Is Mental Illness a Lack of Healthy Coping Skills?

I few months back I was at a 4-day training to learn about  a new group to work with the women in prison whom have violent pasts.  One of the members of the training introduced herself on day 1 to our table, she owned a residential drug and alcohol treatment center and had been using the new program at her site.  On the 4th day we had to do an exercise where we talked about something important to us to another member of our group.   She told me she did not believe in mental illness, thought the DSM IV-r should be "thrown out" and that all disorders were from a lack of coping skills.  I was dumbfounded, but she continued to explain using this analogy; someone whom is neglected as a child is going to need to find a different way to get their needs meet.  At age 2 that means having tantrums, crying excessively and being loud to get mom or dad's attention.  Age 6 may be ongoing conflict with other students to get teachers attention, age 10 bullying other students, being suspended in order to get attention and power, age 15 acting promiscuously to gain male/female attention and at 19 they will continue aggressive behaviors, possibly use substances and have abusive relationships.  At the time I thought this woman was way off base, how can mental illness be from a lack of coping skills?

It has been 2 months and although I believe in mental illness, chemical imbalances and medication, I can see how especially with those with personality disorders how this algorithm works:

Invalidating Environment+Trauma+Lack of Coping Skills= Personality Disorder

I often talk on here and on Twitter about how many women are misdiagnosed have trauma and/or anger issues, instead of BPD.  Someone on Twitter told me last week she was diagnosed with Bipolar, Schizoaffective disorder and attended anger management classes for years and was medicated for such and just found out her "only" diagnosis was Borderline Personality Disorder.

As someone without a mental illness, it is difficult for me to fully comprehend what the experience of having one is like.  I grew up in a mostly validating environment, the trauma I did experience was immediately remedied (due to the validating environment) and I was taught coping skills.  I can remember having anxiety and trouble sleeping as a adolescent and my mom teaching me mindfulness techniques, validating my feelings, normalizing the stress of that age and giving me tapes she has bought to help, while my dad made me chamomile tea and listened to my woes.

More than any other post I would really like feedback from the Borderline Personality Disorder Community about how accurate this "formula" sounds to your life experiences.

Boundary Garden

Those with Borderline Personality Disorder struggle with healthy boundary setting.  From my perspective this is part of their black/white, all/nothing thinking.  Sometimes it's obvious when someone has poor boundaries. The story I always tell to describe what poor, or low boundaries look like is this personal one from when I was 15 years old.  I had just walked off the city bus to walk to go home, as did another classmate I had not seen before.  It was the first week in school, so I guessed she might be new.  I began talking to her, figuring if nothing else it would give me someone to walk home from school with.  Our walk and only conversation lasted 8 minutes and in it she told me her mother had killed herself, she was now living with her father, he didn't know how to cook, was "icked" out buying her tampons, she had an array of mental health issues, told me what medications she was on and showed me scars from when she tried killing herself a few months back.  My radar went into the red danger zone and I immediately knew this was not someone I would want to be friends with, even if it was 16 minutes a day round trip.

Those with all/nothing thinking struggle with making, having and often keeping friends for this primary reason; "they are either my all-time best friend or my worst enemy."  This was a quote from a client, whom I didn't at the time know much about BPD to diagnosis.  I have my clients create boundary gardens to illustrate this point and have a visual for where their friends lay.  Below is the outline of the garden I have them fill in.

Here is an example of one filled in for someone who has low boundaries,

After I have the clients fill in the garden I ask a few questions; which section has the most people in it? Why are people in old brush and not out of the garden? Is there anyone who has been moved towards the old brush or into roses since starting therapy/group/recovery?  It's a great starting point for creating and enforcing boundaries.  I also have the clients put lines where they would like to move people, for example, "my step mom and I have had a better relationship the last few years since she stopped drinking, so maybe it's time to have her as a violet," or "My brother is a close friend now, but I think he has been stealing money from my purse, so maybe we need more distance and he needs to be moved to Geraniums."

It doesn't solve their boundary issues, but it gives them a starting point and a nice visual to begin working on.

BPD and Self Harm Syndrome

Working in a prison, the inmates wear short sleeves at all times (they do have coats they can wear outside and thermals for underneath their shirts at times), and due to my specialty with BPD I find myself often looking down at inmate arms for scars.  I haven't taken any kind of survey, but easily a quarter of the clients, whom are not necessarily mental health clients have scars.  They are quick to tell me the last time they cut, "it's been 2 years," "this was before I was locked up," mostly because they can be sent to segregation for these "dangerous" behaviors and suicidal actions (per the prison).  There is a huge rate of self-harm in those with Borderline Personality Disorder, as well as those with other mental health diagnosis.  There has been a push to create a diagnosis for those whom self-harm called Self Harm Syndrome. 

Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome.The diagnostic criteria for Repetitive Self-Harm Syndrome include:

• preoccupation with physically harming oneself

• repeated failure to resist impulses to destroy or alter one's body tissue

• increasing tension right before, and a sense of relief after, self-harm

• no association between suicidal intent and the act of self-harm

• not a response to mental retardation, delusion, hallucination

Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome.As described in Women Who Hurt Themselves, TRS sufferers have four common characteristics:

• a sense of being at war with their bodies ("my body, my enemy")

• excessive secrecy as a guiding principle of life

• inability to self-protect (often seen in a specific kind of fragmentation of self

• relationships dominated by a struggle for control.

Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles:

• the abuser (the one who harms)

• the victim

• the non-protecting bystander

Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in tandem with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping. source

(Trigger Warning) It's the scars I don't see that worry me the most, the inmates whom have admitted they cut around their genitals as "punishment" for past experiences, which was not their fault.   Those that admit that even a man cat-calling them will give them trauma echo and their first thought it to hurt themselves, as they see themselves as to blame for the situation.  In my experience stopping someone from cutting is a lot harder than taking away the tool.  I meet with a 17 year old while working at a crisis center, whose mom told me he has not cut for a year, since she removed the knives and locked them away.  The young man then raised his shirt and told his mom that he had "found another way," showing her dozens of scars,  Without a new coping skill it is hard to leave an old stand by.  For that matter those who cut state "it works," it distracts from the pain they are feeling and provides temporary relief.  So rather than work on counting days without cutting, here is a list of DBT/CBT skills to do instead of self-harm.  I put my favorite in bold.

99 Coping Skills

• Exercise (running, walking, etc.)
• Put on fake tattoos.
• Write (poetry, stories, journal, etc.)
• Scribbling on sheets an sheets of paper
• Be with other people.
• Watch a favorite TV show.
• Posting on web boards, and answering others' posts.
• Go see a movie.
• Watch a movie from your childhood.
• Do schoolwork.
• Play a musical instrument.
• Paint your nails.
• Sing.
• Look up at the sky. (Night is especially beautiful.)
• Punch a punching bag (with gloves on.)
• Cover yourself with Band-Aids where you want to cut.
• Let yourself cry.
• Sleep (only if you are tired.)
• Take a hot shower or relaxing bath.
• Play with a pet.
• Re-organize your room.
• Clean.
• Knit or sew.
• Read a good book.
• Listen to music.
• Watch a candle burn (no playing with the flames!)
• Meditate.
• Go somewhere very public.
• Bake cookies.
• Alphabetize your CD's.
• Paint or draw.
• Ripping paper into itty-bitty pieces
• Hug someone.
• Write letters or email.
• Talk to yourself (or if that feels weird, buy a small tape recorder.)
• Hug a pillow or stuffed animal.
• Hyperfocus on something like a rock, hand, etc.
• Dance.
• Make hot chocolate.
• Play with modeling clay or Play-Dough.
• Build a pillow fort.
• Go for a nice, long drive.
• Complete something you've been putting off.
• Draw on yourself in red marker.
• Take up a new hobby.
• Cook a meal.
• Look at pretty things, like flowers or art.
• Create something.
• Pray.
• Make a list of blessings in your life.
• Read the Bible.
• Go to a friend's house.
• Jump on a trampoline.
• Watch an old, happy movie.
• Call a hotline or your therapist.
• Talk to someone close to you that knows [how you’re suffering.]
• Ride a bicycle.
• Feed the ducks, birds, or squirrels, etc.
• Color with Crayons.
• Memorize a novel, play, or song.
• Stretch.
• Search for ridiculous things on the internet.
• Hunt for stuff on Ebay or Amazon (you can find ANYTHING there).
• Color-coordinate your wardrobe.
• Watch fish.
• Make a tape of your favorite songs.
• Play the “15 minute game.” (You can't cut for 15 minutes, and when the time is up, start again.)
• Plan your wedding / prom / other event.
• Alphabetize your books.
• Hunt for your perfect home in the paper.
• Try to make as many words out of your full name as possible (then do your friends’ names.)
• Sort all your photographs.
• Plan a dinner party.
• Play with a slinky.
• Find yourself some toys and play.
• Start collecting something.
• Play video/computer games.
• Clean up trash at your local park.
• Go out and perform a random act of kindness for someone.
• Call up an old friend.
• Write yourself an "I love you because…" letter.
• Try to build something.
• Rearrange your house.
• Go through all your old stuff.
• Smile at least five people.
• Play with little kids.
• Go for a walk (with or without a friend.)
• Go to the mall.
• Clean your room /closet.
• Try to do handstands.
• Try to do cartwheels, bridges, backbends, and such.
• Teach your pet a new trick.
• Write a note to a very useful inanimate object thanking it for how useful it’s been.
• Move EVERYTHING in your room to a new spot.
• Get together with friends and play Frisbee, soccer or basketball.
• Randomly go up and hug a friend.
• Randomly search MySpace music for new music. Or use Pandora.com.
• Play the "If inanimate objects talked, what would they say?" game.
• Face paint.

