories and ways of defining BPD No! Screw you! Thanks to Valarie Porr for the inspirationfor this slide!

10. Additionally, many clinicians cannot see the disorder because they focus on the many “Co-Occuring” diagnosis, as BPD “borders” on and combines with numerous other struggles…. Bipolar & Bipolar II Generalized Anxiety Disorder Substance Abuse PTSD Eating Disorders Depression Obsessive Compulsive Disorder Kleptomania Co-dependence Agoraphobia Sex Addiction Often, people with BPD will be given other diagnosis and treated specifically for those, but ultimately the core of our suffering is never healed. This can go on for decades, leading to the conclusion that there are people who are untreatable and incurable. When, in fact, they have not received the right education and treatment. “ Ragaholic” Panic Disorder Personality Disorder Not Otherwise Specified Is there anything I don’t have? I’m certain you don’t have BPD!

11. So what is BPD (minus the confusion, stigma, denial, misinformation and horrible media portrayals?

14. Dr. Marsha Linehan suggests that people develop BPD due to a “biological vulnerability” in combination with a specific environment: 1) High emotional sensitivity 2) High emotional reactivity 3) A Slow return to emotional baseline Quick to heat up Slow to cool down = Symptoms of Impulsivity and Dysregulation Those with BPD typically have three vulnerabilities

16. Before looking at the more “intra-psychic” aspects of BPD (like attachment, rejection sensitivity, and fear of abandonment) let’s focus on the areas of dysregulation Dr. Marsha Linehan lists as being central to BPD. Cognition Behavior Relationships Emotions Self-Image 5 Areas of Dysregulation:

17. Emotions Chronic anxiety Rapidly changing emotions Overwhelming passion / desire Extreme sensitivity Rages Dissociation, being “shut down” People with BPD have been described as “ emotional burn victims ” due to extreme sensitivity. Their interior world is constantly shifting, unpredictable and difficult to express to others or understand. Low tolerance to stress Easily frustrated Boredom Despair Loneliness I cannot deal with this!

18. People with BPD typically use impulsive, self-destructive behaviors as a way to regulate intense, negative emotions and cope with life. Behavior Self- harm: cutting & burning Suicide Attempts and threats Drug & Alcohol Abuse Impulsive Spending Unsafe Sex Vandalism Thrill-seeking Picking fights Shoplifting Binging and purging Geographical cures I can't stop!

19. Relationships Intolerance of Rejection Unstable “Stormy” Relationships Intense Fear of Abandonment Frantic Attempts to Avoid Being Left Other person becomes focal point for self Conflicts with others difficult to tolerate Need for constant assurance Trust is given indiscriminately or not at all Need for closeness pushes others’ boundaries People with BPD have difficulty tolerating separation or perceived rejection from those they are closest too, and can live in constant fear of abandonment. Difficulty internalizing love or remembering positive connections I need you to survive!

20. Cognition Overly Jealous or Suspicious Black and White Thinking Alternately see others as all good or all bad Difficulty holding onto positives Paranoia when under stress People with BPD can have impaired and distorted thinking, especially under stress or when triggered. Inability to recognize consequences of behavior Hyper-vigilant to possible threats Interprets neutral faces as hostile “ Emotional information processing” impairment Nothing is safe!

21. People with BPD have a fragile and shifting sense of self. A sudden change, even a good one, can destabilize a person’s sense of themselves and their place in the world. Self-Image Rapidly Changing Identity Deep Insecurity Depersonalization / feeling unreal Emptiness Confused sexual orientation Sense of self dependant on others Annihilation of self by others through abandonment or engulfment Environment determines self-worth Sense of being bad or wrong Shifting and contradictory goals or values I don't know who I am!

23. There are recognized biological components to BPD Research shows abnormalities in the neural systems that regulate emotions, impulsivity and thinking Emotions Regulation is impaired Amygdala system Impulsivity control problems Anterior Cingulate Orbitomedial Prefrontal Systems Perception and Reasoning disortions Dorsolateral prefrontal system The Best and Most Up to Date information on this is found in Valarie Porr’s Book: Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change

24. How biological vulnerabilities and environment interact: Linehan’s Bio-social model of BPD Development 1. High emotional sensitivity 2. High emotional reactivity 3. Slow return to emotional baseline 1. Indiscriminately rejects private experience 2. Punishes emotional displays while intermittently reinforcing emotional escalation 3. Oversimplifies ease of problem solving and meeting goals Invalidating Environment: Biological Vulnerability Dr. Marsha Linehan proposes that it’s within a specific “person/environment” interaction that BPD develops

25. So what is an Invalidating Environment? Negates Dismisses Disregards Criticizes Punishes An Invalidating Environment A person’s communication and behavior (Feelings, thoughts, preferences, beliefs, sensations) * * Linehan, 1991 An invalidating environment can be anything from highly abusive to a simple mismatch between caretakers and the person who is vulnerable.

27. Despite all this, we now know BPD is treatable! 2 years = 40% Remission 6 years = 68% Remission 10 years = 85% Remission ( Zanarini, 2005, 2006) Remission is defined as “no longer meeting 5 of 9 criteria” However, we must also be aware that remission does not mean “recovery” or having a good quality of life: Recovery involves more than the absence of symptoms.

28. DBT : Dialectical Behavior Therapy (Marsha Linehan, WA) www.behavioraltech.org CBT: Cognitive Therapy (Aaron Beck, PA) www.academyofct.org SFT: Schema-Focsued Therapy (Jeffrey Young, NY) www.schematherapy.com Mentalization (Andrew Bateman and Peter Fonagey, UK) www.menninger.edu TFP: Transference-focused Psychotherapy (Otto Kernberg, NY) www.borderlinedisorders.com STEPPS: Systems Training for Emotional Predictability and Problem Solving (Nancy Blum et al, IO) www.uihealthcare.com/topics/medicaldepartments/psychiatry/stepps/index.html Treatment for Borderline Personality Disorder is now proven effective and available in many places

30. No matter what kind of treatment is done, healing from BPD involves the cultivation of the following qualities for ALL involved Mindfulness: Developing awareness of body, feelings, thoughts, reactions, & surrounding environment Non-judgment: Not imposing our own viewpoint but focusing on facts Validation: Recognize what each person is saying and experiencing, even if you disagree. Pausing and imagining what others are feeling: The pause allows us to respond rather than react Openness: A willingness to experience the symptoms without shutting down or defending ourselves unnecessarily Giving the Benefit of the Doubt: Not jumping to conclusions about other people’s behavior Curiosity: Asking “what is going on” rather than making judgments and assumptions Patience: Allowing ourselves and others to go through the process and accept it won’t be on our schedule Hope: Believing that recovery is possible

31. “ Abandon what is unskillful…. Cultivate what is good.” --The Buddha