Category: Risk

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Subtypes of Borderline Personality Disorder, Part I

“People with [Borderline Personality Disorder] are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” 
― Marsha M. Linehan
     Let me begin by saying I am not an expert on Borderline Personality Disorder (BPD). The information discussed throughout this post, like all my posts, should not be used to diagnose or treat patients. Instead, I would like to share how I’ve come to view BPD throughout my career and how my treatment changes based on that understanding. This, the first post of three, will describe a metaphor I use to help explain BPD to clients and families. The last two posts will describe the specific subtypes (I, II, and gestational) and explore existential treatment options.
     The DSM 5 outlines specific symptoms and diagnostic criteria for BPD. Information can be found here. A few theories on subtypes of BPD already exist. Millon has theorized 4 subtypes, and Lawson identified 4 types of borderline subtypes for mothers. All of these suggestions are useful in long-term treatment. However, I would like to suggest a new alternative to identifying subtypes of BPD from an existential and systemic standpoint.
     Lastly, I may not consistently use person first language throughout this post. This is not to say people with BPD are defined by their diagnoses. Rather; it is important to see this post as my clinical view on BPD rather than the people who suffer with it. 
Borderline Personality Disorder
     Often times, clients with BPD are unaware of their diagnosis or they aren’t sure what their diagnosis means. The DSM 5 describes symptoms in clinical terms which, to the one receiving the diagnosis, may mean very little. When providing treatment for clients with BPD, a primary goal is to help them understand the diagnosis. Therapists would do the same with depression, addiction, or any other diagnosis. As a way of clarifying some of the clinical jargon, a metaphor has often helped to illustrate the critical aspects of the disorder in an approachable way.
The Window Painter

     Imagine we are all born into a room. The architecture of the room has unique and distinct features setting itself apart from other rooms, and is mostly bare without any furniture, paint, window dressings, or decorations. As we mature, we begin to decorate our room as a reflection of who we believe we are. As others look out their perspective window into ours, and as long as the blinds are open, they will see aspects of how we’ve decorated our room. We move past other people’s windows, and sometimes other people, from within their rooms, move past our windows. Regardless of the external changes, we remain in our rooms.
     People with BPD, tend to spend an inordinate amount of time looking out their window without looking into their room. Eventually, they begin to see other rooms are decorated or designed, and they want to appear the same way. Then, instead of working on interior design, they begin to draw on the windows. The window drawing becomes so effortless that, over time, they can change the entire look of a room, nearly on demand. If, when looking into the surrounding rooms, a person with BPD sees primarily pinks, pastels, bows, and trophies, they will paint their windows to match! Then, if there are a new set of rooms appearing out their windows, the paint quickly disappears and a new set of illusions are constructed and painted to match.
     All the while, the inside of the room, the actual room, is nearly devoid of real substance. There are no chairs to relax on, no beds to provide rest, and few lights to illuminate the recesses of the room. After a time, the energy required to maintain a nearly constant vigilance, begins to consume the window painter. When this happens, they start making errors in dressing the window. Someone notices the mistake and asks a harmless question. The Window Painter panics! They turn to see their room and find it empty, save for dust and cobwebs. Consumed with dread and shame, they enable one of the few design pieces in the room: the blinds.
     With the blinds fully closed, the window painting is still very visible, but the Window Painter is hidden. These are not healthy moments of introspection and solitude. These times are when the Window Painter, looking at the back of the blinds, sees no one, no thing, with which to connect. They are utterly alone. Within that instant, thoughts of self-harm and suicide begin to spiral into perseverating patterns of self-destruction.
     This is often when those on the outside, in their own rooms, feel so disconnected and confused. Loving parents cannot understand the source of the destructive behaviors. Friends and social resources begin to be consumed with drama and crises. People begin to distance themselves from the Window Painter. Then, when they peek through the blinds, their worst fears are confirmed: everyone really was leaving!
    Enraged and unable to engage, the Window Painter scratches and claws at the illusion on the window. They throw the blinds open and show the world the cultivated emptiness of their room. This only happens for a few brief moments before the Window Painter sees into the room of another. The connection becomes a juncture, an opportunity, for the Window Painter to bare their emptiness to another. The alternative is to resume painting, pretending, pantomiming, and hoping others interpret their real needs without risking exposing the bare walls.

