Borderline PD -- do we have it all wrong?

[DD214_DOC]

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I'm convinced our conceptualization of borderline PD is completely wrong. While we are just starting to get into dynamics, I'm really bothered by this strange dichotomy towards borderlines. We know they lie/embellish current information, but yet we are quick to believe without doubt the report of their past. I have actual skepticism when it comes to the report of past abuse for a myriad of reasons, but yet all theories I have seen regarding BPD assume that their report of the past is true.

In group recently there was a BPD patient who was supposedly gang-raped by 5 men at a bar. A new non-BPD member joined the group and said it has been a long time since she has been with a man. The BPD patient suggested that the new patient head to the same bar she was supposedly raped at to find a man. My theory is not that she was gang-raped by 5 men, but maybe the first four were consentual but not the fifth? Or maybe it's a way for a married woman to have sex with 5 men in one night and still keep her marriage?

Borderline PD to me seems to be more ASPD with a female flare; more emotional manipulation/aggression than physical aggression or violence. Have any studies been done to attempt to verify the accuracy of their reported histories? Some people even go as far as to believe that BPD is a type of PTSD, which I completely do not buy.

Any thoughts?

 

[strangeglove]

Usually we think of early life trauma/neglect as"causing" BPD, not adult trauma. Certainly, borderlines find themselves in situations that increase their risk for trauma in adulthood due to impulsivity, low self-esteem, substance use, self-harm. Whether this reflects an unconscious need to re-experience early life trauma is an interesting dynamic question. I would encourage you to consider that viewing these patients as lying or manipulating with their trauma history is tied to the
very strong countertransference reactions they often elicit, especially when they make their doctors feel like they are traumatizing them through our efforts to help.

 

[nitemagi]

Usually we think of early life trauma/neglect as"causing" BPD, not adult trauma. Certainly, borderlines find themselves in situations that increase their risk for trauma in adulthood due to impulsivity, low self-esteem, substance use, self-harm. Whether this reflects an unconscious need to re-experience early life trauma is an interesting dynamic question. I would encourage you to consider that viewing these patients as lying or manipulating with their trauma history is tied to the
very strong countertransference reactions they often elicit, especially when they make their doctors feel like they are traumatizing them through our efforts to help.

Indeed. I wouldn't necessarily think about the trauma history as causational, nor worry about the factual basis with trauma in any patient. With hypnosis for example, I warn patients that memories from age regression may not be factually accurate. The point is that in all of it the memory FEELS real, and that's where you start in treatment. Start with what they feel, and work with that. Forget about the blame.

I echo SG's thoughts on repeating prior patterns, but would add in that you should read some literature on control mastery theory, which simply put constructs an idea that an individual attempts to recreate prior bad relationships again and again, as a test to the new person to see if they can work it out differently. Most often they just get their prior problem reinforced. The test for the therapist is behaving differently when they attempt to re-enact the old cycle with you in therapy. They may re-enact passively (as they experienced it in their life, feeling themselves as a victim and putting you in the power/abuser role -- such as with projective identification), or switching to active (playing out the role as the parent, turning you as the therapist into the child and showing you how they felt). Every test (re-enactment) is then an opportunity to teach them these old patterns don't have to be repeated.

And as for embellishment, recognize everyone dealing with wants something. What could they get from embellishing, and can you recognize and offer that goal (eg sympathy) by seeing the need behind the story, offering what is requested without engaging on the subterfuge. One could even say "I don't need to hear about all of your bad experiences to feel for you, and to want to help you."

 

[Iwillheal]

HooahDOc, first off, I don't think all or any research mentions that a person with BPD (or any mental illness) is necessarily truthful all the time or about a particular occurrence, past or present. Yes, people with BPD are more likely to have been abused (in particular sexually) when younger and that may played a role in the formation of their personality character. But not every person diagnosed with BPD has that history--as far as can be corroborated by others. Which is why nobody still knows for sure what causes BPD.

Secondly, BPD is different from ASPD but they're both Cluster B of course and have things in common like manipulativeness but there are differences, like people with BPD are more likely to harm themselves, etc.

Third, the PTSD model is really about very early in life and relationship trauma, not a car accident when you're 20 or anything like that. But yes, BPD's causes remain a very interesting area of research.