My favorite skills I have utilized with clients is to freeze ice cubes (use red food coloring) and when you feel the urge grab an ice cube and melt it in your hands (over the sink or shower) and watch the red color drip down where you would want to cut. I try not to use foul language, but couldn't resist posting this gem.

Why I Became a Therapist?

This week a client in my group asked me how old I was.  I didn't even think before responding "29."  All the Graduate School training about boundaries and "turning the question" to "Why is that important to you?" went out the window quickly.  Later in the day when another person (not in my group) said "you are only 29!" I realized maybe I shouldn't be answering questions about my private life.  Then I meet with my one Borderline Personality Disorder client and hand her the DBT manual and give her the overview of DBT and say to her "DBT is collaborative between myself and you, so come directly to me with any questions you have."  I set up a weekly time to see me and walk back to my office thinking..."collaborative."  DBT is very collaborative and much time is spent on the relationship of both the client and the facilitator (individually and as a team.)  I remember using some personal examples in a DBT group a few years ago and made huge strides with my own "issues" facilitating DBT.

I tell you all this to share with you the question I get asked most often by clients, "What made you decide to become a Counselor?"

It was my last year in Undergrad and I was about to graduate with a degree in Legal Studies, had taken the LSAT's and was about to apply to Law Schools

Just like DBT, there is no black and white and no one answer for this question, but here's how the formula worked for me:

20% My own personal issues, without getting into too many details I had experienced my own trauma in my life as an adolescent and had been through therapy at age 10 for this as well as a few bouts of depression and anxiety in my young adulthood.

20% This was a few years after 9/11 and was still deeply affected by it (still am, if I am being honest with myself.)  I was a participant in a PTSD study from a major university where I took PTSD tests at intervals for a few years and although I never got results, with 1 psych class under my belt knew I probably meet the criteria.

60% My room mate at the time, was my best friend for 10 years when we moved in together at age 22.  I had known her family had a huge mental health history, including a grandfather whom killed himself as well as  a mother whom was unable to work and debilitated by even the smallest tasks.  After a few years (and a lot of therapy) we decided it would be a great idea for us to live together in Manhattan.  Things went well for almost 6 months and then she essentially "cracked,"  without getting into details she became psychotic  thought I was trying to kill her, would accuse me of things I didn't do, and attempted to take her life with pills.  (Remarkably she is fine now, turned out to be a rare blood disorder and she takes medication for it and has not had any issues since.)

I took a Psychology class my 2nd to last semester to fulfill a requirement and the more I thought about applying to Law School, the bigger the stack of unfinished applications sat.  I clearly had a lot of resistance to the path I had created for myself in Junior High School when I first thought about Law School.  The Psychology class had me hooked from day one; the professor was a PhD student studying Criminal Psychology and worked at Riker's Island, one of the largest men's prisons in the U.S.  I immediately choose my plan of attack; I cornered her after class and asked her questions about what she did.  Her job at the prison was to assess male inmates to determine if they could stand trial.  After 1 hour, in which I completely took over the conversation and violated her boundaries I decided that is what I wanted to do.  A few hours later I was at home googling what education I needed.  Within a month I told the boyfriend I was moving to Portland, Oregon (he did come with me-although it didn't work out,) enrolled in 3 extra psychology classes and had 3 very part-time volunteer jobs in order to meet the application requirements.

I currently work at the states only women's prison, as the Dual Diagnosis counselor in a unique intense 6-month program focused on addiction and criminality.  It is amazing to think to yourself "How did I get here?" and I am glad I took a leap of faith 8 years ago.

Here is a picture of me packing/driving/moving across country (again) to Michigan, where I am now.

What is it like to be a DBT Counselor?

When other counselors find out my specialty is Dialectical Behavioral Therapy (DBT) and Borderline Personality Disorder (BPD) I am often looked at with disbelief.  The stigma is still there and I have been told there is something wrong with me to want to work with "the hardest group of people there is in mental health."  I sometimes find myself having to explain that "Borderlines" are not bad people, the stigma isn't true and those seeking services are looking to change.  So, what is it like to be a DBT counselor?

