Reviewing Borderline Criteria Part 3

This is part three of the blog series reviewing the criteria for Borderline Personality Disorder, or Dyslimbia, according to the new DSM V (Diagnostic and Statistical Manual of Mental Health Disorders). First, we looked at category one, “Problems in Personality Function,” which was divided into two groups: problems with the self and problems functioning with others. Difficulties with sense of self, problems with empathy, and problems with intimacy were included, covering criteria 1, 2, 3, 7, and 9 in the older DSM IV. Next we started to look at category two, “Pathological Personality Traits,” which is divided into three groups: Negative Affectivity, Disinhibition, and Antagonism. Last time, we focused only on Negative Affectivity, which included emotional liability, separation insecurity, anxiety, and depression. Let’s move on.

Category 2, Group 2: Disinhibition and Risk Taking

Inhibitions are thoughts and feelings that inhibit (prevent) certain actions. Your inhibitions prevent you from doing foolish or unsafe things. You should have inhibitions preventing you from stealing, for example. It follows that “Disinhibition” is when your natural inhibitions are not working. A similar concept is “impulsiveness,” the tendency to do something on impulse rather than thinking it through. Recklessness, or taking risks on purpose is closely tied to this. People with Dyslimbia traditionally have a lot of problems in these areas.

Examples of disinhibition are promiscuous sexual life, binge drinking, impulsive drug abuse, self-injury such as cutting, spending sprees, gambling, yelling at someone or impulsive speech, and in extreme cases, vandalism and violence. In college, I binged on alcohol quite often in my second and third years. This happens to many college students, though, so I’ll give some other examples. There were a few times in my life when I had sex without protection, which could have easily been disastrous. I had a cutting problem from age 18 until just last year, when my antidepressant kicked in and made me less inclined to do it. I have done some drugs on impulse before just to escape negative feelings. All these examples together show that I had a real problem with disinhibition and recklessness.

Category 2, Group 3: Antagonism.

Antagonism is also called hostility and is described in the DSM as, “Persistent or frequent angry feelings,” or “anger or irritability in response to minor slights and insults.” People with Borderline experience many emotions, but it’s often said that one of the strongest and scariest of those emotions is anger. We feel angry more often than we should, and/or our anger is felt more deeply and strongly than it is by “normal” people. Anger in Dyslimbia patients is often blown out of proportion; that is to say, the smallest things can set us off into fury under the right circumstances.

Extreme anger is something I have dealt with frequently from a very young age. I am fairly good at controlling it in public or around other people, but I let loose when I’m by myself. I curse, yell, growl, punch things, and kick them too. I have a history of breaking things in my home. For me, the rage comes on suddenly, and can be triggered by the smallest things, such as the computer freezing up, sudden loud noises, failing to understand a school subject, and behavior problems with my cat or dog. The rage is very difficult to control, but fortunately, it rarely lasts longer than a few minutes at a time. Appropriate ways to deal with these outbursts are tearing up cardboard boxes, hitting a punching back, going for a run, or listening to music that you can empathize with. Hostility is a problem I still struggle with each day.

So far we have covered Category 1, “Problems in personality functioning,” and Category 2, “Pathological personality traits.” This post has covered symptoms 4 and 8 in the old DSM IV criteria. The last three elements of Borderline diagnosis are straightforward, and rather than lists of behavior problems, they are simply conditions that must be met to be diagnosed. Category three says that the symptoms listed in the other categories must be chronic, long-term problems that happen in many different situations, rather than just having a hard time in your life for a few days or weeks in a handful of situations. Basically, it has be a recurring issue.

Category four says that the symptoms listed above must not be due to factors such as the individual’s age or “socio-cultural environment.” Teenagers are often impulsive and disinhibited, for example, so people under eighteen cannot be diagnosed with Borderline Personality Disorder. The patient must be suffering the symptoms not because of his age but because of a distinct disorder (Dyslimbia). People in crime-ridden parts of cities may be more likely to abuse drugs or engage in other reckless behavior that shows disinhibition. A person can only be diagnosed with Borderline if his or her symptoms are not simply due to a bad environment. Similarly, low income families or social minorities often have symptoms of anxiety, depression, and hostility. To be diagnosed with Borderline, the symptoms must be not be caused by environment alone.

Category 5 says that the symptoms listed above are “not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).” In other words, if your symptoms can be explained by a head injury or by being on drugs, you won’t qualify for a diagnosis of Dyslimbia. Instead, you must exhibit the symptoms when not on drugs and without head injury or similar physical trauma.

We have covered all of the symptoms of Borderline Personality Disorder as described in the new DSM V. These include identity issues, difficulties with self-direction, problems with empathy, problems with intimacy, depression, anxiety, overblown emotions, separation insecurity, disinhibition, and antagonism. Now that we know the criteria for Borderline Personality Disorder, we can begin discussions on how to deal with it, and what’s it’s like to live with it in daily life. Thank you for joining me for this blog series.

Reviewing BPD Criteria Part 2

Review

In the last post, we started to examine the criteria for Borderline Personality, or Dyslimbia, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The defining traits are categorized into 5 sets: 1) Problems in “personality functioning,” 2) “Pathological personality traits” and three other categories that are conditions of the disorder’s appearance. These I will briefly cover after we examine categories one and two.

