We have written extensively in this blog and in our books about the strong scientific evidence that supports cognitive behavioral therapy (CBT) as one of the most effective treatments for both anxiety and depression. CBT is so well studied and validated that frankly, we can’t imagine why it shouldn’t be the foundation of most treatment plans.
At the same time, we’ve regularly recommended mindfulness techniques such as meditation, yoga, and mindful acceptance to our clients (and we practice what we preach). Mindfulness oversimplified involves focusing on and accepting the present moment. Throughout the years we’ve attended numerous continuing education classes to learn more about mindfulness techniques. Mindfulness is a part of Dialectical Behavior Therapy (DBT), Mindfulness Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT) and Mindfulness Based Stress Reduction (MBST). Wow, that’s a bunch of initials.
In my over thirty years in clinical practice, I have run into many challenging problems and issues. These challenges included severe treatment-resistant depression, debilitating obsessive compulsive disorder, and extreme cases of borderline personality disorder among many others. In the vast majority of cases, most clients eventually manage to get much better. But the most vexing issue I have ever dealt with did not involve a diagnosis at all–in the usual sense. It has nothing directly to do with anxiety, depression, eating disorders, or behavioral problems. It is not listed as a symptom of any particular personality disorder.
However, before I tell you what it is, I’d like to ask therapists, counselors, and clients what problems they have found to be the most difficult to deal with in their lives. What issues put up the greatest fight when you’ve tried to confront them? What, if anything, has confounded you and left you feeling stuck over and over again? Did you finally manage to move ahead? If so, how did you do it?
I’d love to know!
When the topic of Borderline Personality Disorder (BPD) comes up, you’ll probably hear the conversation focusing on the issue of anger and rage. Indeed, people who suffer from BPD often struggle with explosive emotional flare-ups. Those episodes capture everyone’s attention.
Other symptoms of BPD such as self-harm, impulsive actions, and unstable relationships stand out as well. However, people with BPD also suffer greatly from profound anxiety. Some people with BPD describe their anxiety as excruciatingly painful and debilitating. Quite often their anxiety centers on deep fears of abandonment. They believe that others will inevitably leave them and, once that happens, they will be left totally unable to cope.
The Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV), a book that defines and describes the symptoms of emotional problems, has been in the revision process for years. Health professionals (and insurance companies) routinely use the manual to guide diagnosis and treatment. Recently, considerable attention has been given to the proposed changes in preparation for the fifth edition of the book (to be released in 2013). The possible changes to the section on personality disorders will certainly generate much discussion and controversy.
More than a couple of decades ago, Marsha Linehan, Ph.D. developed a unique approach to the treatment of Borderline Personality Disorder (BPD) which she chose to call “Dialectical Behavior Therapy” or DBT. Research has established that DBT appears to help reduce some of the worst problems associated with BPD (such as repeated suicidal behaviors, therapy interfering behaviors, etc.).
If you want more information about DBT, consider starting with Wikipedia. In addition, Marsha Linehan, Ph.D. among others have since written a number of great books for professionals and laypersons alike which you can look up on Amazon. We included many elements of DBT in our book Borderline Personality Disorder For Dummies although we mostly tried to integrate the best techniques we could find from everywhere.
Chuck and I are going to get professional pictures for our web site in order to show our readers how much older we’ve become. So, already, I’m a bit worried about my smile. I don’t think I ever worried about the way I looked in pictures until I started to notice pictures of myself in my early 20’s. I hated them all. It must have been genetic because my grandmother who was born in 1882 or so carefully scratched all of her faces off her pictures before she died at age 92. No wonder I am a psychologist.
Scientists have looked into smiles. They measure the muscles in the face and call one smile– that involves two facial muscle movements the Ducheene Smile. For those of you who care, the zygomaiticus muscle pulls the corner of the lips up and the orbicularis oculi pars lateralis muscle lifts the cheeks, narrows the eyes and causes crow feet. The Ducheene smile is associated with real pleasure or amusement. The fake smile, sometimes called the polite smile, only uses the muscles in the mouth region. When people aren’t feeling happy or don’t have a natural talent to bring forth instantaneous joy, they often produce the social or polite smile. In fact one treatment for people with Borderline Personality Disorder developed by Dr. Marsha Lineham suggests that patients practice half smiles in order to control their underline feelings of unhappiness or anger.
When I am unselfconscious, in a dark comedy, feeling silly, or with kids, I usually don’t think about my smiles. However, when I am in front of a photographer, my cheeks and crows’ feet are paralyzed. I must admit, as the wrinkles in my face are overtaking my youth, I’m a bit less self-conscious than I used to be. So that’s good.
But, it brings me to a study that colleague Ken Pope reported on last week. In this study, one group of participants was given Botox (injections that paralyze muscles). This injection was given in the area that paralyzes the muscles that cause frowning. The subjects were then asked to read happy, angry, and sad statements. Those with the …
When I meet new people, they often tell me about someone they know that has some sort of emotional problem. Many people give me a synopsis of symptoms and ask whether or not a person has obsessive compulsive disorder, anxiety, attention deficit disorder, depression, or borderline personality disorder. I’m pretty quick to say that I don’t ever make a diagnosis without seeing a person, but can talk about some qualities that might suggest this or that. I almost always point out that emotional problems are different than physical ailments; they tend to be more dimensional and less categorical. At this point, most people are stifling a yawn and moving on to the next topic (or in your case blog).
