Ask Any DBT or BPD Questions This Weekend!

Hi All,

Quick note.  This weekend I will do a Q&A on twitter.  Feel free to ask me any questions about DBT or BPD.  Tweet them @apazma, DM me to be anonymous, e-mail or leave them in the comments below.  I will re-post all questions (minus names) here after I am done.

Great way to get some professional information!

My Personal DBT Diary Card

I was thinking today while on Twitter that although I do talk about some personal items (mostly my mischievous dog and cooking skills) and I have shared Why I become a Therapist, I have not shared how DBT has helped me.  I currently do not meet any criteria for any DSMIV-r diagnosis, but learning about and teaching DBT has helped me immensely in my life.  Here is a list of the most (and least) common used skills:

Mindfulness: I use this almost daily, so much so during stressful times at work, sometimes while in group that clients have "caught" me suddenly re-positioning myself to do some grounding/square breathing.  This most often happens when someone shares their autobiography or I am dealing with my own personal issue and need to re-focus on the task at hand.  I also use mindfulness when doing paperwork, the dreaded part of counseling.  After 4 hours of Utilization Reviews, "square breathing" and "observe and describe," helps me focus on the task.

HOW Skills: I use these when I come in every Monday to a stack of sheets to file, a slew of notes from clients stating "I need to talk to you ASAP," as well as an occasional bombardment of someone in my office at 7:30am with an urgent issue, that needs to be solved fast.  The HOW skills allow me to non-judgmentally (instead of yelling, freaking out or catastrophizing,) one-mindfully and effectively assess the situation.  In short it helps me to remain calm and prioritize: pick group sheets off floor, quick organize, turn on computer while I read the client notes to me, prioritize highlighting and placing anything urgent on top of pile in front of computer, check e-mails, respond quickly if necessary or it is something short that I don't want on my to-do list, continue working on paperwork to do first (I create a to-do list on Saturdays for Monday.)

Distress Tolerance- Sensations:  All the time in group or one-on-ones I use this skill in very basic ways, sometimes it's as simple as fiddling with a Styrofoam cup I randomly keep in my office, rolling the toilet paper (we don't have the luxury of tissues in prison) into small balls or noticing the heat from the computer on my left leg.

Improve the Moment: Mints, I keep a larger round container in my office and although they are great for some breath refreshing post-lunch I often use it to Improve the Moment.  Simply popping a spearmint piece in my mouth for a few seconds vastly improves whatever I am doing and it also gives me a reason to get out of the chair and look away from the computer for a bit.

Wise Mind: In the prison, we refer to it as "I over E" (intellect over emotion) and use it as a cognitive skill.  I use this all the time, and encourage my clients to do the same.  For example I am now able to notice my ears getting hot, my heart racing before the feelings of anger or panic.  I am able to think very concrete and remind myself almost instantly "this too shall pass."  A close friend/counselor told me she spoke to her anxiety, and for me that seems a little odd, I do talk to my feelings saying things like "This is anger right now, you feel betrayed, upset, sad and disrespected  and this will stop.  Is it valid? What DBT skill can I do to Improve the Moment? What is my best option for being most effective right now. This too shall pass."

Can you tell what days are more stressful and which days I have off?

I am going to stop here, as I could probably list 20 instances in he last 5 days I used DBT skills.  There are some I struggle on still as well:

PLEASE: I try to sleep 8 hours, but stress and the late night anxiety ("I need to remember to pack a lunch tomorrow? Where are my brown shoes? Can I wait until Saturday to wash the dog? Do we have enough OJ for breakfast?") often keeps me up and I find myself staying up to do fun things only to regret it in the morning.

DEAR MAN: I am good with this one up until the end, negotiate is what trips me up.  I do think part of it is due to the power dynamic working in a prison where my word is the final word most of the time.  I am very assertive, but when it comes to moving an inch, I sometimes personalize and I often get stubborn.

