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.

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

Explaining Dissociation To a Non Borderline, Part 2: Personal Experiences

               In part one of my blog series on dissociation, we found out that there are several types of dissociative disorders, and that Borderline/Dyslimbia patients can experience dissociation when upset or under stress. We discussed dissociative amnesia, derealization and depersonalization, and identity disturbances similar to Dissociative Identity Disorder. Dyslimbia patients can also experience short episodes of psychosis (a state of insanity) or delusional thinking. I’d like to tell you some of my personal experiences with dissociation.

                    “Zoning out.” On the more mild end, dissociative amnesia affects me often. Just the other night I was sitting outside and talking to my friends, when suddenly I became aware that I had no idea what they were talking about, and they asking me to answer a question I had forgotten. I was not sure if I had zoned out for five seconds or five minutes. I had been sitting, nodding, and listening, and then suddenly, my mind had detached from the world, only to return a few seconds later, forgetting what went on. Once reminded of the topic, I was able to start up the conversation again.

                  “Who Am I?” Sometimes, I get confused about my identity. This is worse for me than for most borderlines, because I have a co-occuring Dissociative Disorder where I feel like I have multiple selves. For most borderlines, identity confusion can be an overwhelming sense of not knowing who you are. Sometimes people tell me I act very different, saying things like, “Your bearing has changed,” or “The old you would never do that,” or “It’s like you’re a different person.” On some days, you may walk, talk, and dress differently than you normally do. Sometimes, I even want to switch genders. There is nothing objectively wrong with having multiple personalities or identity confusion. However, it can be a scary thing to experience, and may result in many powerful negative emotions. Borderlines may panic or become reckless, and their friends and relatives may be extremely confused.

                 Temporary Psychosis. I often ride the bus in my city, but with both social anxiety, high stress levels, and Dyslimbia, a crowded bus is a scary place for me. One day, I was riding the bus and I got paranoid (paranoia means having non-rational fears). I was scared that other people might read my mind. Even though this made no sense, it was highly alarming to me. Sometimes, when under stress, I also get mild visual changes. I will stare at a wall, and it will look as if the wall is moving. I will stare at a chair, and the chair will look like it’s slightly moving backwards. Lights sometimes seem to have bright colors around them. These are all examples of weak, temporary psychosis.

                    “Demons.” On the more serious side of the spectrum, sometimes I have delusional thoughts that I will believe, if only for a few minutes. An example is when I texted my friend about the people around me; I texted, “the people here must all be possessed by demons. I swear. That’s why they’re all doing this to me.” This can be extremely alarming to both the borderline and his/her loved ones. Luckily, my delusional thoughts only surface in times of extremely intense stress, and only last a few minutes. The best thing to do when a Dyslimbia patient gets delusional is to just accept it and try to help them calm down until they are normal again.

                    “Dolls and Doll Houses.” One of my worst instances of dissociation happened when I was very stressed about school and money. First, I started to feel distant, like my mind was in a cloud. I forgot which bus I was supposed to take home. Then slowly, I started to feel like I was dreaming, and then I couldn’t remember if I was really awake or not. I also felt as if every building and person I saw was some kind of illusion. They were fake, like dolls and doll houses. I also had physical feelings of numbness and cold. I felt like I was “floating outside my body”. These are examples of depersonalization and derealization. For some people, these feelings pass quickly and are not too alarming. For me, they are the most alarming type of dissociation and can result in destructive panic attacks. The best thing to do when you feel dissociated like this is to find a peaceful activity such as art or listening to music, and just wait for it to pass. Panic medications may also be helpful for some people.

              These are some representations of dissociation. I hope the stories have given other Borderlines something with which to relate. By reading these stories, I also hope non-borderline people understand dissociation better.

Explaining Dissociation To a Non Borderline Part 1: What is it?

If you have Dyslimbia/BPD you already know all about dissociation. The goal of this short blog series is to explain dissociation to your friends, as well as understand it better. So the first thing you need to do is explain what dissociation really is.

One of the criteria for dyslimbia is severe dissociation and/or temporary psychosis. Simply put, this means that the dyslimbia patient, when stressed, may go insane for a few minutes or hours. The patient may hallucinate, seeing or hearing things that are not there, or suddenly believe delusional things they know better than to believe normally. This is called psychosis.

