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.

Why The USA Abhors Existentialism

     If you do not express your own original ideas, if you do not listen to your own being, you will have betrayed yourself.  — Rollo May

     The World Congress for Existential Therapy is hosting a conference in London with dozens of existential therapists I would gladly have lunch with. If you are interested in learning more about this, click here. The flight, hotel, and entrance cost are prohibitive to me attending, but I hope one day to present there and have them foot the bill!
    
     In the meantime, something struck me as odd: Why are there so few existential therapists in the States? When I tell people I am an existential marriage and family therapist, they either stare at me blankly or ask what an existentialist is. They get bonus points if they pronounce “existential” correctly. I do not mean to disparage the intelligence of my fellow Americans. After I explain existentialism to them, they seem to understand. What frustrates me is how the term existentialism has been extricated from our vocabulary. The following is my theory why existentialism has such difficulty putting down roots in America*.

     This is just a theory, but here it goes: In 1492, when Columbus sailed the ocean blue, landed in America, and insisted the people living there were Indians, even after they told him otherwise, a path of dominance and brutality was begun. Nearly 400 years later, a zeitgeist of American desire to expand geographically, economically, and ideologically across as much of North America as possible occurred. This “God Blessed” right and desire was identified by John O’Sullivan as Manifest Destiny.

     Manifest Destiny is not compatible with existentialism. At its core, existentialism is relational and requires reciprocity and egalitarianism. At its core, Manifest Destiny subjugates and requires control and dominance. Manifest Destiny is a reason while existentialism requires reasoning.

     There is a vast difference between reasons and reasoning. Reasons are why we do what we do or believe what we believe. Reasoning is the process by which we arrive at our reasons.

     If we garner someones reasons as our own, without going through our own reasoning process, our motivation will be fallow and hollow and shallow. However, if we reason out why we’re doing what we’re doing or believing what we’re believing, then our reasons can easily be adapted when our reasoning is shown to be wrong. It is not an issue of dogma when we discuss our reasoning, it is an issue of dogma when we discuss our reasons. This may seem like splitting hairs, and in truth it may be. However, these hairs start wars. People kill and die over reasons. People can discuss reasoning. Creeds are reasons, prayer is reasoning. Reasons are static, reasoning is dynamic.

     It’s the difference between dialectical discussions and debates. Dialectical discussions are designed to allow two or more people to arrive at a general conclusion of truth. Debates are designed and constructed to prove one opinion correct and an opposing or different opinion wrong through the weight of arguments. Dialectical discussions bring two people closer together while debates encourage separation and exist as a zero sum game.

     And this is where the rubber meets the road: Life does not offer answers. Truth, understanding, knowledge, acceptance, all must be sought out via difficult means of self-discovery. Many Christians struggle with the idea of existentialism because they believe it is postmodern relativism and that it allows room for people to get away with anything; that it makes everything justifiable. Here’s the truth: Thinking in terms of black and white, reasons without reasoning, creates a festering fear that is threatened by anything different or new. It is the type of thinking that lead to the Spanish Inquisition, the Holy Wars, and the conversion by force applied to “savages”. There is no reasoning behind a suicide bomb, only reasons.

     Reasoning, like love, is a process; not a goal. This is where fear often emerges. If we trust the process, we must be willing to consider its results no matter how different they are from our own beliefs. The Disciples failed to trust the process while Christ was being crucified. I believe the argument could be made that extremist groups do not trust the process of their own beliefs and instead take the power and control into their own hands.

     My religion tells me to love my enemy, my neighbor, and myself, equally. My Christian community has failed to show me even how to love myself. This is because, too often, the Church has been more obsessed with being RIGHT, with its own Manifest Destiny, with its self, than it has been with the process it claims to promote and defend. Can we trust the process of love, of existentialism, of dialectical reasoning, or do we lack that bravery? Until we we can be brave enough to do so, Americans will continue to abhor existentialism because it threatens our right to be right at all costs. Existentialism calls us to be in relation. Can this be done when my needs exist to the exclusion of others? As long as being RIGHT in all of its forms (driving the right car, owning the right house, or having “the best”) remains more important than being in relationship with others, existentialism will continue to be perceived as a threat and generate anger and aggression.