Diagnosis

     The primary criteria for diagnosing BPD is “frantic efforts to avoid real or imagined abandonment” (Sperry, 2003. p.93). In the metaphor of the Window Painter, there is a dim awareness of the emptiness of the room. The compulsion to look outward, to the exclusion of personal insight, is fed by the overwhelming fear and dread which awaits those who look inward. This places the Window Painter in an existential dilemma: They want nothing more than to connect with others, to see and be seen. However, their greatest fear is abandonment. If the connections they experience are superficial and communication is primarily passive-aggressive manipulation, then very little rejection is risked. After all, how can someone truly reject someone they don’t really know?
     The sacrifice for this perceived safety is true intimacy. They are not fully known by anyone and therefore unable to truly connect. Behaviors emerging from fearful attachment (Agrawal, 2004) ultimately serve to confirm the greatest fear: Everyone leaves. This cycle repeats over and over again until the person struggling with BPD is truly alone. The mechanisms by which we come to know our selves (insight), our reactions (awareness), and others (empathy), all interact to help form relationships.

About the Doodle

      The Greek letter Phi is used to symbolize many things, including the “strength (or resistance) reduction factor in structural engineering, used to account for statistical [variability] in materials and construction methods” (Bulleit, 2008). While it should not be inferred that people with BPD have reduced strength, Phi is ideal to indicate a certain statistical variability in how BPD reacts to attachment and threats to attachment. In regards to the reactivity of those with BPD, there is a level of uncertainty which is almost always certain. Reactivity, self-harm, manipulation, low insight, and various other factors should be taken into consideration when entering into a personal or professional relationship with someone diagnosed with BPD.
     This is not to imply that people with BPD are too unstable to participate meaningfully in relationships. Rather, there is a greater degree of variability in mood, affect, and reactivity, all of which can add stress to any relationship. Therefore, to have successful, healthy, supportive, and strong relationships, we must take into account this variability and anticipate the need for additional supports. These may include therapy, hospitalizations, group therapy, medications, and education.



Phi
(c) Nathan D. Croy, 2016

   

Sources

     Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment Studies with Borderline Patients: A Review. Harvard Review of Psychiatry, 12(2), 94–104. http://doi.org/10.1080/10673220490447218

     Bulleit, W. M. (2008). Uncertainty in Structural Engineering. Pract. Period. Struct. Des. Constr. Practice Periodical on Structural Design and Construction, 13(1), 24-30. Retrieved from http://www.ce.berkeley.edu/~mahin/CE227web/UncertaintyInStructuralEngineering-Bulleit_Feb08_ASCEJofEP.pdf

     Kreger, R. (n.d.). The World of the Borderline Mother–And Her Children. Retrieved February 06, 2016, from https://www.psychologytoday.com/blog/stop-walking-eggshells/201109/the-world-the-borderline-mother-and-her-children

     Lavender, N. J. (n.d.). Do You Know the 4 Types of Borderline Personality Disorder? Retrieved February 06, 2016, from https://www.psychologytoday.com/blog/impossible-please/201310/do-you-know-the-4-types-borderline-personality-disorder

     Sperry, L. (2003). Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. New York, NY: Brunner-Routledge.