Psychosis is somewhat different from dissociation, which literally means the state of being disconnected. In psychology, there are several types of dissociative disorders. Borderline Personality Disorder is not considered a dissociative disorder, but victims of the disease can experience dissociative symptoms. There are five types of dissociation disorders. Three of them are outlined below.

1)      Dissociative Identity Disorder is characterized by the presence of multiple personality states. There must be two or more very distinct “alters” or persons. While in one alter state, one may not remember what they did in another alter state. An example is a girl who feels she has an alter named Rob who is part of her and “takes over” sometimes. Sometimes Borderlines may temporarily feel they have separate selves, or they may have both disorders at the same time.

2)      Depersonalization and Derealization are experiences of being disconnected from the world. Depersonalization is when you feel you are no longer real or no longer connected to the world, while derealization is the sensation that the world is not quite real, dreamlike, or fake. An example is a person feeling as if they are in a dream, or thinking that the world is a simulation. Borderlines may experience these sensations often, especially when under great stress or when very upset.

3)      Dissociative amnesia can mean forgetting about traumatic events, and this is very common. However, people who have chronic dissociative amnesia will forget things all the time in everyday life, including what somewhat was just saying to them seconds ago. An example is a person “zoning out” and totally forgetting what he and his friend had just been talking about. Borderlines may experience this too.

Now that we know a little bit about dissociation, the next blog post will be practical examples of what dissociation feels like, told in the form of personal stories.

Coming out as Borderline, Part 1: Not a Character Problem

The Great Escape is a Blog about Borderline Personality Disorder, or Dyslimbia. The name came about when my friend asked “How’s life?” I replied, “It’s like a prison, where the guards take me out to be tortured for most of the day and then throw me back in the cell with the rats and mold at night. And there are other people who talk to me from outside and tell me it’s all going to be ok, but it’s like to them the entire dungeon is invisible. They have no idea what I see because we have different eyes.” Nevertheless, I keep fighting every day for the Great Escape.
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One of the most difficult challenges about Dyslimbia is that people rarely understand it, and often misrepresent it. At the same time, removing stigma can only be done by practicing honesty and transparency. Among your friends and family, I believe it is healthy to “come out” as having a Dyslimbia/Borderlines Personality diagnosis.

So how do you explain to people about your sickness? I will be posting a series of topics related to this “coming out” process. I will do this in a rough question-and-answer format. Real life conversions won’t be this cut and dry, but try to model them so that you still answer your friends’ questions clearly. First on the list is telling your loved ones you have an illness, not a character problem.

You: Hey, I know we have had some rough times. I want to explain to you that I have a disorder, and the disorder has been the cause of some of my mistakes in the past. It’s called Borderline Personality Disorder, or Dyslimbia.

Person: A disorder can’t explain bad behavior. I think you’re just over emotional, or uncaring, and you need to try harder.

You (take a deep breath): Think of it like this. Parkinson’s Disease is a neurological disease. Something goes wrong in the brain. As a result, motor coordination is altered. With Dyslimbia, something ‘went wrong’ with the limbic system of the brain. The limbic system controls emotions. Studies have shown that people with Borderline have very irregular limbic systems. This means that the structure of my brain makes it impossible to regulate emotions normally.

Person: So you think the brain controls emotions? And because one of your brain systems is messed up, you have these emotional problems? This makes it sound like you have no control at all, and we’re all just robots to our brain machinery. I don’t believe that.

You: That is not true. I can still control my actions about as well as anybody. I can’t control the way I feel. I might get very very angry over something small, and that feels very uncomfortable, but I can still control myself enough to not yell curse words and break things. I can control myself enough to make the decision to go to therapy. I can control myself enough to practice helpful habits like daily exercise, eating well, and spirituality. I can control myself enough to make a decision to try medications, or to buy self-help books. The only part I can’t control is the emotions themselves. They might appear with no cause. Or they might be extreme feelings in response to tiny events. Does that make sense?

Again, real conversations won’t flow like that. But the point is to be able to calmly explain yourself to someone without a brain illness. Explain that new studies really do show that Dyslimbia is a brain condition, like epilepsy, and not a character problem.