 

[DD214_DOC]

It's certainly interesting, particularly from the outpatient side of things. I have only experienced BPD in the ER or on the wards. Interestingly enough, my current outpatient group that I lead is full of washed-up middle-age borderlines whom I find incredibly irritating and pathetic. On the contrary, the younger ones I seem to be able to tolerate much more. 😳

 

[Iwillheal]

Lol. Younger ones are more energetic--for better or worse--aren't they?
p.s. love the Frasier avy. Adore it, especially the earlier seasons. Can't recall which episode that is but the expression on his face is so funny.

 

[Ceke2002]

From a former Borderline's point of view, I never outright lied about things, but I did embellish, and I did engage in manipulative behaviour. For me the reasons for doing this were usually twofold 1) It sounds pathetic, I know, but I just really wanted someone to love me, only I didn't think anyone could, or that I deserved it, so the manipulative behaviour was a sort of act of desperation - I'll make someone love me, because there's no way anyone would of their own accord, and 2) It was a self fulfilling prophecy in a way, I hated myself, I mean quite literally hated myself, by manipulating someone into a relationship, which would invariably end because of my behaviour, I could then point to myself and say, "See, I hate myself for a reason, I'm a horrible person."

Usually we think of early life trauma/neglect as"causing" BPD, not adult trauma. Certainly, borderlines find themselves in situations that increase their risk for trauma in adulthood due to impulsivity, low self-esteem, substance use, self-harm. Whether this reflects an unconscious need to re-experience early life trauma is an interesting dynamic question. I would encourage you to consider that viewing these patients as lying or manipulating with their trauma history is tied to the
very strong countertransference reactions they often elicit, especially when they make their doctors feel like they are traumatizing them through our efforts to help.

Most of the borderlines I know who have been the victims of unwanted sexual advances do seem to repeat the same mistakes by continuously placing themselves in risky situations. They tend to be victims of child sexual abuse, and will blame themselves, and think that there's nothing they can really do to prevent an assault taking place. The mere fact of their existence is enough that they'll be assaulted, and if they couldn't stop the sexual assaults that happened to them as a child, why bother trying to stop anything from happening to them as an adult.

It's certainly interesting, particularly from the outpatient side of things. I have only experienced BPD in the ER or on the wards. Interestingly enough, my current outpatient group that I lead is full of washed-up middle-age borderlines whom I find incredibly irritating and pathetic. On the contrary, the younger ones I seem to be able to tolerate much more. 😳

I have to admit I'm very glad I no longer meet diagnostic criteria for Borderline PD at the age I am now. It was bad enough dealing with it in my late teens and twenties, I can't imagine how pathetic I'd feel if I was still pulling some of the same borderline cr@p I did when I was just about to turn 40.

 

[whopper]

but yet all theories I have seen regarding BPD assume that their report of the past is true.

The theory per Linehan doesn't require there be actual abuse though abuse fits the theory. It's a combination of a genetic predisposition (but a large amount of the population has the genes) + invalidation on an extreme level.

Invalidation and abuse go together but so do neglect, parents chronically ignoring their children while not emotionally or physically abusing them in a legal sense, or raising them in a manner where the child's emotional needs are not being acknowledged.

Several rich kids I've seen have borderline PD after age 18 years. They were not cutters in general (there were a few), but the emotional dysregulation, problems controlling their anger, and impulsiveness where there. They were not physically or emotionally abused in a clinical sense but their parents pretty much ignored them, dumping them in private boarding schools all their lives.

As for the lying, it's not every borderline person that has this problem, but just as their lives are rocky and unstable, so some resort to lies as a mechanism to get by and that just makes their problem worse because they must start mastering more mature coping mechanisms, plus it likely will tax their conscience on some level, further worsening their likely already low self esteem.

whom I find incredibly irritating and pathetic

Maybe (and I could be wrong), because it's their pathologies have had time to grow roots, are harder to break, and maybe have even spread out into something more annoying and hurtful? Always be in a position to identify your counter-transference. It'll help keep you objective and ranting about it to colleagues could be helpful to you.

 

[Ceke2002]

Maybe (and I could be wrong), because it's their pathologies have had time to grow roots, are harder to break, and maybe have even spread out into something more annoying and hurtful? Always be in a position to identify your counter-transference. It'll help keep you objective and ranting about it to colleagues could be helpful to you.

You could also look at it from the point of view that if these women are able to get help, even at an older age, then you're potentially helping not just them, but any children they might have, either now or in the future. I edited out some of what I'd written in my previous response regarding the abuse that lead to my developing BPD, as not being relevant to the discussion, but with the observation of my own Mother's behaviours, and attitudes over the years, I'm pretty sure the abuse she experienced as a child lead to her forming some sort of personality disorder herself. If she'd had the opportunity to be treated, who knows, maybe the cycle wouldn't have continued with me.