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A Story for Everyone

“Recall how often in human history the saint and the rebel have been the same person.”
                                                      ~ Rollo May, 1975, The Courage to Create, p. 35

     Sitting in the circle, each of us took turns looking at the other wondering who would begin. The six of us knew each other, some more deeply than others, but there was still an unease. The prompt for the group was this: Tell your story. No one knew where to start. There were several revelations as we began talking about how we should talk about our stories.
     We realized that crises are relative. That just because the trauma doesn’t bother you now doesn’t mean it isn’t still important. There had always been people along the way, but we often failed to see them in the moment. And suddenly, I was thinking of Woody Allen.
      Allen brought a “quirky” and “neurotic” perspective to his films which people had not seen before. He told uncomfortable stories in a way that was just fantastic enough to allow people a safe mental distance. As I sat, thinking about how I would tell my own story, a seemingly insurmountable problem occurred: A story requires a beginning, a middle, and an end. Identifying those aspects required an outside perspective. The characters in the story never know how close they are to their own end. The cessation of one struggle could merely be the prelude to the next act. I do not know if I can ever tell “My Story” until it is over. And by then, I would not be able to speak.
     The distance Allen brought to his movies, the perspective, does not exist for us amidst our own existence as it occurs in the here-and-now. While others, through reflection and feedback, can offer glimpses into these perspectives, they are never complete. Which means the designation of “saint” or “rebel” must be put off until our story is over. In the meantime, we can reflect on our past, the history of others, the stories already told, and the parts of our story we have already seen unfold. But let us not be so bold as to imagine we can tell our complete story. Let us also not be so timid as to believe we cannot tell the parts of our story as they happen.
     I would leave you with this thought: Perspective is a requirement for wisdom and time is a requirement for perspective. As we allow our story to fulfill itself, do not miss the foreshadowing, the past struggles, and the joys which have already occurred. We do not know how close we are to the end of our own story, let us make haste in writing and sharing what we can.

Allen
(C) Nathan D. Croy, 2014
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Traps and Trauma

     The difference between children who have experienced trauma vs children who have not is the difference between a well-fed dog and a dog caught in a trap. Being bitten by a dog stuck in a trap will be interpreted differently than the same action by the well-fed dog. The pain and fear of the person bit may remain the same in each case, but the reason behind the bite is very different. The knowledge of this difference could lead us to quickly forgive the trapped animal while punishing the well-fed animal. Same behavior, same outcomes, different levels of acceptance.

     The reason it is more acceptable for the trapped dog to bite is because we expect it. We know they are acting out of fear and self-preservation. The rescuer may even fault themselves for not taking extra precautions when approaching a wounded animal. We do not fault the animal because we see the trauma. Some animals may need extra care and services before they are rehabilitated enough to join a family and be adopted. Some dogs that have been trapped are euthanized and deemed impossible to rehabilitate. Most often it could be possible, but the expense, time, and resources estimated to bring that change about are seen as too great in a cost-benefit analysis.

     Unfortunately, even dogs that are well-fed and well cared for can still bite and are often “put down” for reasons citing temperament. As if “temperament” were an unchangeable aspect of the animal existing in isolation from the environment. This is not including elderly dogs who may be suffering from dementia. While there may be some truth to this, most healthy dogs can relearn how to behave appropriately in a family/pack unit.

     So it is with children who have experienced trauma. The scars are not always as visible as they are with dogs. Children can arrive at school or daycare, interact with children every day, and be caught in an invisible trap they have brought with them from their home. It is not clear we should approach them with caution or additional supports. Good intentions are greeted with snarls and threats. Well-meaning people are driven away, confident their loving actions will not be “wasted” on an ungrateful child.

     All the while, the traumatized child and the trapped dog know two things: 1) Someone more powerful than myself has done this to me, and 2) only someone more powerful than myself can help save me. Therein lies the fear that drives the bite. These victims have learned they cannot trust those who are more powerful than they are, yet they know they are dependent on them for safety. It is a dichotomy of terror with no hope. Realizing this, the dog chews off his paw and risks bleeding to death. Coming to a similar realization, the child cuts off their emotions (reactive attachment disorder, oppositional defiant disorder, conduct disorder, antisocial personality disorder, etc), their connection with reality (schizotypal personality disorder, schizophrenia, etc), both their emotions and reality (Bipolar disorder, schizoaffective disorder, PTSD, etc), or their own self (borderline personality disorder, dissociative identity disorder, etc). Ultimately, they may even choose to end their own life as a means of escaping what they perceive to be a world full of traps and void of help.

