Theory of Mind in BPD

[ClinPsycMasters]

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I was having a discussion with a friend of mine, a student therapist, regarding his BPD patient. We couldn't agree on whether people with borderline personality disorder have ToM deficits. He noted that a recent study, did not find any such deficits:

"Theory of Mind in Borderline and Cluster-C Personality Disorder" (http://www.ncbi.nlm.nih.gov/pubmed/19996717)

I think BPD patients can be hypervigilant and surprisingly perceptive. So seemingly they can read the therapist very well. However, their world of object relations is quite unsophisticated and after (accurately and very perceptively) reading your mood, they often end up relating to you through projective identification, instead of actually understanding (or trying to understand) why you may think this or that, or how you came to that conclusion. So they do have ToM deficits.

 

[strangeglove]

Check this out:

http://en.wikipedia.org/wiki/Mentalization_based_treatment

It's a psychotherapy that operates on the principle that Borderlines are impaired in their ability to impute the mental states of others, i.e. ToM. Keep in mind that ToM is more than just knowing what facts another person knows (standard tests of ToM tap into this, and there should be no reason why Borderlines can't do this), but also how another person would feel, knowing what they know (this is what Borderlines don't get). MBT is about as good as DBT, and probably more interesting to do as a therapist.

 

[sunlioness]

I appear to be suffering from acronym fail this evening. What is ToM?

 

[maranatha]

I appear to be suffering from acronym fail this evening. What is ToM?

Theory of Mind. 🙂

 

[sunlioness]

Thanks. 🙂

 

[ClinPsycMasters]

Check this out:

http://en.wikipedia.org/wiki/Mentalization_based_treatment

It's a psychotherapy that operates on the principle that Borderlines are impaired in their ability to impute the mental states of others, i.e. ToM. Keep in mind that ToM is more than just knowing what facts another person knows (standard tests of ToM tap into this, and there should be no reason why Borderlines can't do this), but also how another person would feel, knowing what they know (this is what Borderlines don't get). MBT is about as good as DBT, and probably more interesting to do as a therapist.

I actually think some particularly intelligent BPD patients do that very well, which makes them experts at emotional blackmail.

 

[toby jones]

There is a rather large body of literature on autism as a Theory of Mind (TOM) deficit. Presence or absence of TOM in that literature is operationalized as whether one can pass the 'False Belief Task' (whether one is capable of attributing false beliefs to others understanding that their limited experience will lead them to come to a belief that you know to be false). The ability to pass the task (to have a theory of mind) seems to come online in normal human infants between the ages of 3 and 5. Animals (e.g., birds, higher primates) have not uncontroversially been shown to pass. Autistic people fail (though can learn to pass) whereas downs syndrome people pass.

I've not been sure what if any point of contact the mentalization / borderline personality stuff is meant to have with that above literature. It seems to be oblivious to it (to the best of my knowledge) and I find it frustrating that they attempt to characterize BPD as a TOM deficit.

Is the idea rather that people with borderline personality disorder have systematic biases in the theory of mind that they actually do have / employ? The idea surely isn't that borderline personality disorder arises from the same deficit that people with autism have - is it?

 

[toby jones]

> I actually think some particularly intelligent BPD patients do that very well, which makes them experts at emotional blackmail.

Interesting mentalization of the borderline predicament...

 

[ClinPsycMasters]

> I actually think some particularly intelligent BPD patients do that very well, which makes them experts at emotional blackmail.

Interesting mentalization of the borderline predicament...

Yes, indeed. Mentalization can be empowering for a hypervigilant patient with BPD, one who interprets the slightest negative reaction from others as a sign of abandonment to come. However, if you are a bright high-functioning person with BPD, are extremely perceptive (perhaps had to be to predict/survive abusive other) of emotional states of others in your life, you can use your knowledge of mentalization to manipulate them willfully and from a position of power. Some don't of course. Perhaps it depends on one's values to some extent and others in the person's life.

Arguably we all manipulate each other to get what we want, though the more we need and the less is available, the more ingenious tactics we need to employ. And that's how politics works my friends.

 

[cokefiend]

So when a person gets a BPD diagnosis they start becoming "aware" of their illness. How can anosognosia relate to theory of mind?

BPD seems to be one of the many episodes that manifests in bipolar. "Abandonment issues" is what we cite to distinguish it as a personality disorder. Can't abandonment issues be indicative of GAD?

From my experience BPD people are always falling on either end of the seesaw. Over-emotionality is their problem. I don't believe in approaching BPD from a cognitive deficit framework. Are there any deficits that can be isolated to BPD exclusively? I see it as a severe form of bipolar affective disorder that manifests as isolated episodes in otherwise functional, mentally healthy individuals.