So that's my best/worst list.  What skills do you utilize most often? Which ones are you struggling/still working on?

BPD and Relationships

In group I have my clients work on the Power and Control Wheel numerous times in the 6 month program.  I think it is really important for those with mental illness and addiction issues to be able to identify what is abuse.  The most interesting part is when I ask them to identify ways in which they were the abuser and used the P&CW against someone else.  It's harder to come to grips with, but a few are vocal about using abuse against someone else, most of the examples are holding children as pawns, physical abuse, comments about a man's sexual performance to belittle him and cheating as a way to demean him.  I bring this up because as I have been considering writing about Borderline Personality and Romantic Relationship, but everyone I try- I get distracted and a more optimistic blog idea pops up.

Until I read "A Woman With BPD Explains Her Actions in Romantic Relationships"  by the author of Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder. In it she has the very honest and personal account of someone with BDP who explains her past relationships and the abusive tactics she has used:

• Purposely broken a gift you gave me 
• Flirted with several other people at a time or having a crush on others while I'm still dating you
• Said some of the most cutthroat things you've ever heard .
• Talked about suicide even though I know it hurts you
• Pulled a "Dr. Jekyll and Mr. Hyde"
• Pushed you away then pulled you right back
• Started an argument out of nowhere

The author of the article goes into depth about why someone with BPD would act this way, most of it boils down to the fear of abandonment as well as mood swings that can cause quick fluctuations of love and hate. Reminds me of I Hate You--Don't Leave Me: Understanding the Borderline Personality.  And yes according to the Power and Control wheel the above 7 bullet points could be broken down like this:

• Purposely broken a gift you gave me Intimidation & emotional abuse
• Flirted with several other people at a time or having a crush on others while I'm still dating you Intimidation & emotional abuse & using coercion and threats
• Said some of the most cutthroat things you've ever heard emotional abuse & isolation & minimizing, denying and blaming
• Talked about suicide even though I know it hurts you emotional abuse & using intimidation & isolation & using coercion and threats & denying, blaming and minimizing
• Pulled a "Dr. Jekyll and Mr. Hyde" emotional abuse 
• Pushed you away then pulled you right back emotional abuse, denying, blaming & minimizing
• Started an argument out of nowhere emotional abuse, minimizing, denying and blaming

So that's the bad news, those with BPD are often the abusers (not saying they are not as often abused) in romantic relationship.  And it may sound like a broken record, but there are ways to get better and once again this is why boundaries are so important. So what steps can be taken to have healthy relationships?  Here is a great article from BPD Central with the 10 Essential Limits for Romantic Relatonships:

The 10 Essential Limits

Keep in mind that a limit is not about rules or telling the other person what to do. You can't control their behavior; you can only control your own. Limits are based on your personal values and about what you will do to take care of yourself. For more information about limits, what they are and what they're not, and how to set and observe them, see my book The Essential Family Guide to Borderline Personality Disorder.

1. No mindreading. Your job is verbalize your own thoughts, feelings, concerns and preferences. By contrast, assuming you know the other person's thoughts and motivations (e.g., "You think that.." or, "You did this/said this because....") is almost always guaranteed to get you into trouble. Mindreading is one of the biggest obstacles to effective communication; it is invalidating, provocative, and almost always based on misinterpretations.

2. Build routines of taking a time out when things begin to get heated. People who are furious simply can't think straight; their brain is so focused on their feelings that logic gets thrown out the window. This is especially true with BPs and NPs. You can test this yourself. Think about something you said in the moment of anger that you regretted the next day (or week).

Talk about time-outs at a calm before they are needed, letting your partner know how this will work and assuring him or her that you two will come back to finish the discussion when you are both calmer. (Your partner, of course, has the option of initiating a time out too.) Find a safe place that is sacrosanct to you where no one else can enter when you need to be alone.

Early exits when either of you is beginning to feel a temperature rise prevents unsafe, hurtful mistakes--verbal as well as physical. Take the pot off the stove by removing yourself early on from a situation you may not be able to handle calmly.

