Emotions Matter Video: Spreading Awareness

Watch our first video, written and directed by Saleena Subaiya, MD, and produced by Anna Yeager.  In this video two women with BPD share their stories and take to the streets of New York City to spread awareness about the disorder. 


The Facts About BPD

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THE FACTS ON BORDERLINE PERSONALITY DISORDER

What is the technical definition of Borderline Personality Disorder?

  • A complex and debilitating disorder of understanding and regulating one’s own emotions that leads to impulsivity, distortions of thought, identity disturbance, stormy interpersonal relationships, rage outbursts, self-harm, self-injury & suicidality.

How does it feel to live with borderline personality disorder (BPD) from a patient’s perspective?

  • Driving an emotional vehicle that is accelerating and cannot hit the brakes
  • Riding an emotional rollercoaster with ups and downs multiple times in one day
  • Constant feeling of shame and worthlessness, and self-loathing without an identifiable trigger
  • As smart as you are, you can’t outsmart BPD

How is BPD affecting our population?

  • 6 people out of every 100 (6%) will develop this disorder in his/her lifetime
  • Men and women are equally affected
  • 10% commit suicide
  • 50- 80% have substance abuse disorder
  • 15-30% of those suffering from substance abuse disorder have BPD
  • 25 -50% of prison inmates have BPD
  • Impairment in functioning is as great as that due to bipolar disorder

How is BPD different than Bipolar Disorder?

  • In BPD there are frequent and intense rapid cycling of emotions, such as anger, anxiety and sadness that are long-standing.  BPD is more appropriately treated with psychotherapy rather than medication.
  • Bipolar disorder has episodes of mood disturbance and increased energy or activity known as mania and hypomania which persist for several days or longer and are associated with other symptoms such as physical restlessness, rapid speech, and sleeping only a few hours per night and not feeling tired. 

How are caretakers affected?

  • Studies have shown that caretakers of BPD patients suffer a significantly higher degree of grief, burden, loss of empowerment, depression and anxiety than caretakers of people with other serious mental illnesses.

What are the proven effective treatments for BPD?

  • Dialectical Behavioral Therapy, Transference-Focused Therapy, Mentalization Based Therapy, General Psychiatric Management
  • There is no proven pharmacologic therapy, yet patients are often on multiple medications

What are the societal issues people suffering from BPD are facing?

  • Stigma that those suffering are “acting out” and manipulative
  • Lack of recognition that this is a real disorder leads to lack of diagnosis
  • Although there are effective treatments, many areas lack trained therapists
  • BPD gets 1/10th the funding of bipolar disorder from NIMH, yet is at least as prevalent
  • BPD is not a billable diagnosis and therefore does not get covered by insurance

 

References

  • Bailey, RC. Burden and support needs of carers of persons with borderline personality disorder: a systematic review. Harv Rev Psychiatry. 2013; 21: 248 – 58.
  • Ball SA, et al. Personality, temperament, and character dimensions and the DSM-IV personality disorders in substance abusers. Journal of Abnormal Psychology. 1997; 106: 545 – 553.
  • Cacciola JS, et al. Psychiatric comorbidity in patients with substance use disorders: do not forget Axis II disorders. Psychiatry Annals. 2001; 31: 321 – 331.
  • Grant BF, et al. Prevalence, correlates, disability, comorbidity of DSM-IV borderline personality disorder:results from the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 2008; 69: 533 – 545.
  • Marco, Jose H, et al. Meaning in Life in People with Borderline Personality Disorder. Clinical Psychology& Psychotherapy (2015). Doi: 10.1002/cpp.1991.
  • National Institute of Mental Health. (2016). http://www.nimh.nih.gov/health/statistics/prevalence/bipolar-disorder- among-adults.shtml
  • Trull TJ, et al. Borderline personality disorder and substance use disorders: a review and integration.
  • Clinical Psychology Review. 2000; 20: 235 – 253.
  • Zimmerman, Mark. Borderline Personality Disorder: A disorder in search of advocacy. J. Nerv. Ment. Dis. 2015; 203: 8 – 12.

Aspects of the Disorder Explained

The Disorder

Some Aspects of the disorder explained

Basics of Emotion Neurobiology
The amygdala is the emotion-processing center and the prefrontal cortex is the brake pedal for the amygdala (the control center for emotions).  People with BPD have an overactive amygdala, experiencing emotions to an infinitely greater degree than the average person, and an underactive prefrontal cortex leading to unregulated emotions.  Their sympathetic, fight or flight, system is on overdrive and they go from zero to sixty on the emotional scale within a few seconds with a slow return to baseline.  Those around them do not understand why their emotions are heightened because their healthy brains do not allow them to experience emotions at this level of intensity.