Category 2: “Pathological Personality Traits”

We reviewed category one last time, “personality functioning,” which was separated into problems with self and problems with others. Next we will take a look at category two, “pathological personality traits,” which are negative, recurring emotional and behavioral traits caused by mental illness. This category is broken into three sub-categories: negative affect (negative emotions, habits, and thoughts), disinhibition (impulsiveness), and antagonism (hostility).

Cat. 2, Group 1: Negative Affectivity

Easily Aroused Emotions

Under negative affectivity, the DSM lists emotional liability, anxiety, separation insecurity, and depression. Emotional liability refers to “Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.” One of the biggest problems for Borderlines is the occurrence of mood swings. The smallest things can change us from a good or neutral mood into livid irritation, frightening panic, or overwhelming hopelessness. The most insignificant of comments can make us suddenly terrified that we are being abandoned or fill us with a nagging craving for comfort resulting in neediness.

An example that reoccurs in my life is shame associated with depression. If I’ve done something wrong, such as snapping at a family member, telling a lie to get out of something, or failing to meet a self-imposed deadline, I usually own up to my mistake pretty quickly and try to make amends. That doesn’t stop the feelings, however. I become so depressed that I can’t do anything but lie in bed for a few hours, and I become so ashamed that I have urges to cut myself in order to punish myself for doing that one little wrong.

Disproportionate Emotions

For those with Dyslimbia, mood swings can be debilitating, interfering with everyday activities and messing up our relationships. Not only do our moods change easily, but the emotions we experience are often on a whole different level compared to those without Borderline Personality Disorder. Many people with this condition say that their problem is feeling too much. We are the people who feel like it’s actually the end of the world when people say it’s not. This what the DSM means when it says our emotions are out of proportion for the situation. Here are a few personal examples.

After a serious breakup, it would be normal to be depressed and maybe even see a counselor if it continues. However, after my last breakup, I attempted suicide and was barely saved. If someone tells me there’s a storm going through the area where my sister lives, I get so anxious that I feel sick, my heart races, and I start thinking, “What if she dies?” Some worry would be normal, but panic is not normal for such a situation. This last example kind of goes under group three, antagonism, as well, but here goes. I get insanely angry over the tiniest things. Knocking something over or spilling a drink can make me so angry I hit things or break things. If I read about people who are cruel to animals, I experience detailed fantasies of killing them and their families, images that are difficult to “turn off.”

Separation Insecurity

That pretty much covers the emotional liability piece. Now, we’ll take a look at separation insecurity. We often don’t like to admit it, and not everyone with Dyslimbia suffers this symptom acutely, but the majority of us feel like we simply cannot deal with abandonment or rejection. I’ve already given the example of trying to kill myself after I was suddenly dumped in my last major relationship. Long before that, the initial trigger that started my self-injury habit was being dumped by my first boyfriend. It isn’t just lovers that we can’t handle. The person who I considered to be my best friend rejected me and stopped all contact with me because of my atheism. It’s been almost two years since then, and I still think of her, missing her acutely, every few days. At first, I had thoughts of stalking her because I couldn’t deal with the separation. It felt, to me, like one of my own sisters had died. In reality, all that happened was I lost a friendship, which was for the best anyway because she was rather bigoted.

The DSM describes separation insecurity as, “Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.” In other words, because we fear abandonment so much, people with Borderline often feel like they will no longer be able to function or no longer to able to live if that person leaves us. That is what’s meant by “loss of autonomy.”

I can’t speak for everyone with Borderline Personality Disorder, but for me, I have never yet been able to live for my own sake. I require a loved one to live for, or else my life is worthless. Although I am trying to conquer this mindset in therapy, it still holds true for now. With no significant other, I am currently living for the sake of my Dad, who already suffers periodic depression and would never recover if I killed myself. All that to say, when the one person we have been living our lives for suddenly leaves us, our worlds are destroyed. In a spiritual sense, it is like we die each time our significant other leaves us, and we must start life again from scratch afterward. Speaking for myself, I was never autonomous to begin with.

Although the new DSM V does not mention this, the old DSM IV pointed out something else about Borderline separation insecurity: sometimes we believe we have been rejected or abandoned when, in reality, that hasn’t happened. This is extremely difficult for Dyslimba patients to admit, because while our logical minds are telling us that no evil was done to us, our powerful emotional minds are screaming at us that we’ve been cruelly forsaken.

An example from my life is when my good friend (with benefits) dropped out of the college we went to and returned to his hometown. Since he had been doing poorly in school for several semesters, and frequently voiced the opinion that he didn’t like his major, it should not have been unexpected that he dropped out. However, for a while there, I firmly believed he left the school because he was sick of me, and even though we were not in a committed relationship, I believed that he had abandoned his responsibility to stay with me. (A lot of time has passed since then and though we do not often talk, we are on friendly terms and I have apologized for my neediness.)

Anxiety

Anxiety and depression are negative emotions in the negative affectivity group. Literally speaking, this refers to transient (temporary) feelings; however, it’s also well-known that clinical mood disorders often co-occur with Borderline Personality Disorder. “Comorbidity” is the presence of two or more disorders at the same time in the same patient. Major Depressive Disorder (AKA clinical depression), Generalized Anxiety Disorder, and many variations of anxiety such as Social Phobia can be comorbid with Dyslimbia. But whether they are temporary feelings or full-on disorders, depression and anxiety are difficult to deal with either way.