3. Regularly do things you both enjoy and share positive reactions to your partner. The two of you need positive shared time and interactions to keep the relationship connection solid.

Positivity makes relationships worth having. The more appreciation, agreement, affection, playfulness, attention, etc you offer each other, the sunnier your relationship will be.  And the more you give, the more you'll get.

4. Focus on what you can do to improve situations rather than criticizing each other. And if you do feel it could be helpful to say something to your partner about what she or he has been doing, offer it as feedback, not as a criticism or complaint. People with personality disorders take criticism very badly, so it doesn't work to change their behavior.

Instead, learn ways to bring up your concerns without being critical and triggering the other person's defenses (well, as much as you can for a person with BPD/NPD). To give feedback offer a when-you statement, as in, "When you xyz, I feel abc"). Especially avoid the phrase, "You make me feel."  That's blame.

Remember that it's not your job to tell your partner what he or she should or shouldn't be doing. It is up to you to be honest about how you react as a consequence of your behavior. Your partner's concern for your feelings will tell you a lot about their capacity to show their love.

Just because you stop criticizing them won't stop them from criticizing and blaming you. With your own therapist or one of my books, formulate a strategy for how you will respond. My books go into this in detail.

5. Do not speak with contempt, ever. Studies have shown that couples who communicate contempt for each other are the most likely to break up. This principle is most important with regard to listening. Dismissive or eye-rolling as a form of listening dooms relationships.

6. No hostile touching; no putting hands on each other in anger. No threats or hurting property, either. Have a zero tolerance policy. Men, take any physical aggressiveness by your girlfriend or wife seriously; abuse of men is an underreported epidemic. Document, document, document, and be in communication with the police.

Never put your hands on your partner. Even if it is a mild pat, your partner may exaggerate it and make false abuse claims. You may end up in jail and unable to see your children.

7. Each person needs to have his or her own space, private time, and friendships as well as joint ones. Keep up with your friends and family and never become isolated. Isolation is the kiss of death to your confidence level, well-being, and sense of reality. Find at least one friend or counselor you can be honest with about what's going on. You need outside perspective, even if that threatens your partner.

8. Take responsibility for having and managing your own feelings, verbalizing your concerns and preferences, and being responsive to your partner's concerns and preferences.

9. Come to a mutual agreement about monogamy (or lack of) so you are honest and on the same page. Do not put up with infidelity (however you define it) that goes against your values. With infidelity, your sense of self-esteem will take a huge nosedive and your marriage will eventually be in name only. Again, formulate strategies with a therapist.

10. Work on problem-solving, not blame, and find win-win solutions so "Your-way" and "Their–way" differences lead to an "Our-way" solution that you both feel good about.

BPD and Medication

A counselor friend this week asked me the following question:  If there is no medication for Borderline Personality Disorder why are so many on medications?  Pretty valid question.

No medications have been approved by the U.S. Food and Drug Administration to treat borderline personality disorder. Only a few studies show that medications are necessary or effective for people with this illness. However, many people with borderline personality disorder are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time, but there is little evidence that this practice is necessary or effective. source

I have meet many people with BPD who have another diagnosis (or 5); Anxiety disorders, depression, PTSD, etc.  So for some people they are receiving medication for a separate disorder, which sometimes has overlapping symptoms.  For those of you who follow me on Twitter you know my issue with being people misdiagnosed with a plethora of other diagnosis, that gets added to each year when BPD is the only one.  Putting that aside I also think some people with BPD (especially those whom are newly diagnosed) are given Benzodiazaphines (I will save my opinion on that for another rant) to cope with the anxiety caused my BPD.