     What’s the answer? Individuals choosing genuine relationship over, but not to the exclusion of, self. I do not expect America to change. I do expect you to change. The only question now is, are you brave enough?



World War No.
(C) 2014, Nathan D. Croy

*Just to be clear, I realize I’m being ethnocentric, or egocentric, or some type of “centric” when I say “America” instead of The United States of America. I know the term “America” could mean North or South America. It’s just easier to type, so leave me alone.

Pharmacological Sanity

     When I was originally diagnosed with ADD, it was called Minimal Brain Dysfunction. This diagnosis was designed to address children who seemed to function poorly in school and other social settings, but could not be clinically diagnosed as mentally retarded. For a time, this worked, but then someone noticed a discrepancy between these children’s school performance and their IQ scores. While their IQ’s tested in the normal to high range, their performance was abysmal. Researchers realized children with this diagnosis seemed to struggle in focusing long enough to take in information in a way that allowed them to retain it. This new theory lead to different types of treatment. I underwent testing for food allergies, adhered to a strict diet with mineral and vitamin additives, biofeedback sessions, and was even in a trial study for Prozac. My father claims I would have blackouts while on Prozac and even began having suicidal thoughts at the age of 8. I received therapy from several immanent psychiatrists and psychologists, one of whom was Dr. Hunt who still runs the Center for Attention and Hyperactivity in Tennessee. My father had his masters in counseling and when Dr. Hunt suggested that my parents check me into a mental institution, forget they ever had a son, and focus their time and energy into their “healthy” daughter, my Father asked Dr. Hunt, “Why can’t you just admit that you can’t help my son?” Needless to say, this concluded our sessions with Dr. Hunt.

     My entire family worked hard to stay with me throughout my years of rebellion and boundary testing. Through the overdoses. Through the depression. Through the denial and rage. They showed me, through modeling and through actions, what it means to truly love someone. But that’s not what this post is about. This post is about the benefits and risks of medication vs alternative/holistic means of treating ADD/ADHD.  
   
     While I have ADD, I am also a marriage and family therapist who has worked with many families and individuals who’s lives have been impacted by this disorder. Some articles claim exercise reduces symptoms of ADD and it is difficult for me to think of a reason why, after consulting a physician, anyone would not incorporate exercise into their daily routine. For me, this has not been enough. Despite diet changes, added vitamins and minerals, and lots of other attempted fixes, what has worked for me is medication. I still exercise, and I should probably eat better, and at this time in my life and for the past 16 years, medication has helped control the symptoms of my ADD. It has helped me maintain my marriage and provide me with a greater amount of impulse control and levels of tolerance.

        This post is being written in reference to a twitter conversation I recently had. My decision to take medication to help with the symptoms of a neurological disorder was fairly quickly disparaged. The reply asked if I had every tried taking an art class rather than simply using medication to treat my symptoms. While my illustrations are evidence I did not pay attention, I have taken art classes. What got to me about the tweet is this: If I were taking medication for depression, would the same person have been as quick to ask if I had tried alternative means of treatment?  
     
         No doubt about it; ADD is over diagnosed and over treated. Many children are over medicated for a variety of reasons. However, this does not mean medication is not necessarily effective when used appropriately. To that extent, I would suggest more research be done in the area of diagnosing. Finding out if ADD/ADHD has a trauma or relationship attachment component to it vs. it being organic and purely physical. More accurate diagnosing for many disorders may play a key role in allowing doctors to target treatment and medication in order to treat the person rather than just treating symptoms while having very little etiological understanding.

        In the meantime, let me tell you a story about a friend of mine who was in high school with me and had been diagnosed with ADD and refused to take medication. When I asked why he chose not to, he stated that he didn’t want to and it felt weird. I asked my friend why he wore glasses. He said he was near sighted and without his glasses probably wouldn’t have been able to function day-to-day. I reflected back to him the incongruence that he chose to wear glasses to correct his vision but refused to take medication to correct his neurology. He laughed me off and said it was different and complained that I didn’t understand. The truth was, I deeply understood, and wanted him to experience the same form of freedom I had.