I have Generalized Anxiety Disorder, and as a result, I never stop worrying, even about the smallest things. I have experienced panic attacks, which are harmless but extremely frightening; you actually feel as if you are going to die. Anxiety about upcoming social situations and anxiety about school were the main triggers in the past. (Now, I manage my anxiety with medication, and do not experience panic attacks.) DSM V also mentions “fears of falling apart or losing control” under anxiety. I don’t know if this is the case for everyone with Dyslimbia, but one of my biggest fears is losing control of myself and doing something terrible.

Depression

Depressivity is described in the DSM V as, “Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.” Which of these symptoms show up and how strong they are varies by individual with Borderline Personality Disorder. For me, all of them are applicable.

I have Major Depressive Disorder comorbid with my Dyslimbia, and when I’m not panicking or raging, you can count on me to be depressed in bed, unable to motivate myself to function. Ultimately, this led me to seek help from Social Services (Disability). My emotions and my spirit tell me that both my situation and the world at large are hopeless, beyond redemption. While the logical part of my brain disagrees, it is not strong enough to overcome the feelings most of the time. As for pervasive shame, I am a professional at self-loathing. There is no one in this world that I hate more than myself. I believe that, objectively, someone like me deserves to be killed.

I already gave an example of my suicidal behavior. There have been five instances where I set out with the intention of taking my own life, though only two were fully thought-out plans (which failed or were interrupted, resulting in hospitalization). Not everyone with Dyslimbia has tried to kill themselves and some will never go that far. However, pretty much all of us suffer from recurring thoughts about suicide. My preoccupation with thoughts and wishes for my death was termed “suicidal ideation,” by my psychiatrist, and the thought pattern became deeply ingrained within me even when I had absolutely no intention of acting on such thoughts.

Fortunately, modern medicine, along with therapy and support, can usually correct this problem over time. After trying no less than fifteen different antidepressants, I finally found that taking and staying on Zoloft significantly reduced my suicidal ideation. It was actually pretty amazing. For four and a half years, I was tortured by suicidal ideation. But by the sixth week of being on zoloft, suddenly my mind didn’t want to keep wasting time thinking about dying. I have passing thoughts related to suicide once or twice a week, but they are never strong ones anymore. Starting in September 2016 and on, I no longer want to kill myself (though I would deserve it if I happened to die). Note that Zoloft is only the medicine that worked for me, and the one that works for you may be different.

Alongside “Thoughts of suicide and suicidal behavior,” the old DSM IV used to include “selfmutilating behavior,” AKA self-injury such as cutting. The new DSM V does not list self-harm as a criteria for Borderline anymore. However, it is a symptom of many who suffer from the disorder, and I feel that it goes hand in hand with discussions of negative affectivity and depression. Self-harm includes such habits as cutting oneself with a blade such as a razor or knife, and burning oneself with lighters, cigarettes, hot objects, or hot liquid. There are many faces of self-harm and I don’t want to go into detail for fear of triggering someone.

There is no one absolute reason for why people self-harm; the reason depends entirely on the specific person. One thing that is fairly true across the board, however, is that cutting grants some form of immediate gratification, whether you were after the pain, the scar, the sight of blood, the feeling of punishment, or any other reason. People with Borderline Personality Disorder have a long-standing reputation of falling prey to various forms of immediate gratification where an alternative with delayed gratification would be healthier. You could say we have addictive personalities. That makes us much more likely than the average population to form a habit of cutting.

This information covers symptoms 1, 5, and 6 in the old DSM IV. Thank you for taking the time to explore the symptom of Negative Affectivity with me. Next time, we will cover Disinhibition (impulsiveness) and antagonism, which are also included in Category Two, “Pathological Personality Traits.”

Reviewing BPD Criteria Part 1

The Diagnostic and Statistical Manual of Mental Disorders (the DSM) is the book used by psychiatrists to identify and diagnose patients with psychological problems and mental illnesses. The world of Psychiatry is constantly changing, so every now and then, a new edition of the DSM is published to provide needed updates. The fifth edition, the DSM V, came out on May 18, 2013. There were many changes to many different disorders, and among those was Borderline Personality Disorder, which I often call Dyslimbia. Most of what changed was the format of the diagnosis process rather than the symptoms themselves. Even so, I think it would be appropriate to review the DSM V’s criteria for Borderline Personality Disorder.

The defining traits are categorized into five sets: 1) Problems in “personality functioning” which is then divided into two categories, problems with self and problems with others. 2) “Pathological personality traits” (recurring emotional and behavioral traits due to mental illness), which is then broken into three categories: negative emotions, disinhibition, and antagonism. The other three categories are simply conditions of the disorder’s appearance, which I will briefly cover after we examine categories one and two. For the purposes of this blog post, we will examine category one. Next, we will examine the second set of symptoms as well as the three conditions attached to the symptoms. By breaking everything down, we will be able to see the symptoms in detail.

Category 1: Personality Functioning

Cat. 1, Group 1: Problems with Self

Problems with self include identity issues and difficulties with self-direction. Symptoms under identity issues include the feeling of not knowing who you are, feeling like your identity changes a lot, beating yourself down with criticism, feelings of emptiness, and, of course, “dissociative states under stress.” (See my blog series about dissociation if you don’t know about it.) As for self-direction, this refers to how people with Borderline have unstable or frequently changing life plans, interests, dreams, or even morals.