I work full-time in a prison, the female inmates are in a 6-month program, I find that month 1 everyone is knocking on my door about medications, someones their mental illness is valid often it is not (mostly due to drug use.)  Month 2-3 some mental health issues come to surface, as the program is intensive 20-hour a week therapy and people are now dealing with things they have stuffed for so long and they have a decent amount of clean time.  Right now my group is in month 3, what started as 11 on medication (out of 21) is now 5.  I asked the group why it has dwindled down significantly in 90 days.  The answers not surprising; 'we now have cog skills, I started journaling, grounding techniques, coping skills, I take to my bunkie about it.'  Many of these women are using skills over medication.*

So maybe medication is not available to you (Big Pharma will be another rant as well,) or maybe you are on medication and looking to gain more coping skills- here is a list of modes to get well for BPD:

• Dialetcical Behavioral Therapy Self-study material
• EMDR mostly used to handle trauma
• EFT (tapping)
• MBT used more in UK (Thanks to anon comment for the info)
• Social Support. Talk to others who may understand what you are going through. 
• Behavioral Activation. Engage in an activity that might take your mind off the stressful situation for a little while. 
• Relaxation Exercises. Practice a relaxation exercise, such as deep breathing or progressive muscle relaxation.
• Grounding. Practice grounding exercises that are designed to keep you "grounded" in the present moment, rather than caught up in replaying events in your head, worrying about the future or zoning out. 
• Mindfulness Meditation. Practice mindfulness meditation, which helps you to observe and describe your experiences without judging or rejecting them. 
• Active Problem-Solving. Consider the problem at hand: Is there a way to solve the problem directly? (source for 5-10)

*I am not saying medication may not be necessary for some

BPD Community Pinterest

I love Pinterest and I find myself spending more and more time sharing inspirational quotes I find on there.  So, I decided to create a Pinterest Community page.  E-mail, comment here or DM on Twitter with your e-mail address and you can view, share and add your own pins.  

As an FYI I had to set it up as a business account, otherwise it would sync with my personal account (and only so many people can look at Corgi boards!) 

I won't be doing any kind of "screening" before someone posts on there, so if you see anything triggering or inappropriate let me know and I will be quick to delete and if necessary un-invite someone.

BPD Community

Mental Illness and Self Identity

Since the book contest has been going on for a week (congrats winners!) I have not been blogging, but now my ideas are running amok so it's time to put down on paper what's swirling around my mind.

I have been getting a lot of questions about the new changes to the BPD diagnosis in the DSM5 coming out in May 2013, which was just finalized this weekend.  The new diagnostic criteria for BPD in my opinion is vague and covers too many people.   But what if looking at the current criteria, and after years of therapy, DBT, CBT, therapy, heck even EMDR therapy you now meet 1 or 2 of the criteria when 5 or more criteria equals a Borderline Personality Diagnosis?  Well, first off you no longer have a BPD diagnosis (per the DSM IV-r) but does this make you "cured?"

"Recovery may seem like an illusory concept. We still know very little about what this process is like for people with severe mental illness. Yet many recent intervention studies have in fact measured elements of recovery, even though the recovery process went unmentioned. Recovery is a multidimensional concept: there is no single measure of recovery, but many different measures that estimate various aspects of it. The recovery vision expands our concept of service outcome to include such dimensions as self-esteem, adjustment to disability, empowerment, and self-determination. However, it is the concept of recovery, and not the many ways to measure it, that ties the various components of the field into a single vision. For service providers, recovery from mental illness is a vision commensurate with researchers’ vision of curing and preventing mental illness. Recovery is a simple yet powerful vision  (Anthony, 1991.)"

I have worked with many people whom were diagnosed with a mental illness, and though therapy, groups and sometimes medications, were doing better; holding down jobs, attending college, making friends and felt like they were lost for a while, "I have been Bipolar for so long who am I now?"  I think this mindset can be especially true for some with BPD, since the therapy is so intensive and the community is so tight-knit.

