Borderline Personality Disorder and Dissociative States

shirt-tie-w-out-white-background-final-10We have come to the last, (and perhaps most difficult to describe and comprehend) symptom on the DSM IV, namely: “transient, stress-related paranoid ideation or severe dissociative symptoms”. The DSM 5 includes it under significant impairments in personal function with a similar descriptor of: “Dissociative states under stress”. When we see this definition we immediately think of two severe disorders, paranoid schizophrenia and dissociative identity disorder; however Borderline Personality Disorder (BPD), although having some similarities, is essentially quite different.

First the semantics. Transient merely means that the symptom is not continuous but comes and goes depending on the levels of stress and subsequent anxiety. The term ideation refers to negative mind states or thinking patterns involving negative past experiences that, again, may come to the surface under stress.  Paranoia here is much gentler than the kind of paranoia that we see in Paranoid Schizophrenia. By my own experience, I would describe it as a feeling that I do not belong, and the world out there is a dangerous place that required that I was always perfect, vigilant, and careful in my interactions with people. This leaves us with the term dissociative that we will examine more closely in the rest of this blog.

One study, although quite different in design, seems to bring what is happening into focus.  Ludascher et al (2007) applied electric stimulation on the right index finger with twelve female patients with BPD and twelve healthy controls. They found significantly elevated pain thresholds in patients with BPD, with a significant positive correlation between pain thresholds and dissociation, as well as between pain thresholds and aversive arousal. In a follow-up study, Ludascher et al (2010) using script-driven imagery, produced dissociative states in participants with BPD. These states on fMRI’s were characterized by decreased pain sensitivity and significantly increased activity in the left inferior frontal gyrus (part of the OFC) which is at least partially responsible for empathy, processing pleasant and unpleasant emotions, self-criticisms, and attention to negative emotions.  From these two studies we see suppression of emotional pain and interference in the functioning of some of the sections of the orbitofrontal cortex (OFC).

Typically when an emotional situation takes place (usually involving intimate relationships or high self-worth activities like work and some sports), the OFC and amygdala are activated, thus empowering us to take action and resolve the situation. Once it is resolved, these impulses are then channeled through the pleasure center of the brain producing a sense of joy and accomplishment. Serotonin and endorphin neural circuits are then activated giving us a sense of peace and euphoria.  However, if the emotional situation is too intense (such as a break-up), we will eventually but a block in place along those neural circuits connected to the images and thoughts and feelings.  This is a natural body function that is usually put in place to block the neurotransmitters that are coming from intense pain. The neurons simply withdraw their receptor docks, thereby preventing the messages from proceeding from the painful neural pathways to the OFC of the brain. Out of sight, out of mind. Works for most people.

But if this process has been corrupted by severe emotional problems during childhood such as emotional neglect, coupled with a supersensitive genetic predisposition, the OFC will not be able to process any additional emotional insult. The whole emotion processing system gets shut down. This theory is supported by Jones et al (1999). They assessed twenty-three patients with BPD, and 23 matched controls, with the Autobiographical Memory Test (AMT) and self-report measures. As expected, participants with BPD scored significantly higher than the control group on measures of depression, anxiety, and trait anger. However, they also scored higher in dissociative experiences that appear to be connected to general memories on the AMT. They concluded that patients with BPD had difficulty in recalling specific autobiographical memories, perhaps related to their tendency to dissociate, which may help them to avoid reliving memories that may have been emotionally painful.

These studies suggests that under stress, we lost souls with BPD tend to shut down emotional pain sensations because of our past painful experiences. Again, in my own case, whenever I was personally or professionally challenged by someone, and I felt my self-worth was at stake, I could actually feel a sense of numbness flowing through my brain and through the rest of my body. Quite simply, this suggests that some of us with BPD may have developed some kind of defense mechanism to interrupt the flow of pain within our brain. Because this pain is emotional in nature, it might indicate that we bypass our amygdala thus having an interrupted or numbing response when faced with an emotional situation.

Now this sounds like a perfectly good way to deal with overwhelming emotional situations, but there is a major drawback, which brings me to the last study in this section.  Ebner-Priemer et al (2009) used an aversive differential delay conditioning procedure with 33 unmediated patients with BPD and 35 healthy controls. They discovered patients that BPD with high state dissociative experiences and showed impairment in responding to emotional learning. They concluded that emotional, amygdala-based learning processes, may be inhibited in acquisition and extinction processes in therapy and should be closely monitored in exposure-based psychotherapy. It would appear that we do not respond well to traditional therapy methods. The amygdala, and parts of the OFC mentioned in these studies, are designed to provide the plan and the power to solve problems, including highly emotional ones. It is part of a circuit that leads to resolutions, a trip through the pleasure center of the brain, and to a nice comforting flow of serotonin. When we shut down these mechanisms, we shut down our ability to solve problems and to feel the joy and contentment of growing through our experiences.  And, unfortunately, we do not respond well to therapy.