I will provide examples from my own experience as someone suffering from Borderline Personality Disorder. Throughout my entire life, I have beaten myself down with criticism, never believing in myself. Even when I won writing contests in college, even when I was constantly among the top students in my college classes, I still felt like I wasn’t doing enough and that I was actually an unintelligent person. Developing a solid sense of self (who I am) took years, since I often thought, said, and acted on completely different values. I was only able to find myself by dissociating and thinking of myself as being five “personalities” (or five different mindsets) in one person. At any given time, I am a mix of two or three of those five sides of me. Figuring out who you are, when different sides of you seem so completely incompatible, is a common struggle for those with Dyslimbia.

(For a time, in college, I also frequently experienced dissociation such as depersonalization, derealization, and even a few isolated cases of dissociative amnesia. These symptoms are under control now. If you’re curious about dissociation and what it means, see my blood series about dissociation.)

Cat. 1, Group 2: Problems with Others

Interpersonal issues have been split into problems with empathy and problems with intimacy.

People with Borderline Personality Disorder are perfectly capable of empathy, and in some cases, I believe we can be more empathetic than normal people given our heightened capacity for emotions. Nevertheless, when we are under stress or having mood swings, we have trouble understanding what others are actually feeling and what they need. Borderlines have a strong negative bias, often believing that others think negatively of them when no such negative feeling exists. To some, this interpretation bias could be considered a lack of empathy.

Here’s two examples you may be able to identify with. We’ll start small. The other day, I decided to wear mascara even though I very rarely wear any makeup. When my sister later asked if I was wearing mascara, I didn’t want to answer. I wanted to lie. To me, it seemed obvious that my sister had seen how bad I was at putting on makeup, and she was going to criticize me. However, I read my sister completely wrong; she actually wanted to say that the mascara looked good on me. With my negative bias, that never even occurred to me.

A more extreme example is my relationship with my father. Time and time again, I believe that he resents me or thinks poorly of me because of my inability to hold down a job. Often, I go for a few days without having any real talk with my father, even though we live together, because I feel like I “know” that he is disgusted with me. When I finally work up the courage to talk to him again, and I mention feeling useless, he is always supportive. He tells me that he knows I am trying, that I’m getting psychological and psychiatric help, and that he’s glad he is able to live with me. This never ceases to amaze me, since I always go back to thinking that he must think badly of me.

As for intimacy, this refers to the Borderline’s “intense, unstable, and conflicted close relationships.” Symptoms and markers include being distrustful, having fear of abandonment, sometimes interpreting things as abandonment that are actually not, and being too needy. In addition, there is the phenomenon sometimes called “switching,” where the person with Dyslimbia switches between idolizing someone and intensely hating someone. Having more balanced feelings toward someone is difficult for us; we are do-or-die, hate or love, worship or revile. Sometimes the intense feelings of loving someone result in becoming too obsessed with them and their lives, while the feelings of great dislike can result in complete withdrawal from the relationship.

For a classic example of the “switching” phenomenon, look at my first major romantic relationship that went on from age nineteen to twenty. While it is natural to absolutely adore one’s significant other, my idealization of my boyfriend and my emotional reliance on him reached unhealthy levels, to the point where he was my only support system. (Friends and family were out of the picture.) When that boyfriend broke up with me– and it was rather sudden from anyone’s viewpoint– I felt so hurt and angry that I refused to talk to him. I badmouthed him to everyone I knew. I wasn’t able to stop hating him until a full two years later, and even then, our friendship was sensitive and rocky. This is only one example of a lifelong pattern.

In addition, when I feel I have been abandoned, it destroys my world, leading to self-injury and long episodes of Major Depressive Disorder. It has been almost two years since my best friend stopped speaking to me because she no longer wanted to be friends with an atheist; two years have passed, and I still think of her and miss her every few days. This preoccupation with abandonment is a classic symptom of Dyslimbia.

That’s all for Category 1, Problems in Personality Functioning. This category covers the symptoms that were numbered 1, 2, 3, 7, and 9 in the older DSM IV. Next time, we will examine category two, “Pathological Personality Traits,” which includes three groups of symptoms: negative emotions, impulsivity, and hostility.

The Wisdom of Mindfulness

Introduction to DBT

Ever since I experienced the onset of Dyslimbia/Borderline four years ago, I have consistently looked to therapy and psychiatry for help. For a long time, nothing seemed to be improving. This is not uncommon for people with Borderline; in fact, until about twenty years ago, many people believed that Dyslimbia symptoms hardly improve, if at all,  by using therapy or medications. Then, sometime in the 1980s, Dr. Linehan developed a promising new treatment: Dialectical Behavior Therapy.

If you have Borderline Personality Disorder or if you know someone who has it, you may already be aware of Dialectical Behavior Therapy, or DBT for short. Nevertheless, I will explain this treatment in case you have no clue about DBT. It’s a type of talk therapy that can be used one-on-one with a counselor or discussed in group settings. According to The Linehan Institute, DBT was developed especially for people suffering from Borderline Personality Disorder. The four main teachings of DBT are Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation, In other words, it teaches people to live one moment at a time, calmly handle distressing thoughts or events, communicate well with others, and learn how to redirect or effectively “control” emotions.