Take for instance a client I worked with whom had Bipolar disorder with psychotic symptoms; he had been attending NAMI groups for years, most of his friends were from the mental health clinic I worked at, his calendar was filled with Bipolar workshops, meetings, and events he had been attending for years.  After years of therapy and medication he was still attending these events and at some point I told him he was the poster child for "Bipolar Success."  He was confused by this term "success," he asked, "am I cured?"  I opened the DSM IV-r and read through the criteria for his current diagnosis- he meet 2, when 5 was needed.  After I assured him that he was not going to be dropped from services due to this (oh, insurance woes,) we spoke about if he should continue to spend 20 hours a week surrounded by those with a mental illness he no longer has? Should he drop all his friends? Was it appropriate to discuss at NAMI meetings issues surrounding a mental illness he no longer has? Should he tell people?

After a 50 minute session and a follow up phone call (he was "freaking out!") we decided his plan of action; it is okay to continue the relationships he has created, he can be a role model for others regarding what recovery looks like; attending NAMI meetings-okay BUT new doors are now open he didn't think were when he was diagnosed before; college classes, a healthy relationship (he was too embarrassed prior to have one,) and  full-time employment over collecting disability.  He was (understandably) so attached to his identity that he didn't know who he was without it.

I understand this isn't the case for all people with Mental Illness, as some hide their mental illness from others, are not properly diagnosed and some even avoid the reality of their illness.

Here is a great list of people's stories regarding their mental illness recovery Connections: Stories of Recovery from Mental Illness:

"Today, LeRoy doesn't see any doctor for therapy. He sees his doctor simply to refill his prescription when needed. His treated Delusional Schizophrenia affects him as much as treated diabetes or high blood pressure would. He takes responsibility for it, and life goes on.  "I take my pill at bedtime. I haven't really had any side effects," he says.  But perhaps there has been a side effect his job. As a survivor of a mental illness, LeRoy realized he now has a responsibility not only for his own recovery, but for the healing of others. So he's made a career of it. LeRoy helps other people with mental illnesses, called clients, as they walk their own road to recovery.  He says he may be making less money than he set out to earn, but he's helping more people than he ever thought he could.   In addition to mentoring and supporting people with mental illnesses, LeRoy tries to teach the public about mental health issues. He speaks to churches, schools, and practically any group or individual who wants to hear about the bravery of those who battle mental illness.  It's easy for LeRoy to talk about bravery, because it's bravery that helps him accept himself, accept his diagnosis, and go forward.  "You can't deal with your mental illness until you can agree with yourself that, 'Hey, I have a mental illness so I need to be responsible and take care of it.' "  He's brave. He's responsible. He's taken care of it. LeRoy Simmons is a survivor, (pg. 13.)"

 I would love feedback from anyone who no longer meets the criteria for BPD regarding how they got recovery and how (if at all) their identify was wrapped up in their diagnosis.

November Book Giveaway

Update: After seeing all the lovely comment's about Debbie Corso's work I have decided to give away 10 copies of her book instead of 5

It was a great success last month, with 5 people winning Debbie Corso's last book (1 person even paid it forward giving away another 5 copies!)  On November 30th her new book Stop Sabotaging a 30 Day DBT Challenge to Change Your Life will be available for purchase on Smashwords.

And I am happy to announce I am the introduction writer!

Starting on Friday November 23rd at 11:59pm until Friday November 30th at 11:59pm I will be giving away 10 copies of Debbie's new book as well as 1 copy of Brene Brown's The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are and the 1 copy of Buddha and The Borderline

There are 2 ways to win one of *10* of Debbie Corso's book:

1) Leave a comment here with an e-mail address stating which book your prefer

2) Become a fan of my twitter then tweet: "Just entered to win 1 of 10 copies of Stop Sabotaging by Debbie Corso.  Follow @APazMA and RT to enter #BPD #DBT"

There are 2 ways to win the other 2 books:

1) Leave a comment here with an e-mail address stating which book you prefer. 
2) Become a fan of my twitter then tweet: "Just entered to win 1 of 5 copies of (book title).  Follow @APazMA and RT to enter #BPD #DBT"