Impulsivity 
Impulsivity is a hallmark feature of BPD.  When self-injury or drug abuse is involved it is often misconstrued as an intended suicide attempt; however, its purpose is to regulate unbearable emotional states.  Non-suicidal self-injury such as cutting, substance abuse and unsafe sex are some of the ways individuals cope with their emotional pain.  When describing cutting episodes, many say that they do not realize they’ve cut until the episode is over.  The emotional pain is so tremendous that the mind shuts down until it is completely distracted by physical pain.

The Negative Bias & Rejection Sensitivity
People living with bpd have impairment in the evaluation of neutral facial expressions and attribute more negative emotions to such expressions.  A mere neutral facial expression can generate a negative feeling such as disapproval or disgust.  These feelings are taken personally which then leads to emotional instability.

They have an elevated expectation of being rejected and ruminate about this expectation.  When rejection is perceived they react intensely towards it either with extreme anxiety or anger.  This often leads to avoidance of situations that will create rejection, which propagates social isolation.

For example, if Danielle who has BPD is waiting for her friend Hannah to meet her for dinner and Hannah is running late Danielle will begin to think that she is a loser and not worth a friendship.  These feelings will build to an extremely negative point where she may do something impulsive such as drive away recklessly or cut herself.  

Memory Impairment
Areas of the brain responsible for processing emotional stimuli overlap with areas associated with learning and memory.  The limbic system houses areas of the brain including the amygdala and hippocampus.  It supports functions such as emotion, behavior and long-term memory.  Studies of individuals with BPD have shown decreased hippocampal volume, the memory storage area of the brain.  

We have always learned that it is easier to remember something that is tied to an emotion than something that is not.  People with BPD have an elevated susceptibility to attend to and to store emotional information.  Given that people with BPD are often in a negative state of heightened emotions, they tend to remember content tied to these states.  This negative emotional content is more likely to transfer into long-term memory and consolidation, allowing for its better recall.  Unfortunately, the storage of emotional content comes at the expense ofnot storing other non-emotional content.  

For example, Danielle and her brother Nicholas grew up in a loving household where their father always gave them a hug and kiss before he left for work in the morning.  One morning when Danielle (7yrs old) and Nicholas (9yrs old) were eating breakfast before school and their father gets an emergency call from work requiring him to rush out of the house.  Their mother quickly helps him put his coat on and gives him his car keys and he yells goodbye and jets into his car.  Danielle feels rejected and insignificant to her father that day because she did not get a hug and kiss from him.  She ruminates about it all day and interprets this as not being loved by her father.  Nicholas doesn’t think anything about it and by the time they are grown up he has no recollection of the event.  Danielle, now age 20, still recalls that day when dad never said goodbye.  She’ll compile similar negative memories in her life and may even think that her father was never there for her.

Identity Disturbance
There are many different aspects of the self that play a role in identity.  Some of which are the ability to identify our feelings, identify the feelings of others, memory and level of self-esteem.  Individuals with BPD experience alexithymia, which is the inability to identify their own emotions.  The very heightened emotions they express outwardly are unidentifiable inwardly and they often cannot identify the emotions of those they are unintentionally hurting.  They in turn lack the tools to sympathize, converse and apologize.  The memory impairment they experience (explained above) creates a negative life narrative with missing important information.  The aforementioned traits play into having low self-esteem and an overall feeling of worthlessness.

Mentalization 
Peter Fonagy, one of the founders of mentalization, describes it as “the ability to understand others in terms of their thoughts, feelings, wishes and desires.” In other words, it is the ability to reflect on a situation and entertain other viewpoints.  Mentalizing is crucial for successful interpersonal relationships, regulating emotions, building a sense of self and personal security.  In BPD, mentalizing is deficient.

Danielle in the above example is unable to entertain alternative thoughts that may be going on in Hannah’s mind.  Hannah may be thinking about how stressed she is that she cannot make it to dinner on time, how sorry she is for making Danielle wait, how much she is looking forward to having dinner and catching up with Danielle.  Immediately Danielle feels rejected and thinks Hannah does not value her at all and stays with this sentiment without offering herself reflection.

Mentalization based therapy teaches the individual to examine his/her interpretation of the scenario based on external features and then generate possibilities about the internal states of mind.  It slows down the individual and encourages him to be mindful of his assumptions.