Many people report improvement from DBT, and even the American Psychiatric Association supports it efficacy, even publishing a book about the treatment. Just because DBT produces good results does not mean it’s an easy process; in particular, many people struggle with understanding Mindfulness. Many dislike it at first, but Mindfulness is one of the key principles in DBT, so it’s necessary.

What is Mindfulness? 

Mindfulness has various forms, including the practice of meditation. In the words of Dr. Arnold, Mindfulness “is an awareness of thoughts, feelings, behaviors, and behavioral urges.” It is the ability to observe, describe, and participate in each moment, appropriately and non-judgmentally. For a common example, take meditation. Many meditations require you to focus on your breathing while being aware of your physical body, thoughts, and feelings. The more you do this, the more you train your mind to recognize and calmly observe facts about yourself and the world around you.

Ultimately, Mindfulness is about awareness. With awareness comes knowledge, and with knowledge comes power. You cannot beat an enemy you know nothing about. In the same way, you cannot beat troubling Borderline symptoms without knowing yourself and how your mind and body work. Some people (like myself) take a long time to “catch on” to Mindfulness, and it’s a little bit different for each individual. I will share my own experience with this more abstract form of therapy.

I used to be one of those people who didn’t really believe that Mindfulness would help. At first, I thought it was all about meditation, which has never worked for me, even with professional help. I also doubted that something so abstract could really produce results. Both my arguments, though, were eventually laid to rest.

First, Mindfulness is not a lofty, metaphysical practice. According to studies, it can significantly change people for the better, right down to literally changing their brains (Holzel 2011). Secondly, Mindfulness is not “all about meditating”; it’s about living in the moment, and finding a way to do that works for you, the individual. I discovered that I can practice Mindfulness with Writing Meditations. I focus much better when writing and am less likely to get overwhelmed and quit compared to traditional meditation. If you can’t sit still, you can try walking meditations. If you get distracted from the present moment, it doesn’t mean that you are doing it “the wrong way”… simply by being aware of the fact that you are distracted, you are being Mindful of your thoughts.

How Mindfulness is Starting to Help Me

Although I first learned about Mindfulness over two years ago, I only started to really understand it a few months ago, when I began attending a new DBT Group. So, what does it do for me, you ask? So far, it has helped me on two fronts: more awareness of my physical body, and more control over racing thoughts. Normally, I don’t pay enough attention to my body, and I don’t go out of my way to meet its needs. With mindfulness, I’m better able to locate and define chronic pain, and with that awareness I am learning to do things to appropriately soothe my pain. Better pain management leads to better mood, in general, for me. Then there is the part about my racing mind.

Many people with occasional or clinical anxiety report “racing thoughts,” and for me, this symptom is even more extreme. All kinds of thoughts, from bizarrely random to severely troubling, race through my mind and disappear from my short term memory almost as soon as they appear. This is why I can’t meditate without writing: writing allows me to “catch” and “pin down” some of those crazily spinning thoughts. Thanks to the writing exercises, I know my own mind better, and I feel like it’s getting slightly easier to keep my thoughts in order.  These improvements may be small, but I wouldn’t be surprised if continued Mindfulness practice started helping me in big ways, too. In the meantime, remember: even a baby step is still a step. Mindfulness is a great way to start taking baby steps.

References

1. American Psychiatric Association. “Practice Guideline for the Treatment of Patients with Borderline Personality Disorder.” Book. 2001.
2. Hölzel, Britta K., et al. “Mindfulness practice leads to increases in regional brain gray matter density.” Psychiatric Research 191(1): 36–43. Academic journal. 2011.
3.  “What is DBT?” The Linehan Institute Behavioral Tech. Web. 2016.   >http://behavioraltech.org/resources/whatisdbt.cfm

Stigma and Mental Health

According to the Government of Western Australia Mental Health Commission, three fourths of those with mental illness have suffered from stigma. When a group has stigma attached to it, that means society thinks of them as abnormal or negative. In the case of mental illness, stigma causes stereotyping, misunderstandings, discrimination, and sometimes even hatred toward those with an illness. Borderline in particular has a lot of stigma attached to it, because people with Borderline are harder to understand and get along with than the general population.

How to Help Stop Stigma

Learn! The best way to help stop stigma is to learn the truth about mental illnesses so you have a better understanding. Don’t discriminate against someone with a disease, and if others exhibit prejudice, try to gently correct them. If you know friends or family members with mental illnesses, be sure to support them, because they may not be getting support from society. It’s best if you can learn from these people firsthand about how to treat them. It’s also a good idea to be open to sharing your own experiences to find out what feelings you might have in common with those who are stigmatized.

What Not to Say

Along with not discriminating, learning the facts, sharing the facts, and getting to know those with mental illness, there are a few things I would advise you about. There are certain things to avoid. Some should be obvious. It should be obvious that, until you know how a person feels, you should avoid any jokes or teasing about a mental health problem. Here are a few other tips for communicating with or about people with mental illness.

1. Don’t make it sound like the person is at fault for their illness. Even if this were true, it would not help your relations to say things like that. Likely, your friend or family member already suffers guilt for having a disease, and being reminded of this is not helpful for anybody.
2. Don’t make assumptions about the “cause” of a person’s illness. A common myth is that psychological disorders are entirely genetic. On the other hand, it’s also a common myth that a single life event or trauma must have caused the illness, such as a car crash or a shooting. In reality, most mental illnesses come from a combination of environmental and biological factors. Long story short: it’s not simple.
3. Don’t imply that the person is wrong for seeking help for their illness. Some people tell those with illnesses that they are just being labeled, that psychotherapy is unhelpful, that medications are a conspiracy, or that whatever problems they are having must be in their diet or should just be treated by a primary care doctor. Some of those things may be true for some people or in some cases, but the process of mental health treatment is different for everybody.