You could also possibly use that as motivating factor with older Borderlines. I know even when I was having treatment in my 20s it was still definitely a motivating factor for me. Once I'd learned there had been a cycle of abuse in my family, I was loathe to have it repeat with me.

 

[whopper]

Borderline PD to me seems to be more ASPD with a female flare;

Forgot to address this. On the surface it may seem like this, but it's not. The theories behind how it develops, how to treat it, the evidence showing that some of those treatments based on those theories work, no it's not antisocial. Antisocial doesn't get better with treatment unless you consider extreme and harsh punishment and behavioral only improvements treatment. (E.g. they get an electric shock if the don't behave--then the behavior decreases but the ASPD is still there). Borderline does get better with treatment more often than not.

A fault I find with the psychiatry profession as a whole is the lack of education on borderline PD, especially when we get so many patients with this disorder. If we get these people, shouldn't we be educated well on treating it? At least referring out to the right person so we won't treat it if we're not going to educate ourselves on how to treat it?

Instead we got a strange situation that just mimics the dysfunctionality of the disorder itself. We often times don't teach our residents how to treat it, but we get these patients with it, and we don't educate on at least developing a good referral system so the borderline patients can get the right treatment, we aren't addressing the lack of education with treating borderline PD, then we stick them with us to treat and we don't know how to do it.

And what ends up happening as a result of this is we get psychiatrists then seeing borderline patients with disdain. Borderline PD training sessions don't earn CMEs (at least all the ones I've seen so far), further worsening the problem with MDs not getting education in it.

So yes, I do agree we have it wrong. Bottom line is we should treat it and if we don't know how to do it, refer out. Why continue a revolving door where these patients pay money to get better with a provider that doesn't know how to treat their disorder?

 

[Iwillheal]

From a former Borderline's point of view, I never outright lied about things, but I did embellish, and I did engage in manipulative behaviour. For me the reasons for doing this were usually twofold 1) It sounds pathetic, I know, but I just really wanted someone to love me, only I didn't think anyone could, or that I deserved it, so the manipulative behaviour was a sort of act of desperation - I'll make someone love me, because there's no way anyone would of their own accord, and 2) It was a self fulfilling prophecy in a way, I hated myself, I mean quite literally hated myself, by manipulating someone into a relationship, which would invariably end because of my behaviour, I could then point to myself and say "See, I hate myself for a reason, I'm a horrible person."

Of course no two people who meet the criteria for BPD are exactly alike but the "self hatred" theme seems common enough. I've also seen "shame" come up quite often--I'm not suggesting that is/was the case with you. In my view, once therapists understand that BPD is a symptom of a psychological wound that cuts right to the core, a symptom that concerns the very identity and being of the person who is caught in the shadow of a bad/good dichotomy, they can have more sympathy for the person's struggles.

 

[billypilgrim37]

Last night in the ED:

Clinician: "You already saw that patient? Why is she here?"

BP37: "Because when she was little someone was very, very mean to her."

Clinician: "Okay, cool, that's what I'll tell the insurance company."

 

[Ceke2002]

Of course no two people who meet the criteria for BPD are exactly alike but the "self hatred" theme seems common enough. I've also seen "shame" come up quite often--I'm not suggesting that is/was the case with you. In my view, once therapists understand that BPD is a symptom of a psychological wound that cuts right to the core, a symptom that concerns the very identity and being of the person who is caught in the shadow of a bad/good dichotomy, they can have more sympathy for the person's struggles.

Shame was definitely a part of it for me as well, and it tied in a lot with the self hatred. I was ashamed of my own existence, I didn't feel I'd earned the right to take up space in the world. Plus I felt a lot of shame the older I got, and the more I realised just how abnormal my relationship with my Mum especially really was. I just wanted to be a normal girl, with normal behaviours, and a normal, healthy relationship with my family, and I did feel very ashamed, and isolated, when things just weren't like that. I know a lot of Borderline's I've spoken to have expressed similar feelings. Self injurious behaviour can compound that sense of shame as well.

 

[Ceke2002]

Indeed. I wouldn't necessarily think about the trauma history as causational, nor worry about the factual basis with trauma in any patient. With hypnosis for example, I warn patients that memories from age regression may not be factually accurate. The point is that in all of it the memory FEELS real, and that's where you start in treatment. Start with what they feel, and work with that. Forget about the blame.