First off I have done DBT groups for almost 2 years, as well as phone coaching, group consult and individuals, not all the clients have been identified as BPD.  Most of this is because BPD isn't covered by insurance.  The following is what it is like, both good and bad about running a DBT group. I understand each group is different and forms it's own culture.  Here is a list of my experiences as a DBT counselor.  The following is my opinion in it's most blunt form.

• Some DBT clients will hold counselors accountable.  The group was 2 hours long with a 10-15 minute break, the one time we (co-facilitators) were late we were asked to apologize by multiple members of the group.

• Some DBT clients are initial combative regarding "changing their ways."  I have been open about this in the first session of group.  DBT is hard to initially get into, first off what you have been doing is ineffective and here some tools to get you to be more effective.  Some clients get upset, over personalize and feel judged by this.  I have had 1 person cock back his fist to hit me (security guard grabbed him by his hood and pulled him back), 1 person curse me out then protest outside with a sign and 2 threatened lawsuits. Resistance is part of the norm for DBT groups, although it can be both uncomfortable and triggering for others.

• Some DBT clients have issues with the Zen Buddhist part.  I have had numerous clients have huge issue with the non-Christian base for DBT.  Even the idea of mindfulness or regulating your breathe has drawn criticism.  At one point we as co-facilitators had (per higher up staff) to allow clients to choose to be in the mindfulness exercise that took up the first 10-15 minutes due to a pending lawsuit.

• Some DBT clients often need concrete examples to understand DBT.  This includes a 2 hour session just to cover the definition of dialectics.

• Some DBT clients with addiction issues are often the "best" clients in group; the most engaged and the most honest.  I think part of this is due to how open 12-step groups are and how much they have shared in the past.

• Some DBT clients find it difficult not to get "stuck in the story," and it is often hard to re-direct back to the skills they used when discussing diary cards. 

• In 2 years we "graduated" 2 people; with 8-10 people in the group at the beginning and slowly people dwindling down this was a remarkably small number of people.  I would guess in 2 years we had a total 40 clients start DBT.  Some of this was due to people "dropping out" due to scheduling conflict, insurance issues and attendance.

• In DBT women outnumbered men, men were more likely to "drop out" of the group and need more examples to understand concepts.

• Rarely did anyone use the phone coaching, although it was strongly encouraged.

I am a huge fan of DBT and am still a firm believer in how great it can be for all people.  I also will say that most of the clients were not like the bullets listed above; completed modules, grew and gained skills.  I still enjoy doing DBT and working with those with BPD, although running the groups can be very stressful at times.  Part of the problem with the agency I did DBT groups was economic as all the clients were on state insurance and their coverage would get dropped for various reasons.  We also didn't have a DBT team (just the 2 counselors who co-facilitated) and some of the other counselors/case managers did not understand DBT, so they weren't getting the one-on-ones focusing on DBT.  I will also admit we did a quick screening process for new clients, meet with them for 30 minutes and made sure they understood what they were going to begin- I think a lot of clients has heard of DBT from someone or read an article and were quick to sign up without truly understanding what DBT is.  I do take responsibility for some of these issues as well as some of the bullet points, including some of the client's behaviors.

I still recommend DBT to a lot of my current clients (incarcerated females with substance abuse issues) and feel it is the best chance of a successful life if you have BPD.  Feel free to leave any comment about your experiences in DBT groups or any questions about DBT or BPD.

Temporary Treatment Options for BPD

Earlier this week I was talking to someone on Twitter (whom has a great website for Borderline Personality Disorder) whom was feeling triggered, used her DBT skills and then went to Intensive Outpatient Program (IOP.)  Many people on Twitter then had questions as well as discussed some opinions to those with BPD and pro/cons of hospitalizations.  After reading a ton of research articles here are some options and pro/cons of each.  I understand those without insurance may not have many options and some depend on your area:

Inpatient:  Simply put admitting yourself into the hospital for a period of time.  First off as a counselor who has done this with clients I have run into a few problems; 1) the psychiatric unit is full 2) the client needs to be in "immediate risk of hurting themselves and others" and one time since it was self injury and not suicide they were essentially rejected at the front door.  The other issues particular to those with Borderline PD is that hospitalizations are sometimes too "cushy."  In Kiera Van Gelder's book, The Buddha and the Borderline," she explains her hospitalizations in this way, "when I climb into bed, the white hospital sheets feel as cool ans fresh as peppermint." Kiera find her hospitalizations difficult as she feels too comfortable/attached and the discharges feel like yet another rejection.  Hospitalizations also rarely provide any skills or groups specific to BPD and is mostly a quick stabilization for some people. Inpatient likely won't keep those who aren't at immediate risk for longer than a few days.