But our blog readers tend to be persistent, so let me continue. In the medical model, which psychology too often tries to emulate, a person has a disease and that disease can, in most cases, be verified by a medical test. For example, your biopsy reveals cancerous tissue or your blood test suggests that you have been invaded by parasites. Or the sore throat, fever, and a positive culture are consistent with a diagnosis of strep throat. Good medical diagnosis then hopefully leads to specific, specialized treatment.
The diagnosis of mental disorders is not so black and white. You don’t catch depression. And the symptoms of depression can look very different among people. Some with depression sleep too much or eat too much. Some toss and turn all night and lose their appetite. Some weep; others rage. There’s no blood test or MRI for assessing a diagnosis of depression. And unlike pregnancy, you can be just a little anxious or depressed.
The same diagnostic issue is even truer for what are known as the personality disorders. For example, the diagnosis of Obsessive Compulsive Personality Disorder (which is different than the more commonly known, Obsessive Compulsive Disorder) requires a person to demonstrate four of the following eight symptoms (according to the DSM IV TR):
In the past several decades, we’ve watched the treatment of Borderline Personality Disorder (BPD) evolve from a virtually hopeless status with no clear answers as to what may work, to a far more sophisticated and hopeful array of possibilities (see our earlier blog on Increasing Hope for the Treatment of Borderline Personality Disorder). Have you ever wondered or worried that you might have BPD? The actual, current approach to diagnosing BPD is quite complex, but the four components that most folks with BPD demonstrate include:
If this description seems to fit you, please see a licensed mental health professional for a diagnosis. Although we see the mental health diagnostic system as highly flawed, there’s enough value in understanding the nature of your problems that we do recommend you get yourself checked out.
But if you discover that you have something like BPD, what should you do next? First, try …
My wife, Dr. Smith, and I are big fans of mindfulness approaches to therapy and we’ve included discussions of mindfulness in most of our self help books within the For Dummies series (including Borderline Personality Disorder For Dummies). In brief, Mindfulness is typically described as involving focused attention on experiences in the present moment as well as acceptance and openness to whatever the present entails. Experiences are observed and noticed rather than evaluated and judged.
A real advantage of taking a Mindful approach to experience is that relatively few present moment experiences are truly “awful” or intolerable. In fact, the vast majority of things that gravely upset people have to do with imagined, future catastrophes or guilt, shame, and self loathing over past actions.
One of our favorite discussions was about me learning the value of mindfulness in our earlier book, Depression For Dummies and it goes as follows:
Charles never feels as grounded and at peace as when he takes our dogs on a long jog three or four times each week. He heads out the door and in just a few minutes makes it to the West Mesa overlooking Albuquerque. You can see the entire city laid out at the footstep of a majestic mountain range. The view is stunning and you can see many miles out to the horizon.
The mesa is laced with dirt roads and gullies created by occasional downpours that blow through the otherwise parched land. Rabbits routinely dart across the running path. And once in a while, you can spot a coyote in the distance. Charles connects with the experience by noticing the rhythm of his running, the obvious joy the dogs exhibit, the quiet, and the (usually) gentle breezes.
Because he runs a long way, sometimes predicting a sudden downpour is impossible. The first few times rain started to drizzle, Charles cursed his fate and picked up the pace to return home as quickly as possible. But frequently Charles got soaked before he arrived home, and he felt distressed at his soaked condition. After all, everyone knows it’s awful to get drenched in the rain.
People sometimes ask us if they should stay with a partner who has Borderline Personality Disorder. They tell us that their loved one can flip from wonderful to horrible in a split second. They wonder whether they should keep working on the relationship or abandon ship.
We tell those asking this question that people with Borderline Personality Disorder (BPD) indeed engage in a wide variety of behaviors and states of mind. Not surprisingly, people who care about those who have BPD often ask which of these various states represent the “real” person–the difficult states or the endearing ones? In order to answer that question, let’s first take a look at some of the disagreeable states as well as what may cause them. Then we’ll review the positive behaviors and the causes for those. We’ll conclude by filling you in on which ones reflect the “true” person at the core. And most importantly, we’ll give you a few issues that may help guide you in making this difficult relationship decision.
Negative Behaviors and States of Mind
People with BPD often inflict harm on those they love (sometimes quite intentionally; other times without conscious intent at all). They can say and do things that are perceived as astonishingly hurtful. Furthermore, people with BPD often fail to understand appropriate limits and boundaries of those they care about. Thus, a man with BPD might attempt to control his partner by demanding that she cut herself off from her family because they don’t “like him.”
In addition, those with BPD often criticize their partners for not “doing enough or earning enough” for them or their family. They may burst into rage, anger, or impulsive actions with seemingly little provocation. Often their partners who don’t have BPD find that their self-esteem suffers and they begin to question their own sanity, thinking that their partner is right–they really aren’t doing enough or they’re doing things the wrong way.
What causes such distressing, yet inappropriate behaviors in those with BPD? All too often, people with BPD completely fail to understand the nature of their behavior and how it affects those they care about. In addition, people …