I echo SG's thoughts on repeating prior patterns, but would add in that you should read some literature on control mastery theory, which simply put constructs an idea that an individual attempts to recreate prior bad relationships again and again, as a test to the new person to see if they can work it out differently. Most often they just get their prior problem reinforced. The test for the therapist is behaving differently when they attempt to re-enact the old cycle with you in therapy. They may re-enact passively (as they experienced it in their life, feeling themselves as a victim and putting you in the power/abuser role -- such as with projective identification), or switching to active (playing out the role as the parent, turning you as the therapist into the child and showing you how they felt). Every test (re-enactment) is then an opportunity to teach them these old patterns don't have to be repeated.

And as for embellishment, recognize everyone dealing with wants something. What could they get from embellishing, and can you recognize and offer that goal (eg sympathy) by seeing the need behind the story, offering what is requested without engaging on the subterfuge. One could even say "I don't need to hear about all of your bad experiences to feel for you, and to want to help you."

What they said 👍

Learning how to recognise behaviour patterns, understand how those patterns might have come about, and replacing them with healthier behaviours and coping strategies was definitely a major part of treatment for BPD, at least for me. Part of that was also learning to differentiate between experiences in my childhood that could objectively be described as abuse, and other stuff that was more my own misinterpretation through over sensitivity. At first I reacted with 'how dare you invalidate what I went through', but in time it did actually help me to realise that not every uncomfortable, or difficult experience in life necessarily equated to something completely dark and overwhelming, that I was powerless to cope with in a healthy manner.

I do have to give kudos to any therapists who can, and do work effectively with Borderline PD patients. Not only do you need the patience of a saint, there's a heck of a lot of emotional baggage to unwind, and get through. It's weird in a way, being recovered now and looking back on how I used to think and behave, it's like, 'wow, damn, how did my therapists actually manage to not blow their stack at me in sheer frustration'. 😱

 

[Iwillheal]

I echo SG's thoughts on repeating prior patterns, but would add in that you should read some literature on control mastery theory...

Recently I was reading a paper on narcissism by Alan Rappoport, and came across his website where he talks about his therapeutic orientation and control mastery theory. I had heard of the theory before and had looked at some papers by Weiss. The theory makes intuitive sense to me and I think is a useful and interesting way to think about therapeutic interactions, but I have not found good empirical support for it. It's not exactly a fringe theory but despite its appeal and similarities to psychodynamic theory, I feel hesitant to take it seriously.

 

[vistaril]

I'm convinced our conceptualization of borderline PD is completely wrong\/QUOTE]

haha.....im convinced we dont really know what "our conceptualization" of it even is....at least meaningfully.

 

[whopper]

haha.....im convinced we dont really know what "our conceptualization" of it even is....at least meaningfully.

If you've read Linehan's research and opinions, I do think she's onto something with conceptualization. As for us psychiatrists, she's not a psychiatrist, so I would agree with you that as a collective whole as a profession, "our conceptualization" is poor given how little training we have in dealing with it yet we are given the borderline patients all the time.

 

[F0nzie]

This thread reminds me of the still face experiment:

[YOUTUBE]http://www.youtube.com/watch?v=apzXGEbZht0[/YOUTUBE]

The experiment highlights how a benign unresponsive affect in a parent can result in significant negative affect and distress in the child. In the extreme end of the spectrum, imagine the effects of abuse? We're seeing a brief snapshot here. What are the long-term effects of children that have been raised this way? Despite the fact our research has not yet fully explained the developmental significance, these types of experiments and research do give us a conceptualization of the developmental aspects of personality disorders such as BPD. Psychodynamic therapy can also help the therapist with the conceptualization of the individual patient, help the patient gain insight, and hopefully provide a corrective experience. I think DBT is an excellent form of therapy for emotion regulation as well. For those psychiatrists that prescribe the ALL-IN-ONE regimen consisting of a mood stabilizer, antidepressant, antipsychotic, and benzo for your borderline patients- shame on you, you're making a lot of these patients worse.

 

[aphenomenon]

Usually we think of early life trauma/neglect as"causing" BPD, not adult trauma. Certainly, borderlines find themselves in situations that increase their risk for trauma in adulthood due to impulsivity, low self-esteem, substance use, self-harm. Whether this reflects an unconscious need to re-experience early life trauma is an interesting dynamic question. I would encourage you to consider that viewing these patients as lying or manipulating with their trauma history is tied to the
very strong countertransference reactions they often elicit, especially when they make their doctors feel like they are traumatizing them through our efforts to help.

I like this, thanks.