*The exception to the issue with Inpatient and BPD is that there are a few specific inpatient programs for those with Borderline Personality Disorder.  There is a thorough list here and as always if you have money you will get the best care*


Intensive Outpatient/Partitial Psychiatric Hospitalization: These programs provide more services than most inpatient programs.  For instance DBT and mindfulness groups for 3 hours a day, 3 days a week is a typical format for BPD-specific IOP programs.  There are more programs that are available for BPD here and because it's short (read: cheaper) insurance is more likely to cover it.  In Buddha and the Borderline, Kiera talks about MAP, a mood and anxiety program utilizing Cognitive Behavioral Therapy (MAP), she attends everyday from 7:30am-4pm.  The group at her clinic includes "cognitive behavioral skills, assertive communication skills, depression and anxiety, behavioral scheduling, relapse prevention, impulse control. There is also stress management, self-assessment, mood regulation, positive events scheduling, family issues, life transition, community meetings, treatment planning and contract writing." This is a less comfortable options, plus as a counselor I like the idea of how "real world" sleeping in your own bed, and continuing to handle your life, albeit part-time. It is harder to get attached to this kind of program and it focuses on long-term goals rather than temporary medication management and nightly fever checks from nurses. IOP can vary from a week to a few months.

Respite: This option is the lowest intensity of all and not available everywhere.  Respite is known as the place where caregivers for elderly or children with physical or mental health issues essentially go to "get a break." When I worked in Portland, Oregon there was a respite in some of the larger counties for mental health issues.  Essentially mental health respites are typically in large houses where 6-10 clients live temporarily, it's a toss up if you share a room or not (think low-end bed and breakfast) but it is always same-sex rooms.  There is typically a shared space like a living room/sitting area where people chat, read and watch TV.  There is typically one case manager and sometimes (often depending on who is working) there might be a group a day, there is an open space and people can leave during the day, but need to return by curfew.  The residents are typically de-escalating from a mental health issue and are looking to relax for a bit.  I had a client tell me she liked respite because they made her peppermint tea when she couldn't sleep.  From the respites I know they do not specialize in BPD or do any skills group- but it might be a good place if you need some "head space" to think, figure things out and a safe place to be.  Respite stays vary but typically 3-7 days and include meals.

As always the first goal of any intensive treatment is safety, and if you are thinking of hurting yourself or someone else go immediately to the hospital to get well.  The above options are for non-life threatening situations only.

My Favorite Mindfulness Techniques

As a DBT therapist working full-time in a non-DBT facility (I will be opening a private practice in a month for DBT) I often use mindfulness exercise in my position.  Working with mentally ill incarcerated women with substance abuse and extensive trauma backgrounds makes things a bit difficult.  First off some of these women do not like to close their eyes, listening to instrumental music and the "typical" mindful techniques (they use the tern "grounding") often include focusing on your breathe or counting tiles.  These are useful techniques, but for our clients not as practical as needed for this population.   Here is my list of mindfulness techniques and stop-by-step directions:

• Comparison: Start by looking at 2 items that look near identical say 2 matching pillows, 2 matching chairs or even both your feet.  Notice the first of this object, for instance notice the first pillow; what color is it? what is the texture? is it cold or warm? does it make a sound? notice the small details.  Now look at the second object; notice the first pillow; what color is it? what is the texture? is it cold or warm? does it make a sound? notice the small details. Now look at both items together; what differences to the two items have.  (I have the inmates do this with what chair they are sitting in and have the switch chairs with someone in a different style one as theirs.)

• 5 Senses:  First to yourself say 5 things you see, now 4 things you can touch, 3 things you can hear, 2 things you are smell and last what do you taste in your mouth right now (This is from Helping Women Recover by Stephanie Covington PhD.)

• Square Breathing: Similar to belly or diaphragmatic breathing, breath in as deeply as is comfortable for and picture a line being drawn outward now take a deep exhale and imagine the line extending upward, take one more in breathe and image a line being drawn across creating a top.  Take a moment and breath out imagine the square being completed with the last line going downward.

• Finger Lettering: Choose a word of affirmation and spend a minute thinking about that word.  For example let's say the word is "Hope," now finger spell the word, you can do this in the air in front of you or just imagine the shape of the letters.  "H" goes up in a straight line, has another paralleled line and a short line in the middle connecting it....now continue until the word is gone.

Feel free to leave any mindfulness techniques that you use in the comment section or tweet me @APazMA

Borderline Diagnosis in Men

I have an obsession with Celebrities and particularly celebrity gossip; I like the juicy overly personal stuff;  Britney Spears shaves her head, Lindsay Lohan drunk driving, Mel Gibson calls a cop "sugar tits" while drunk driving.  I try to stay away from the speculation gossip, the who is dating who and especially the who has mental illness part?  Even that seems off bounds to me, although I do like it when someone (especially someone outside of the norm) comes forward.