Would anyone say that it can be viewed as one end of the bipolar spectrum with schizoaffective on the other end?

 

[ClinPsycMasters]

So when a person gets a BPD diagnosis they start becoming "aware" of their illness. How can anosognosia relate to theory of mind?

I'm not sure. Assuming they accept the diagnosis and get treatment, there should be improvements in ToM.

BPD seems to be one of the many episodes that manifests in bipolar. "Abandonment issues" is what we cite to distinguish it as a personality disorder. Can't abandonment issues be indicative of GAD?

Well, GAD is sort of like a pot with a little bit of everything in it. Much more pronounced fears of abandonment, in addition to identity disturbance, affective instability and so forth are unique to BPD--consisting of inflexible, maladaptive, dysfunctional patterns in whole bunch of situations, which is why it's a personality disorder.

From my experience BPD people are always falling on either end of the seesaw. Over-emotionality is their problem. I don't believe in approaching BPD from a cognitive deficit framework. Are there any deficits that can be isolated to BPD exclusively? I see it as a severe form of bipolar affective disorder that manifests as isolated episodes in otherwise functional, mentally healthy individuals.

I don't think it's related to bipolar though I see the similarities. The mood swings in BPD are significantly shorter in duration, and significantly more responsive to environmental cues. BPD patients are hypervigilant. Many have a history of abuse and neglect, so the abandonment issues are perhaps rooted in childhood trauma. Of course this is not always the case but often enough there is evidence indicating childhood issues.

Would anyone say that it can be viewed as one end of the bipolar spectrum with schizoaffective on the other end?

To be honest, I don't really understand what you mean. Schizoaffective disorder may be seen as the area of overlap between schizophrenia and biopolar. Where does BPD fit in exactly? Are you suggesting that at BPD is the mildest form of bipolar and situated at one end of bipolar continuum, followed by bipolar, and then schizoaffective disorder at the other end, as the most severe form of bipolar?

 

[cokefiend]

To be honest, I don't really understand what you mean. Schizoaffective disorder may be seen as the area of overlap between schizophrenia and biopolar. Where does BPD fit in exactly? Are you suggesting that at BPD is the mildest form of bipolar and situated at one end of bipolar continuum, followed by bipolar, and then schizoaffective disorder at the other end, as the most severe form of bipolar?

BPDs are reacting to the world as they experienced it in a world everyone knows of. SZ-As are reacting to a changing world. They are experiencing a change in physiology that manifesting itself at the interphase of the mind and the physical world. Some ideas stay in, others creep outside. BPD is strong internalization of the outside - not the externalizing of the inside. I'm trying to describe what I "got" from your reply.

Everything is taken real personally in BPD??? e.g. they pick up on the smallest negative expressions and let it blow up into a profanity (with everyone and all the time). It sounds like anxiety.

Now I might be making an unjustified leap... So if the outside is internalized it can cause euphoria or suicide - depending on where they are in life.

What if a BPD person reacts best to a med not indicated for BPD. E.g. chemically there is no argument for it's use in this illness yet it helps in treating unwanted behavior from the patient's perspective. Are pills and skittles filling the emptiness/abandonment issue?

Forgive me if this is tedious for you.

 

[ClinPsycMasters]

Okay, first off, I only have my masters in clinical psychology so I'm far from an expert in either BPD or bipolar, and my replies are based on my limited knowledge/experience. Now on to your post....

BPDs are reacting to the world as they experienced it in a world everyone knows of. SZ-As are reacting to a changing world. They are experiencing a change in physiology that manifesting itself at the interphase of the mind and the physical world. Some ideas stay in, others creep outside. BPD is strong internalization of the outside - not the externalizing of the inside. I'm trying to describe what I "got" from your reply.

I have a little difficulty understanding this, but by "internalization of the outside" do you mean to suggest that BPD patients' issues with self/emotion regulation stem from things that happened to them in the real world? That environmental factors are more important in BPD, as opposed to the importance of biological factors (your reference to "physiology") at the root of schizoaffective disorder? If so, we're mostly in agreement.

Everything is taken real personally in BPD??? e.g. they pick up on the smallest negative expressions and let it blow up into a profanity (with everyone and all the time). It sounds like anxiety.

If that is a question, then the answer is yes. When you have difficulty regulating your "self" then it keeps popping up in social relations, communications, fantasies, etc. To protect the "self" you feel the need to be extremely alert.

And yes, you are right, anxiety plays a major part in all of this. Hence, a seemingly innocent but critical comment about ther person's appearance may be seen as rejection of the person and indication of future abandonment, which produces great anxiety. Unlike someone with dependent personality disorder, the person with BPD may react to signs of pending abandonment with fury and rage (and "profanity"). People with BPD have trouble regulating their emotion and their rage may alienate their partner--which is not exactly the end result that they wanted. It would help if the partners knew that often enough tremendous anxiety and fear is what drives the person's temper issues.