Sense of Self Part 3: Support Your Sense of Self

“Identity disturbance” is a benchmark symptom of BPD, characterized by “markedly and persistently unstable self-image or sense of self.” This sense of not knowing who you are can manifest in many ways, and many people with Dyslimbia struggle to cope. In this blog series, we’ve discussed the importance of directional thinking and coming to understand and predict your own behaviors. In this final part, I’m throwing together some of my miscellaneous thoughts about Sense of Self.

Self-Affirmation

One of the best ways to continuously encourage and strengthen your sense of self is to affirm it. Self-affirmation means honestly complementing yourself. Some people struggle with this—myself included. It can feel so silly to self-affirm, and I have such a hard time believing what I’m saying, like that “I’m attractive” or “I’m a good person.” Most days I don’t really believe I’m worth anything. In order to combat this, first find a method of self-affirmation that you can live with, and then repeat it enough so that you slowly start to accept it.

Someone recommended that I look at myself in the mirror every day and say my self-affirmation aloud; I couldn’t stand doing this! Instead, what I try to do is write out examples of when I’ve done things worth being proud of; and in my journals, I frequently assure myself that I’m doing the right thing and that I’m a good person. Find a form of self-affirmation that works for you. Though you may have to force yourself to do it on most days, if you self-affirm enough, your mind will slowly start to believe the things it hears.

Friends and Family

You will never have a stable sense of self if you are not in a supportive environment. Even if you were self-affirming every day, if you are surrounded by toxic people, your mind won’t be able to accept the good things you’re telling it. Toxic people are people who cause you large amounts of stress or people who put you down or discourage you. It’s extremely important for people with Dyslimbia to have supportive people around them. If possible, try to make sure you have at least one friend or family member who will study your “sense of self” with you—somebody who knows and accepts you for who you are.

Directional Thinking: Using Objects

Directional thinking is the continued process of channeling your thoughts in one direction, or toward one theme or lesson. Making sense of self your “theme” to think on for a while can be very beneficial. In everything you do, try to draw things back to how they relate to self-understanding. My best friend came up with a great idea to aid this kind of directed thought.

Pick an object that is carried with you or is frequently within sight. This could be a bracelet or any form of jewelry, a clock, your favorite pen, your water bottle, or even your shoes. Then, every time you catch yourself looking at or touching the object (e.g., fidgeting with a bracelet), remind yourself of that day’s theme and think on it—consciously direct your thoughts. This use of objects seems like a great way to help directional thinking, and I’m excited to try it myself.

This Week’s Personal Example

This is an example from my life of how it can help you to have a good sense of self. I frequently battle with suicidal ideation, and due to certain circumstances, I knew that the suicidal thoughts were going to be worse in the next few days to weeks. Knowing this about myself, I then designed a plan; I made a list of ten things I can do to distract myself next time I start thinking suicidally. In order to make an effective list, I had to know exactly what kind of activities would work for me and which ones wouldn’t work. For example, I didn’t put “do chores” on the list, because that takes me a lot of energy and might make me feel worse in a crisis. Instead I listed more mindless activities, such as watching anime, playing my favorite card game, and reading a book.

I can’t stress this enough: unless you know yourself very well, coming up with effective coping strategies will be nearly impossible. So take some time, please, to develop your sense of self and battle the dangerous Identity Disturbance.

Sense of Self Part 2: Know Thyself

Developing a Sense of Self

One of the criteria for Borderline Personality Disorder is “Identity disturbance: markedly and persistently unstable self-image or sense of self.” What this means is different for everyone, but basically it’s a sense of not really knowing who you are. This can be debilating, and many people with Dyslimbia struggle with it. Therefore, it becomes useful and even essential to develop a good sense of your own identity. There are several ways that beginners can go about doing this.

Goals

When it comes to developing a sense of self, it’s important to set goals. This is because “knowing yourself” means knowing what you want. Most people have life objectives or plans for their career or living situation, etc., but it’s much more important to list short-term goals—even daily ones. Meeting those goals will boost your self-confidence and sense of self, and you can learn about yourself from your failures and shortcomings, too. As for me, I have the following daily goals: Do some exercise (even if it’s just a short walk), find a social activity (such as calling a friend on the phone), engage in something therapeutic (talk counseling, mindfulness exercises, meditating), do something relaxing, do something useful or helpful (chores, work, etc.), and be sure to eat enough. You can also benefit from having personality goals; for example, I want to be a “Courageous, Healthy, Helpful, Capable, Strong, and Self-Controlled” person.

Personal Example

Examining your reactions to certain events or your patterns of thought can also help you develop a sense of self. For a personal example from last week, I meditated and examined my responses to grief and loss. This is because a death occurred in my family last week. I realized that my pattern of grieving is generally as follows: Shock, Anger, Guilt, Depression, and slow Acceptance. Knowing this about myself means I can better monitor and understand my responses and behaviors. When I feel like blaming someone for my cousin’s death, I make a mental note that this is normal Anger-stage grieving for me, and try to behave kindly, not judging myself, until I am past that stage.