Brandon Marshall, the Miami Dolphins receiver, today announced that he suffered from Borderline Personality Disorder (BPD). The mental illness affects 2 percent of the adult population and is less well known than other disorders like schizophrenia and bipolar disorder. It is characterized by mood swings, unstable self image, troubled relationships and fears of abandonment.BPD diagnoses are overwhelmingly more common among women. Nearly 75 percent all BPD diagnoses are made in women. There is speculation that both Marilyn Monroe and Princess Diana suffered from BPD. 

The mental illness -- which may arise from childhood issues of abandonment, trauma and sexual abuse -- is also characterized by a high incidence of self harm and suicide. Nearly 80 percent of those diagnosed with BPD report having suicidal tendencies. Other typical symptoms include disproportionate anger, impulsive sex, periods of alcoholism and binge eating. BPD often occurs in conjunction with other mental illnesses like anxiety and depression.Perhaps the biggest issues for those suffering from BPD are low self image and constantly shifting relationships. People with BPD quickly swing from idealizing a loved one to hating them over a perceived slight. 

BPD is usually treatable although it often goes diagnosis or gets mistaken for another mental illness, most typically bipolar disorder. Treatment includes talk therapy, dialectical behavior therapy Article

I must admitt I don't follow sports either this just came across my google alerts, but for full effects this is what he looks like:

Simply put he doesn't fit the profile we typically hear about (or see in my office) with Borderline Personality Disorder.  He is a 28 year old African American male, standing 6' 4" and weighing 230lbs.  The most common image we have from media about BPD is Girl Interrupted, where a waify white female who chain smokes is in a mental hospital for 18 months for her Borderline symptoms.  Recent articles are now saying the split for diagnosing Borderline Personality Disorder is 50/50, where in the DSM IVr it was stated at 75/25 with an overwhelming amount of diagnosis as female.  I personally have had a handful of men in the DBT groups I have ran (the groups were not diagnosis specific, but the agency was 50/50 male/female.)  I never had a male complete the program, and they were more likely to listen, be quiet, pay attention then drop a few weeks in under the radar so I never had the opportunity to ask why.  Being I have yet to work with a male diagnosed with BPD and couldn't find much research,besides this brief article that lists traits men with BPD have:

1. Initially comes on very strong and romantic. Borderline men tend to be very sensitive and romantic. In a sense they are addicted to the notions of romance and love. Initially this can be one of the more alluring qualites of these men. 

2. Quick to declare his love. A borderline man will sometimes profess his love on a first or second date. In truth borderline men either have a very distorted sense of love, or simply don't know what genuine love is. 

3. Substance abuse issues, including alcohol, and perhaps drugs like cocaine, marijuana, and pills. Chemical addiction among borderlne men is very common. This male is essentially self-medicating himself in order to soothe his deep emotional pain and feelings of being unlovable. 

4. Overly jealous. Bordeline men are very insecure despite their apparent confidence. In relationships they will react with hostility and jealousy around other males. 

5. Grandiose. Borderline men tend to be very boastful. They are grandiose in the way they think and talk about themselves. They will brag, exaggerate, and lie about their accomplishments and their abilities. In reality this narcissism is an attempt to compensate for a very fragile sense of self. 

6. Great lover. Borderline men tend to be hypersexual or even sexually addicted. Women describe them as fantastic and very giving in the bedroom. Borderline men will use sex as a replacement for true intimacy or love. In addition a borderline man will use sex as a way of winning or securing a woman. 

7. The suggestion of a breakup sends him off the "deep end". At the heart of borderline personality disorder is the issue of “abandonment”. Any indication of a breakup, whether real or perceived, will activate fear, anger, and incredible sadness in him. This male will even preemptively end a relationship if he feels that a breakup is coming. 

8. Impulsive and reckless. Impulsivity is a hallmark feature of this disorder. This can include gambling, promiscuous and unprotected sex, reckless driving and speeding, driving while intoxicated, excessive spending, etc. 

9. Bad temper. This male being very insecure is highly sensitive to perceived slights or criticism. His anger can be explosive and well out of proportion for the situation. 

10. Frequent mood swings. Rapidly changing moods are very common with borderline disorder. This male can go from feeling confident and arrogant to insecure and depressed within hours. 

 Being I have zero experience any males with Borderline Personality Disorder want to speak about how their symtpoms manifest oppose to females with BPD?