Now I might be making an unjustified leap... So if the outside is internalized it can cause euphoria or suicide - depending on where they are in life.

Not quite sure what you mean but suicidal gestures are quite frequent in BPD population.

What if a BPD person reacts best to a med not indicated for BPD. E.g. chemically there is no argument for it's use in this illness yet it helps in treating unwanted behavior from the patient's perspective. Are pills and skittles filling the emptiness/abandonment issue?
Forgive me if this is tedious for you.

There are no medications that can take away BPD in its entirety. Some meds like antidepressants can ameliorate the symptoms. Of course if the patient does very well on a mood stabilizer such as lithium, the doctor may suspect that the patient has bipolar disorder instead of BPD. In any case, usually psychotherapy (mentalization, DBT, various cognitive therapies, etc) is recommended in addition or instead of medication. But I digress. Medications and therapies help manage the disorder but not cure it. Therefore, pills do not fill the "emptiness/abandonment issue." However, this does not mean there is no hope. Patients do improve with appropriate therapy and/or medication. People with BPD also improve as they get older. Having a supportive and stable partner, family, and friends helps as well. Having a purpose in life and committing oneself to a particular path can also benefit the person.

 

[cokefiend]

I don't think medications help with theory of mind. In the end don't they serve to confuse the issue so that patients can no longer react the way they normally would since they don't know what to react to. It's mind control, zombification. From what I gather they need guidance and elucidation more than anything else. The question is who wants to take on this kind of responsibility. Why do so many bpd people resort to a wide variety of self-medications? Is all of their substance abuse due to being too aware of the psychosocial cues in their relationships? This suggests that they sacrifice their souls for the sake of maintaining a balance between their life and their people. I'm not one to buy into the existence of personality disorders that easily. The idea of incomplete personalities is offensive. Who doesn't use defense strategies they learned from others? The one thing that stands out is the separation/abandonment issue. At one point or another don't most people react to that type of feeling with various methods of disillusionment.

 

[ClinPsycMasters]

Why do so many bpd people resort to a wide variety of self-medications? Is all of their substance abuse due to being too aware of the psychosocial cues in their relationships? This suggests that they sacrifice their souls for the sake of maintaining a balance between their life and their people.

They self-medicate partly because they're in a lot of emotional pain. The emotional pain comes from their difficulty with regulating their identity/emotions but also their oversensitivity. In addition, they're impulsive. Hence, if you are oversensitive to social cue, you may note the slightest negative reaction, which then you misinterpret as the person rejecting you, and that's followed by tremendous fear of abandonment and rage at being dependent on this person's love or whatever, and impulsively you head to medication cabinet. This is, of course, an exaggerated and oversimplified account but you see what I'm saying? Note that sometimes the person with BPD is actually right, in that some people do reject them, specially because they can come across as clingy. However, the issue is that often any rejection feel traumatic to them.

 

[cokefiend]

I can't recall where I read this and I don't know if it was in a journal or just some random publication. Anyway it was about secret schizophrenics. The ones that are under the radar. One of the ideas presented was that in certain dysfunctional, nontraditional families the SZ child has a pivotal role in maintaining family cohesion. It wasn't suggesting that the family created the SZ, but that the SZ had a high likelihood of finding his/her niche and purpose within the structure of the family. Is there anything similar in theories about BPD. Are there some general familial characteristics that let BPD manifest.

Also, is it possible for someone with BPD to become a bit more detached and objective regarding his/her social interactions with help from coaching. If someone is there to tell him/her the dynamics as society at large sees it, is it not reasonable to think that over a year or so he/she will be able to view social interactions from a more reasonable perspective in addition to their own hyperemotional perspective. After 15 years or so you'd think the person with BPD has become accustomed to having mood swings every day and just accept it as part of life.

 

[ClinPsycMasters]

I'm not that familiar with the literature on patients with schizophrenia and particular role in dysfunctional family. Generally speaking, I do believe that sometimes both the patient and the family members may try to meet their needs through each other in the most curious manner, and this can happen in schizophrenia, borderline, addiction, etc. So the sick role can have secondary gains for the patient but also for certain members of the family.

As for the second part of your reply, I certainly believe that through therapy and/or meds, those with BPD can improve significantly. Some of the newer therapies teach mindfulness and acceptance, so the person learns to observe the intense emotions, accepting that they are built this way (or have become this way for whatever reason) and that is the reality of the situation. So while trying to learn how to regulate their emotions, they also learn to accept the intense feelings instead of avoiding them or impulsively trying to make them go away by self-medicating.This can take some time but there is a lot of hope.