Rules: After I receive 200 entries or by 11/30/2012 at 11:59pm EST, whichever comes first I will contact the 7 winners and ask for an e-mail address for those on twitter so I can "gift" the Stop Sabotaging e-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 there are any issues.  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 of the other 3 books will need to send me their physical address to have the book shipped from Amazon via DM on twitter or e-mail.  The winners will be selected at random from my blog and twitter.  2 entries per person per day allowed (1 on here and 1 on twitter, so 14 total max.) 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.  Next month I might give away Linehan's DBT workbook & 3 months of DBT coaching for the holidays....will update!

Dealing with trauma issues with BPD

Although the DSM IV-r criteria for Borderline Personality Disorder does not include trauma, it is often a common thread in those with the disorder.  Often on Twitter I see a tweet started with "TW" (trigger warning) before something that may be triggering, it's a safety boundary for many in the BPD community.  In DBT we strictly enforce the rules about saying things that can be triggers, sometimes those who don't have BPD don't realize how harmful what they say can be, sometimes people try to stir up some drama and some are so disconnected from their trauma they don't understand how someone could be hurt by what they are saying.

Adults with borderline personality disorder (BPD) showed excessive emotional reactions when looking at words with unpleasant meanings compared to healthy people during an emotionally stimulating task, according to NIMH-funded researchers. They also found that people with more severe BPD showed a greater difference in emotional responding compared to people with less severe BPD. The study was published in the August 1, 2007, issue ofBiological Psychiatry. [source]

This week myself and a client came to the conclusion that talking about her trauma only continues to hurt her more than help her.  Creating a boundary became necessary since other clients continue to push her to speak about the horrific trauma thinking that like them she needs to "get it out and give it away." In group she announced this decision and the overall look was puzzled, so we decided to allow questions as this appeared to go against everything they have been taught since being in therapy.  The questions were in 3 categories; 1) doesn't keeping it in, keep us sick? 2) How does talking about it make it worse? 3) So what are you going to talk about then?  The group decided to respect her boundary, although they were skeptical.  I decided to not go into the details of Borderline Personality Disorder since the client had told me she was not comfortable with that.

The end question was then "Ms. Paz, how is she going to work on her trauma issues without talking about it?"  I spoke about working on how the trauma affects you now; relationship issues, boundaries, PTSD symptoms and focusing on coping skills and grounding techniques instead of living in the past.  The group was still unsure about this plan as it goes against what they have (thought) they have known for most their life.  HEre are some ways to work on your trauma without talking about the trauma [source]

1. Tell yourself that you are having a flashback  

2. Remind yourself that the worst is over.  The feelings and sensations you are experiencing are memories of the past.  The actual event has already occurred and you survived. Now it is the time to let out the terror, rage, hurt, and/or panic.  Now is the time to honor your experience.  

3. Get grounded.  This means stamping your feet on the ground to remind yourself that you have feet and can get away now if you need to.  (There may have been times before when you could not get away, now you can.)  Being aware of all five senses can also help you ground yourself.  

4. Breathe.  When we get scared we stop normal breathing.  As a result our body begins to panic from the lack of oxygen.  Lack of oxygen in itself causes a great deal of panic feelings; pounding in the head, tightness, sweating, feeling faint, shakiness, and dizziness.  When we breathe deeply enough, a lot of the panic feeling can decrease.  Breathing deeply means putting your hand on your diaphragm, pushing against your hand, and then exhaling so the diaphragm goes in.  

5. Reorient to the present.  Begin to use your five senses in the present.  Look around and see the colors in the room, the shapes of things, the people near, etc.  Listen to the sounds in the room:  your breathing, traffic, birds, people, cars, etc.  Feel your body and what is touching it: your clothes, your own arms and hands, the chair, or the floor supporting you.  