Borderline Changes for DSM-5

I am often inspired (sometime it's "stuck") by what I see throughout the week.  I try to "Ride the Wave" as often as possible but there are think about something past it's expiration date in my head.  Case in point the term "Borderline Personality Disorder," which someone on Twitter had issue with.  As I begin writing this blog about the possible DSM-5 revision  and clicked on "personality disorder" I had the same thought- calling it a personality issue makes it sound minimal and like you have a bad personality.  

Back to the topic: What changes might be in the DSM-5?  First off, the DSM is the manual for which people are diagnosed   I had a college professor say it was like ordering lunch of a Chinese food menu; choose 2 of  5 choices of meat; 2 of 4 sides and 1 of 6 beverage choices and viola you have a diagnosis.  It's a little more complicated than that but you get the idea. Currently it's a 5 Axis system, where Personality Disorder is on Axis II (which insurance companies typically only cover Axis I.)

The DSM 5 proposed revision will make ALL diagnosis on one Axis, like it is done in most other countries. So for example Jane Doe's Diagnosis: Major Depressive Disorder Moderate, Borderline Personality Disorder, Disease of the eye, Problems with living environment, GAF 55.  

Currently the criteria for Borderline Personality Disorder is as follows:

A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation).
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

The proposed DSM-5 revision is as follows:

A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by - and/or separation from - significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: 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.
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger.
 3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

Okay so following all that information, I am really interested in feedback from those currently diagnosed with Borderline Personality Disorder.  Please comment here and join the discussion or tweet #BPDDiagnosis.  As someone without the diagnosis here is my opinion- it's vague.  It is so vague that I am concerned that people will be over diagnosed with it, that insurance will not cover any care for those with the diagnosis. Or will it be diagnosed appropriate, as many people who don't have the diagnosis meet the criteria and more people will get the help they need?

The DSM-5 doesn't come out until May 2013 so don't fret.

Book Contest

Contest starts Friday 10/5 at 11:59pm EST and ends Friday 10/12 at 11:59pm EST

I am a huge fan of Debbie Corso's writing and her book Healing from Borderline Personality Disorder: My Journey through Dialectical Behavioral Therapy is now available here for download.  I believe in both Debbie's writing as well as DBT so much, I am giving away 5 copies this week and there are 2 ways to win one;

1) Leave a comment here with an e-mail address.  (You can create a 1 time junk e-mail address)

2) Become a fan of my twitter then tweet: "Just entered to win 1 of 5 copies of Healing from Borderline Personality Disorder by Debbie Corso.  Follow @APazMA and RT to enter #BPDBook"

After I receive 200 entries or by 10/12/2012 at 11:59pm EST, whichever comes first I will contact the 5 winners and ask for an e-mail address for those on twitter so I can "gift" the book to you.  I will not use your e-mail address for anything else besides sending the book and an e-mail confirming the book was sent.  If I can not get in touch with any winner within a week (and I will try my hardest to do so) I will give the remaining book(s) to another contestant.  The winners will be selected at random.  2 entries per person per day allowed (1 on here and 1 on twitter, so 14 total max.)  I will give 2 books to 2 winners from the blog and 2 books to 2 people from Twitter, the final book will go to whichever method gets more entries. Failure to comply with rules, such as tweeting your entry more than once a day will make you disqualified.  If you have questions tweet me!

Please play fair as I plan on doing this once a month with different books I purchase.

Parenting with Borderline

During last week's Twitter "Ask a DBT Therapist" a follower asked if it is possible to "heal" from Borderline.  As we wrote back and forth for a bit she said this line that had stuck with me, "it's a daily struggle even after a lifetime of therapy and self help. I hope my kids don't learn it...l I wonder of they are better off without me."   I spoke with her about people with Borderline Personality Disorder likely have invalidating parents and childhood abuse, which she admitted was true for her case.  I told her she can (mostly) control those 2 factors in her own children and left it there.  5 days later I am still thinking about the statement..

 "I hope my kids don't learn it"

I have not read anything on Borderlines raising children until last Sunday and since then have read just about everything on this subject to speak on it to the Borderline Community. Every article I read from every journal I could find stated that yes parents with Borderline often have issues with their children regarding "attachment and structure" every study involved mothers who were diagnosed as Borderline, but received no intensive mental health services.  There are no studies on those (who like the woman I was talking to on Sunday) have "a lifetime of therapy and self help," no studies on mothers with Borderline whom have done Dialectical Behavioral Therapy (DBT), have grounding techniques, skills or tools.

Tami Green has a Blog where she talks about her own struggles with Borderline Personality Disorder in it she talks to Dr. Blaise Aguiree about those diagnosed with Borderline raising  children.  He came up with this set of 10 guidelines for raising children, which utilizes a lot of DBT skill:

1. Validate your child and teach them to self-validate. Validating is, basically, the ability to articulate to your child that you understand their experience to be true and valid for them. This is key to helping your child learn how to trust himself.