Shame 
Shame is one of the major characteristics of BPD.  It is defined as a painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior.  It differs from guilt in that it is a feeling of the whole self and guilt is a feeling about a situation.  Individuals with BPD feel shame most of the time for no identifiable reason.  Some argue that shame is the underlying feeling behind chronic suicidality, self-injurious behavior, anger and impulsivity.  It can lead to avoiding social situations or other situations where it may be provoked.

Sleep Disturbance
Individuals with BPD have a different sleep structure than healthy individuals.  They have decreased REM latency and total sleep, more stage I sleep and less stage IV sleep.  Individuals themselves report reduced total sleep quality and sleep time, decreased sleep efficiency, feeling significantly more exhausted and a worse evening mood.  Studies also show that they suffer a greater rate of nightmares, higher levels of dream anxiety and more disturbed sleep than normal individuals.

Functional Impairments
Studies have shown significant impairment across the full range of traditional neuropsychological testing which includes attention, cognitive flexibility, learning and memory, planning, processing speed and visuo-spatial abilities.  Overall the level of intelligence has remained equal to those without BPD.  Individuals with BPD have trouble making a decision when there is a scenario with many options.  It becomes easier to make decisions when there are few options without any ambiguity.  The orbitofrontal cortex and the anterior cingulate cortex are areas of the brain responsible for decision-making and they have found to be impaired in those with BPD.

 

Misconceptions

They are manipulative

The reality is that the individual is engulfed in misery and pain and will do anything out of desperation to anesthetize his feelings, including resorting to intolerable behaviors.

BPD can’t be diagnosed in adolescence or childhood

The major problem is that BPD is often diagnosed too late, after the individual has made detrimental life decisions. Almost all individuals exhibit signs of BPD by adolescence. It can be seen in infants who have sleep disturbances and children who have temper tantrums that are disproportionately longer and more frequent than the average child. Recently articles have been published supporting the case that which BPD can be diagnosed before the age of 18.

All BPD patients have been abused

Although a history of abuse can lead to the development of BPD, this is not always the case. Parents often feel shame about their child’s diagnosis because of this. There simply have not been enough studies proving the other reasons for the development of BPD. There are some genetic studies attempting to identify the BPD gene that are currently underway.

They are untreatable or treatment resistant

There are effective treatments such as DBT, Mentalization based thereapy (MBT) and Transference Focused Therapy (TFT) that when given by trained clinicians have been proven to be effective. In addition to effective treatment given by clinicians, family members play a huge role in recovery. This is an interpersonal issue and when families learn to understand the disorder and create a more validating environment individuals become less dysregulated and are more likely to stay in therapy.

Medications are effective

Although it is worth trying various medications to manage symptoms of BPD, such as anxiety and depression, there have not been any large studies proving that medications are helpful. Despite this most individuals are on multiple unhelpful medications and suffer from their side effects.


Treatment

Treatment

Therapies Explained

Dialectical Behavior Therapy (DBT)
The definition of dialectic is to weigh and integrate opposing viewpoints with a goal to resolve apparent contradictions.  DBT is a form of cognitive behavioral therapy whose goal is to balance change with acceptance.  It includes four sets of behavioral skills that are mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation.  The most standard form of DBT includes a skills training group, individual therapy, phone coaching and therapist consultation team.

Mentalization Based Therapy (MBT)
Peter Fonagy, one of the founders of mentalization, describes it as “the ability to understand others in terms of their thoughts, feelings, wishes and desires.” In other words, it is the ability to reflect on a situation and entertain other viewpoints.  The core of MBT is to teach someone how to mentalize.  MBT consists of twice per week sessions alternating between individual and group therapy.

Transferance Focused Therapy (TFP) 
TFP is based on the belief that images of oneself and of influential people over the course of growing up create the psychological structure and that these images are distorted in BPD.  This psychological structure is usually in the subconscious and becomes the lens through which the person interprets life experiences.  In TFP the individual with BPD experiences and lives out the internal images that make up his psychological structure in his relationship with the therapist which in turn familiarizes the individual with the images in his own mind and resolves the conflict.

General Psychiatric Management (GPM)
GPM is a once-weekly therapy that includes prescribing medications and family interventions.  Developed by John Gunderson, MD, the therapy tries to create a “containing environment” in which individuals with BPD can learn to trust and feel.  This therapy requires clinical experience, but is the least theory-bound and easiest to learn of the empirically validated therapists for clinicians without extensive training.