6. Get in touch with your need for boundaries.  Sometimes when we are having a flashback we lose the sense of where we leave off and the world begins; as if we do not have skin.  Wrap yourself in a blanket, hold a pillow or stuffed animal, go to bed, sit in a closet, any way that you can feel yourself truly protected from the outside.  

7. Get support.  Depending on your situation you may need to be alone or may want someone near you.  In either case it is important that your close ones know about flashbacks so they can help with the process, whether that means letting you be by yourself or being there.  

8. Take the time to recover.  Sometimes flashbacks are very powerful. Give yourself time to make the transition form this powerful experience. Don't expect yourself to jump into adult activities right away.  Take a nap, a warm bath, or some quiet time.  Be kind and gentle with yourself.  Do not beat yourself up for having a flashback.  

9. Honor your experience.  Appreciate yourself for having survived that horrible time.  Respect your body's need to experience a full range of feelings.  

10. Be patient.  It takes time to heal the past.  It takes time to learn appropriate ways of taking care of yourself, of being an adult who has feelings, and developing effective ways of coping in the here and now.

 Stay safe.
AP

Borderline Personality Disorder and Hallucinations

I often (maybe too often) talk about the misdiagnosis of those with BPD and along with many other diagnosis I find those with BPD have been diagnosed with Schizoaffective Disorder due to the hallucinations.  Part of this I believe is also the disassociation those with Borderline Personality Disorder deal with from past trauma. The term Borderline came from the original belief that those with BPD were  on the border between psychosis and neurosis.  Although this is no longer the belief, some still suffer with the psychosis elements.  

[source] A study of 171 Borderline personality disorder (BPD) patients revealed that 29.2% reported hallucinations. Most patients expressed that the hallucinations were distressing, occurred with great frequency over prolonged periods, took control of actions or behavior (especially, self-harming behavior) and had a critical quality. Although the majority of hallucinations were auditory, visual and olfactory hallucinations were also reported.

Hallucinations: Coping Strategies [source]

When voices are distressing, some patients may self-adjust their prescription medications or use drugs or alcohol to minimize the hallucinations. But there are better ways to deal with this issue.

• Fighting back. This technique involves yelling or talking back to the hallucinations. While resisting the voices may seem like a good idea, studies show that the "fight or flight" response can lead to depression, since the voices typically don't go away on their own.

• Passive acceptance. Although accepting that the voices are part of life for a person with schizophrenia seems to have more positive emotional effects, some argue that the danger of acceptance is that the hallucinations may start to consume your life.

• Mindfulness techniques. In a trial of a therapy called Acceptance and Commitment, participants significantly reduced the effects of their symptoms, and had slightly fewer re-hospitalizations, than a control group using traditional therapy. With this philosophy, the patient agrees to acknowledge the voices but does not agree to accept guidance from them.

For coping with delusions, not all strategies work for every person, and many people report using more than one strategy.

• Distraction. Focusing on a task, reciting numbers, taking a nap, or watching television can help distract the person from delusional, often paranoid, thoughts. A recent study showed that the choice of distraction is important. Researchers found that choosing favorite music or a news program was a more effective distraction tool than white noise. The study also reported that a personal music player with headphones might be the best way to listen to music when trying to ignore delusions. Headphones minimize other distractions, and people who used them tended to stick with this technique even after the study was completed.

• Asking for help. Some people with schizophrenia seek out the company of friends and family when they are experiencing delusions. Friends and family can help by providing a distracting activity, or even just a listening ear.

• Religion and meditative activities. People who are religious believers report using prayer or meditation to help deal with their active schizophrenia symptoms. Yoga, exercise, or walking can also shift the focus from the delusions and provide a sense of calm.

• Be selective. Some voices are positive and some voices are negative. An organization called Hearing Voices takes an interesting approach: The voices may not be physical beings, but they should still treat you with the respect that you expect from other people. This group recommends engaging with the voices, but politely. The patient should ask the voices to make an appointment, or tell the negative voices that they are not welcome until they have useful information.

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.