Personality Type

Another interesting way to work on your sense of self is to find out your personality type. There are many types of personality tests and some are more helpful than others. I have always found the Myers-Briggs Typology to be the best test for learning about oneself. In this test, you are given a four-letter Type (there are 16 total) in response to your answers. Each letter represents a different dimension of behavior or character. I am an INFJ.

The first dimension, I versus E, means extraverted or introverted. While introverts get most of their energy from being alone, extraverts usually draw energy from other people in social interactions. The second dimension is sensing versus intuitive (S and N). Sensing types are generally more practical and in touch with their senses, and think about things in terms of parts and pieces. Intuitive types usually prove more abstract and theoretical, thinking about things in terms of the big picture. T and F stand for Thinking versus Feeling, and this depends upon how you make most of your decisions. If you are very objective in your decision-making, you are probably a T, while an F thinks subjectively. Finally, the fourth letter would be J or P, Judging versus Perceiving. J types show more organizational and planning habits, while Ps tend to be more spontaneous and flexible.

With a test like the Myers-Briggs, you can understand a) where you draw your energy, b) how you relate to the world, c) how you make your decisions, and c) how spontaneous or premeditated your actions tend to be. Knowing this much about yourself can be really helpful. With better understanding comes a better chance of adjusting your behaviors.

Remember that understanding yourself can help you in a pinch. When you feel empty or dissociated or extremely out of it, having a solid identity to cling to can save you.

Sense of Self Part 1: Directional Thought

What is Directional Thinking?

Many people with BPD struggle with negative self-image and difficulty controlling their thoughts and emotions. The fight to gain control of my racing emotional thoughts can be debilitating. That’s why I’ve decided that practicing “directional thinking” is a great idea.

Directional thinking simply means focusing your thoughts on a particular theme or idea, in order to have more control of the “inner dialogue” that everyone possesses. Many churches have discovered this secret and use it by writing or reading daily spiritual devotionals. The devotionals give you a particular theme, topic, or Bible passage to think hard about. Every time you catch yourself thinking scattered or emotionally charged thoughts, try to fit or redirect your thoughts into the “theme” given that day.

Not everyone likes spiritual devotionals, though. I’m an atheist, for example. In a case like this, you must think up your own self-devotional. Pick a theme you want to think about, something that has a lot of bearing on your life. For my first “devotional,” I chose to think about my Sense of Self for a week. I’d like to share my experiences with readers in this multi-part blog series on Sense of Self.

Identity Disturbance

Everyone goes through times of uncertainty or change, and everyone makes occasional decisions they later regret or don’t understand. For people with Borderline Personality Disorder (or Dyslimbia), though, these occasions are chronic and recurring. One of the criteria for BPD is “Identity disturbance: markedly and persistently unstable self-image or sense of self.” What this means is different for everyone, but basically it’s a sense of not really knowing who you are.

For me, “identity disturbance” manifests in several ways. First, since I also have a dissociative disorder, I sometimes feel like I have multiple personalities. My desires are so conflicted between totally different options, to the point where I feel like I am more than one person. Even if you know you don’t have multiple personalities, though, identity disturbance can still be very real and very frightening. I often become mentally anguished because I have this idea of who I’m supposed to be, and yet I’m doing things that don’t fit with that model, leaving me confused and frustrated. Identity disturbance is different for everyone, so if you care to share, please comment below. At any rate, it’s a problem that most people with BPD have to battle.

Today’s Example

In order to have a more stable self-image, it’s important to have goals concerning what kind of person you want to be. For instance, I want to be a “courageous, healthy, helpful, capable, strong, and self-controlled” person. Then, when I feel I don’t know who I am, I think about small steps I can take to become more like my ideal self. Equally as important, I give myself examples of how I’m already a person who shows many of those qualities. Let’s look at an example of this kind of directional thought from my own life.

Last night, I made an unwise decision and drank to excess, waking up today sick and hung-over. I also slept in very late, and realized my goals for the day could not be met thanks to my bad decision. On top of that, I received an invitation to a job interview on very short notice—with an intimidating company. As a result, I began to have a lot of racing thoughts, crippling anxiety, and intense self-loathing. Then I considered what I could do to calm my thoughts, and remembered my theme of Sense of Self.

Distracting from my panic, I told myself what I had done recently that proved I am “capable, strong, and self-controlled.” I thought about what small steps or actions I could take toward my goals, and how each one would prove I am “courageous” or “healthy” or “helpful.” To my surprise, exercising this directed thinking helped me through the intense anxiety until my medicine had time to kick in.

In summary, I believe directional thought could be a great tool for people with Borderline. In the next part of this blog series, I’ll continue discussing my experiences as I try to form a stable sense of self.

Explaining Dissociation Part 4: How to Help People

Now we know what dissociation is, and some ways in which it can be treated. But the non borderline may be wondering, “What can I do?” Or the borderline patient might be looking to give suggestions to their loved ones about what they can do. Well, the best way to help a sufferer of dissociation is first know how to NOT help them.

Things That Don’t Help People with Dissociation–

Minimizing our problem. This includes statements like “it’s not a big deal” “just relax” “others have it worse” and “everybody goes through the same thing.” This is damaging to the person with dissociation, because we need to feel like our experiences matter.  Chances are, the person is already trying hard to put perspective on their problem, and being preached at to try harder will make them feel incompetent.