     There have been instances where people like this have been “put down”. It happens under the guise of justice and death penalties. It happens through social isolation and institutionalization. It happens socially and economically and religiously. Through these processes, humanity is enacting the age-old rite of self-preservation on a social level. “We” are protecting “Us” from “Them” because “They” are threatening. It makes complete sense and, evolutionarily, protects us from threats. However, too often we are in a rush to protect, to diagnose, to define, and to dispense. The onslaught of managed care has taught us to ignore the traumatic traps and treat the paw, the specific injury, and discharge the patient in under seven sessions.

     In the process of being so quick to protect ourselves from the threat, we have become the very thing we thought we were protecting ourselves from: Isolated. Isolation is a social tool of punishment designed to either alter behavior so “they” becomes more like “us” (a part of our pack), or else relegate “they” to alienation and almost certain death. This ensures homogeneity and easy identification of who “we” are. The United States claim not to be savage, to be moral, to be respectable. Yet, if we are judged by how we treat our sick, our young, and our old, we are incredibly cruel, immoral, and lack any modicum of respect. If the sick could heal themselves, we would not need doctors. If the traumatized could free themselves, we would not need therapists. If the elderly were cared for by family, they would not need retirement homes.

     This is not strictly about government policies, universal healthcare, or insurance companies. This is about a society becoming so consumed with living a safe life they have failed to live a life. Convenience, ease of use, and customer satisfaction has replaced effort, attentiveness, and prudence. Somewhere along the line, acquisition of material goods and resources became synonymous with safety and wellness.

     So we abandon the dog that threatens us. We forget the child that scares us. We ignore the parent that cannot remember us. We waste our lives on things, and are surprised when things dominate our lives. To quote Kierkegaard in The Sickness Unto Death:

     “What we call worldliness simply consists of such people who, if one may so express it, pawn themselves to the world… The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were nothing at all. No other loss can occur so quietly; any other loss – an arm, a leg, five dollars, a wife, etc. – is sure to be noticed.”

     And this is just what has happened. We have become worldly at the expense of our own selves, at the expense of those smaller, weaker, poorer, or sicker than ourselves. This has happened without a sound, with no notice, and it silently continues on, perpetuated by greed, fear, and the unending pursuit of safety. Let me assure you of one thing: a safe life is no life at all. There will be traps and traumas for all of us. Each of us will require the aid of another who is greater than ourselves to free us from these traps through relationship with patience founded on deep love. Just as each of us will encounter a trap, each of us will encounter another in their own trap. Will we risk being bitten?

(C) Nathan D. Croy
Trap
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Suicide & Autonomy

     From an existential standpoint, the morality of suicide is not always cut and dry. Ironically, this is where an atheist has better ground than a deist in regards to arguing against suicide. If the goal of life, a well lived life, is to be a life of Love, then, from an atheist’s perspective, suicide is the ultimate in destruction of relationship. Death, brought about by choice, ends any and all chances of reconciliation. There are no more opportunities to forgive, or redeem, or interact. No more opportunities to live authentically or with existential purpose. By that merit alone, the act of suicide could be labeled as unhealthy and requiring treatment.
    
     For deists, there is an afterlife. If we apply the same life goal of living Love, then there is another chance. Christian hymns declare this is “not our home” and that Christians are simply “passing through”. The argument I have heard is that suicide takes over what only God can ordain: Life and death. However, God ordained many people to be born deaf, but we invented cochlear implants. God ordained many people to be born with horrible eyesight, but we invented glasses. If the Old Testament is to be taken literally, God was so threatened by a building he confused our languages, but despite this, many people have learned multiple languages. By these examples, it would seem that God has ultimately ordained us with free will. Would it not logically follow that our freedom of will would extend to the self exercising the will. Christians have used this same argument to defend the death penalty. “The criminal knew the consequences of his behavior and decided to commit murder. Therefore, they assented to loss of their own life”. Yet, ability to assent to loss of life is withheld from those who are suffering.