        Medication isn’t the answer. No pill will ever make someone perfect; and if it could, it would be at the expense of their own humanity. However, unless it’s doing more damage than good, please be careful not to disparage a persons means of maintaining sanity.

Pharmacological Sanity
(C) Nathan D. Croy, 2014

Just Love.

   What hill am I willing to die on? This is an important question, and one everyone should know. For every aspect of our existence, in each phase, we will have to fight some battles. Deciding which ones are worth fighting is often more important than how many battles we win. Even if someone had an adequate amount of resources and energy to fight every battle, they would eventually run out of time. And, more likely than not, they would run out of ground (i.e., they would be on the morally wrong side of at least a few of the battles). This leads us to learn how to prioritize; figure out what matters and why. In my own life this has not always been easy. I am often overwhelmed by the moment and lose sight of context. However, an attempt at increasing personal awareness of our own priorities should be done at frequent intervals, otherwise, we may forget what is important.

      This week I read John 15:17. It quotes Jesus saying, “This is my command: Love each other” (NIV). When Christ was put in the position to summarize all of Scripture and God’s desire for our lives, he summed it up in three words: “Love each other”. That was, quite literally, the hill he died on. I will not often get into theological issues on this blog because I want it to be as inclusive as possible and, for many people, any theological statement becomes one they want to die on. I’m not interested in that. What I am interested in is my own hill. For me, the hill I am willing to die is “Love each other”.
     What I am discovering is this: love is very difficult. Trying to decipher what the most loving action or intent is in any given situation quickly reveals how limited my scope of awareness is. I am certain that I will be a failure at loving everyone. I am equally as certain that I will still try. What would it mean if you joined me?

 

Not me, nor I

    “So modern man was set up in an undeclared war upon himself. ‘Conquering ourselves’ of the Victorian nineteenth century became ‘manipulating ourselves’ in the twentieth. The human dilemma of subject relating to object…became perverted into the subject, ‘I’, exploiting the rest of myself, the impersonal object ‘It’. This sets up a vicious circle — one of the outcomes of which is the overflowing of our psychological clinics. The vicious circle can find relief, so long as it remains within this deteriorated form of the dilemma, only in the diminishing of the subject, that is, the reduction of consciousness. But alas! we cannot in the long run expect healing to come from applying more of the same disease we seek to cure.” ~ Rollo May, Psychology and the Human Dilemma (1996, p. 79)

     Read Huxley, Postman, Buber, Frankl, Kierkegaard, Nietzsche, Fromm, or a hundred other authors who focus on the existence of individuals in relation to themselves, and a theme will emerge. Primarily, I believe, this theme is ultimately one of fear. The distraction to the point of losing one’s self that May’s quote speaks about (above) is, on the surface, a form of denial. But the question that begs to be asked is this: What is it that I’m trying so hard to deny, i.e., what am I protecting myself from? The word “protect” implies threat, and the perception of a threat is met with fear.
     Denial is fear of reality. Pride is fear of powerlessness. Envy is fear of inadequacy. Gluttony is fear of poverty. Sloth is fear of failure. There may be room to disagree with me on the particulars, but the fact is this: Fear is ever present, it is only our awareness of the fear that wanes. One point I would like to be clear on is that I do not believe each of us is under a constant threat of loss or pain in some form or another. While the existence of potential for suffering is universal, the potential for joy is just as likely.
     Here’s the challenge: Find your fear, face it. If my struggle is pride, what would it mean to be powerless? If my struggle is enviousness, what would it mean to not have “it”? Am I gluttonous? What would it mean to give something away? Am I slothful? What would it mean to try and fail? If we begin asking these questions, with trusted friends and/or professionals we may discovery a bravery that we had forgotten long ago. Begin asking the question without being so concerned with the answer, and you may be pleasantly surprised at how enjoyable the challenge of fear can become.

copyright Perryscanlon.com