Commanding us to be normal. Statements like, “just calm down” “come back to earth” “snap out of it” “just be happy” “just think about it rationally” are completely pointless. The borderline is mostly  incapable of being rational when in a severe dissociated state, and if they could just act normal again, they would! So don’t waste your time telling them things they cannot currently do.

Shaming Us. “Be strong for your family” “this isn’t the real you” “strong people don’t act like this” and “toughen up” are examples of making the dissociated person feel ashamed. Again, this will not help— if  the patient could snap out of it, they already would have. Shaming will make them feel worse and may prolong the episode.

Strong emotional reactions. When a borderline is in temporary psychosis, anger, or dissociation, it is best to avoid strong reactions, so long as the borderline is not being violent. Try not to act horribly shocked or disappointed, as this make the borderline feel extremely guilty and even more helpless than ever.

Saying it’s a character problem. If you think borderline is a character problem, you are scientifically incorrect. More on that later. The dissociation is likely a result of brain abnormalities, so don’t reject the person for their neurobiology unless you would reject a person based on their skin color, height, sex, or weight.

Helpful Tips—

When a friend is in a dissociated state, the key is to remain calm, and remain present. Dissociation and temporary psychosis fade away quickly in borderlines. No matter how crazy they sound, how distant they seem, or what important things they have forgotten, it’s critical that you calmly listen. Instead of trying to offer  advice, offer your presence. Tell them/us you will stay with us for as long as we need.

Brain Abnormality

Dissociated people are often accused of being stupid, slow, or too careless due to amnesia and derealization. They may also be accused of faking when they feel their identity has been split. However, none of these accusations are true. People like me with dissociation don’t have any more or less “character problem” than you do– it’s a brain thing. Dissociation has been linked to brain abnormalities. It’s not something we can just will away by trying to be better people.

For example.  The hippocampus, a brain center that helps memory, is smaller in patients with some dissociative disorders. The right prefrontal cortex, which helps with memory and processing, is under-active in dissociative amnesia. So, it’s a brain thing, not a character thing!

Closing Words

Dissociation is a defense mechanism that went wrong. Sometimes, it works. Severe detachment from the world, and/or from the self, means you are protected from trauma that is happening. You essentially are not there. But the brain overcompensates, and victims of dissociation may start to dissociate at the smallest triggers, or over nothing, during random conversations. Life gets very difficult as you constantly live in a cloud, separated from the world, forgetting important details, forgetting who you are, thinking that the world is a puppet show or a hazy dream. Unfortunately, there’s no known cure for dissociation, but improvement has been shown through professional therapy techniques. And everyone would be better served to learn something about dissociation.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3233754/

http://stantatkin.com/wp…/uploads/2012/09/Brand2009.pdf

Explaining Dissociation Part 3: How to Cope

Review

So far, we have learned about the common types of dissociation that people with Borderline/Dyslimbia may experience.  We looked at personal examples of Dissociation interfering with life. Now you, the Dyslimbia patient, may be wondering, what can I do to help myself with this problem?

Some people may feel they need no real help. If dissociation does not actively interfere with your life, then don’t worry about it. I knew one person with regular dissociative amnesia who was content because he would tell his friends his forgetfulness was due to alcohol. I, however, recommend seeking help if dissociation interrupts normal social interaction.

Psychotherapy

The National Alliance on Mental Illness notes that most dissociative symptoms are due to trauma (and/or, for borderlines, an inability to process stress). Because of this, the best treatment is talk therapy. Therapists can help patients work through traumatic memories and learn ways of coping with stress. This is a slow process that may take years, but the medical and scientific communities are fairly confident in the general effectiveness of talk therapy.

Medications

The National Alliance also notes that medicines are sometimes used for dissociation.  When people are being treated for dissociation with a co-occuring problem, such as depression, the antidepressant medicine may also help the dissociation.

Helpful Tips– 

Here are some practical things you can do to help treat dissociation. Some are taken from the web article “Coping With Trance States: The Aftermath of Leaving.”

1) Stay Healthy.  Exercise can help many people feel less “zoned out.” Some people with dissociative disorders may become worse when drunk or on certain drugs, so either avoid these substances, or always use with extreme caution and a friend nearby.

2) Avoid Triggers. Certain areas, people, experiences, or thoughts can trigger dissociation. For example, when I experience extreme loneliness I tend to dissociate. While a therapist can help you slowly adjust to your “triggers” — the things that make you dissociate– you should not try to do this on your own. Avoid overwhelming situations wherever possible.

3) Keep in Touch with Reality.  You may find having a regular daily schedule helps you stay grounded. Calenders and to-do lists can help with this.  Reading regularly can help comprehension, which might over time reduce the feelings of “zoning out.” Keeping up to date on something — like world news, for example– might do the same.

Remember, dissociation can be one of the scariest things you will ever experience, but it doesn’t have to rule your life. Even if we feel like we are trapped inside the prison this terrible disorder created for us, we must maintain hope for the Great Escape.

 “Coping With Trance States: The Aftermath of Leaving.” http://www.nwrain.net/~refocus/trance.html

 “Dissociative Disorders.” http://nami.org/content/contentgroups/helpline1/dissociative_disorders.htm