     Which leads me to this question: If I, as an existential therapist, am presented with someone who is suicidal, what is the proper response? Taking Hippocrates into account, at the very least, my job is to first do no harm. Who here has not seen someone in great emotional, mental, and/or physical torment that seemed to exist with no end? Is it harmful to force that person to live when they could easily take their life? By denying a person the right to commit suicide, am I not denying their own autonomy and therefore reducing them to a being incapable of authentic living? And is this act, in and of itself, a form of existential suicide because it automatically denies a person their free will and attempts to force another to relinquish their personal will to the will of another?

     I do not know if this is the right answer, or if there really is one. Some cultures have extolled the honor of suicide. Others embraced euthanasia or physician assisted suicide. There does not seem to be an innate answer. Regardless, there is an incongruence with any society that upholds death penalties while condemning suicide. Here is why: Existentially, life is about potential. It’s why I struggle with abortion, death penalties, and suicide. While this is not the appropriate place for a debate on what does or does not constitute life, it is an appropriate place to talk about existential potential.

     The murderer could go on to become a healer. The sufferer could go on to be healed. While there is nothing, including serving life in prison, a person can do to bring back the dead, there is still time to make their life greater than it was. While there is nothing anyone can do to remove the scars and pain of past trauma, there is the possibility of converting the trauma into a meaningful beauty. There is potential in our pain, our mistakes, and our crimes. There is space for healing, restitution, and forgiveness. Death is the cessation of that possibility. By that fact alone, suicide may be inherently inauthentic as it denies the person their potential and future self.

(C) Nathan D. Croy, 2014
Hanging Question
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Bad Hair Cut

     Let’s pretend you live in a small town. It’s so small, there are only two barbers in the entire town. One barber has hair so amazing it’s talked about in hushed tones and people have begun using the word “coif” to describe it. The other barber has horrible, awful, terrible hair. It’s bad. If you didn’t know better, you’d say he had half of it permed and the other half was cut by a blind man with a severe muscle tick.
     It’s two days before an important job interview. Your hair is beyond shaggy. You’re new to town. Which barber cuts your hair?
     Clearly you have the barber with the bad hair cut, cut your hair! It’s a small town, remember? Only two barbers? That means the barber with the horrible haircut cut the other barbers majestic hair! And the barber with the horrible haircut? Well that was inflicted upon him by the barber with the great hair!
     In Thus Spoke Zarathustra, Nietzsche writes that, “Some cannot loosen their own chains and can nonetheless redeem their friends.” In The Wounded Healer, Nouwen takes this idea a step further and writes that it is only by realizing our own broken woundedness we are able to help others heal. Nouwen expounds on that idea to say that the inherent reciprocity of relationship means that as we facilitate the healing of others, we will begin healing ourselves.
    What I’m trying to get at is this: Perfection is not a requirement for helping others. We do not need to have a perfect marriage before we help someone with their relationship. We do not need to have perfect grades to help someone know a better way to learn. We do not have to have perfect hair in order to be a good barber. Think about this: Tiger Woods has a golf coach. I bet all my worldly possessions that his golf coach is no better at golf than Tiger Woods. However, he may have a better understanding of the game, its physics, its nuances, and he is able to communicate that understanding in a way that improves Tiger’s game.
     So you have a bad hair day. Our bad hair days become fodder. It is from our broken, wounded, pain, that we are able to sympathize with others. This does not make the bad hair day any less frustrating. It does not make our injuries any less painful or our trauma any less damaging. However, if we are brave, these experiences can help heal others. And, if we’re lucky, the very process of helping others may help heal our very self.

Bad Hair Day.
(C) Nathan D. Croy, 2014