And also, teach your child that no matter what, even the most compassionate humans are limited in their ability to understand an another person's experience. Most people don't set out to be mean and insensitive, and yet they may come across as being so. And also some people are intentionally vindictive. Either way, it is vitally important your children don't expect others to validate who they are, but rather that they learn to validate their own experiences.

2. Teach your child non-judgmental and dialectical thinking. Dialectical thinking is the ability to hold two opposing viewpoints at one time. This discipline develops more effective problem solving, better relationship building, and less black and white thinking (splitting).

3. Give them many opportunities to explore their own unique talents and competences. Guide them towards what you see they like, ask them questions about their preferences, let them make decisions. Get them talking about what is uniquely fun and interesting to them.

4. Know your own self very well. Understand your feelings, beliefs and behaviors and also expect that your child is distinctly different from you.

5. Teach distress tolerance and self-soothing skills. Those with BPD have a hard time regulating their emotions. Rather than reinforcing temper tantrums or backing down from requests just because they seem distressing to your child, teach them how to calm themselves and tolerate these types of interactions.

6. Learn not to react. Keep yourself grounded and model effective, not reactive, behavior. Firm, consistent, calm interactions are the goal.

7. Increase skill-building instruction and opportunities in the areas of: personal responsibility, interpersonal effectiveness, time management, basic finances, and appropriate social responses. On the other hand, and just as important, lower your expectations of them that are not consistent with their true selves and innate value system.

8. Attach consequences to bad decisions and reinforce good decisions. Prepare them for real world living, even if they face real challenges associated with a disability of any kind. Let them know that, even if there are challenges, you have 100% faith in your child having a meaningful life. Part of that belief is knowing you expect them to be able to navigate real-life situations.

9. Teach your child to consider others' feelings, thoughts and behaviors while also firmly holding to a strong understanding of their own needs. It is not an either-or life we live. We can remain firm in our own value system, while also contemplating and accommodating another's belief. How simple, and also how advanced a concept this is.

10. And finally, don't take life too seriously. Life is full of ups and downs. Teach them to go with the flow and don't sweat the small stuff. Life is good and meant to be enjoyed and it all turns out just fine. No one is perfect and life is about learning and growing from our mistakes.

This book was also recommended on most of the articles I found on parents whom have Borderline diagnosis.  I will warn you it's hard to find even online and it's about $50.

Bipolar vs. Borderline?

One of the joys of my job is that I diagnosis clients with mental illness, I find it necessary for someone to have the right diagnosis in order to move forward with treatment.  I often explain Mental Health diagnosis's as looking like a Venn Diagram with much overlap and often very little differentiation.

The tricky part is the past diagnosis's the clients have had.  There have been multiple clients that when I asked for current diagnosis they listed 5 contradicting diagnosis and the more I probed and speak with them the more it looked like 1 or 2 total.   This all brings me to a point regarding Bipolar  Borderline.  Most of the women that I have meet whom are diagnosed as Bipolar are not.  When I ask for mania symptoms they tell me things such as "I yell at my teenage son," "I blow up at my husband," "I get so angry I...." or "Sometimes I just don't want to talk to people and hide."  All of these are normal reactions for people with little/no coping skills.  I don't know anyone (even without a mental health diagnosis) whom wouldn't have at some point said yes to all 4.  I think this over diagnosis happens for a few reasons:

• Women are not suppose to get angry
• Anger in women sometimes feels like anxiety and a loss of control
• Psychiatrists don't know what Bipolar really is diagnostically
• Mood swings are viewed as "rapid cycling"
• It's easier to medicate a disorder than help someone with coping skills

For these reasons I take a lot of time and consideration into diagnosing women with Bipolar, especially those with trauma and abuse in their history.  Many of these women more likely have Borderline Personality Disorder (I am unable to "officially" diagnosis Axis II because of other reasons) and Post Traumatic Stress Disorder.  

Here are the difference between Bipolar and Borderline Personality Disorder (via Psychology Today article )

1. People with BPD cycle much more quickly, often several times a day.

2. The moods in people with BPD are more dependent, either positively or negatively, on what's going on in their life at the moment. Anything that might smack of abandonment (however far fetched) is a major trigger.

3. In people with BPD, the mood swings are more distinct. Marsha M. Linehan, professor of psychology at the University of Washington, says that while people with bipolar disorder swing between all-¬encompassing periods of mania and major depression, the mood swings typical in BPD are more specific. She says, "You have fear going up and down, sadness going up and down, anger up and down, disgust up and down, and love up and down."

*Do not diagnosis yourself-leave it up to the professionals*