So what is the answer? Again, I can only refer to my personal experience. I underwent an extensive  therapy including group, cognitive, and an assortment of other strategies, with only limited success. My true healing took place when I begin to see myself as a higher self in conflict with a mind self (talk about dissociative disorder). Only then, with the support of my higher self, was I able to explore my past emotions, cry with some, yell and scream at others, and feel the hurt and loss with the rest. It allowed me to  accept them, be thankful for their part in making me strong, and put them behind me. Then when old feeling returned, and I felt the numbing sensation coming on, I would connect to my higher self, and allow it to flood my mind and soul, cry, and move on.

Here are my five suggestions for those of us with a dissociative element in our BPD:

  1. We face our emotions. We notice that numbing sensations when we begin to shut down. We seek a quiet moment and allow the feelings to surface.
  2. We call upon our higher self to give us courage and strength to face them, deal with them, cry if we have to, or be angry with the people involved. We then allow the higher self to complete the circuit as the serotonin pathways are activated and endorphins are released.
  3. We continue to process these past emotions through contemplative therapy. In my case, I entered a state of meditation where I become aware of my higher self. I then allowed my mind to bring up past pains and deal with them. I did this on consecutive days until all the old wounds were healed. It took me several weeks before I felt the issues had been resolved.
  4. Whenever they resurface, I thank my mind for bringing it to my attention. If the time and space are appropriate, I give it permission to experience the old emotions. I soothe it with my higher self. “There, there it’s okay to feel this way. It’s okay to cry.  it’s okay to be angry.”
  5. If the timing is not appropriate or if an emotional reaction might lead to further conflict and pain, I allow my mind to suppress the emotion with the promise to resolve the issue and the emotions behind it during the next day’s meditation. Once I feel comfortable with, and in control of my emotions, I will bring it up at the next opportunity with my intimate friends and family. If it just an acquaintance from work or community, I may just let it pass and chalk it up to experience.

 

 

 

 

 

 

Ludascher, Petra; Valerius, Gabriele, Stiglmayr, Christian; Mauchnik, Jana; Lanius, Ruth A; Bohus, Martin; and Schmahl, Christian. Pain sensitivity and neural processing during dissociative states in patients with borderline personality disorder with and without comorbid posttraumatic stress disorder: a pilot study. J Psychiatry Neurosci. 2010.

 

Ludascher, Petra; Valerius, Gabriele, Stiglmayr, Christian; Mauchnik, Jana; Lanius, Ruth A; Bohus, Martin; and Schmahl, Christian. Elevated pain in thresholds correlate with dissociation and aversive arousal in patients with borderline personality disorder. 2007.

 

Jones, B; Heard, H; Startup,M; and Swales, M. Autobiographical memory and dissociation in borderline personality disorder. Psychol Med. 1999. Psychiatry Research. 2007.

Ulrich W. Ebner-Priemer, PhD, Jana Mauchnik, PhD, Nikolaus Kleindienst, PhD, Christian Schmahl, MD, Martin Peper, PhD, MD, M. Zachary Rosenthal, PhD, Herta Flor, PhD, and Martin Bohus, MD. Emotional learning during dissociative states in borderline personality disorder. Journal of Pschiatry and Neuroscience. 2009.

 

Borderline Personality Disorder and Anger

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We now move on to Symptom eight on the DSM IV, namely, “Inappropriate, intense anger or difficulty controlling anger.” On the DSM 5, it is listed under pathological personality traits in antagonism and includes “persistent or frequent angry feelings”, and “anger or irritability in response to minor slights and insults.” Some articles describe this out of proportion anger as “BPD rage”. There is a relatively small sample of research on the topic, but I have located two well designed projects that should shed some light on the topic.

Cackowski et al, in a small sample of twenty-nine female BPD patients, 28 ADHD patients and 30 healthy controls, found that BPD patients reported higher trait aggression and hostility, a stronger tendency to express anger when provoked, and a tendency to direct anger inwardly. They concluded that there may be a significant impact of stress on anger in BPD patients; however, it appears to be directed towards the self rather than to others.

Krauch et al used functional MRI to observe brain scans when twenty BPD and twenty HC adolescent participants were exposed to scripted imagery. They found that adolescents with BPD showed increased activity in the left posterior insula, the left dorsal striatum, and the left inferior frontal cortex. The insula is connected to our old friends the amygdala and the thalamus and is part of the limbic system involved in processing emotions. It is also believed to be involved in the processing of physical and emotional pain in an attempt to create homeostasis or balance during interpersonal relationships.  The striatum is part of the forebrain that is believed to be involved in the reward system, inhibitory control, and impulsivity. The inferior frontal cortex is, of course, our administration center that employs mind states to solve problems.

So what does this mean in layman’s terms? Quite simply, it shows that we unfortunate souls with BPD have overactive brains in the areas involving negative emotions and subsequent behavior. When our emotions are activated by minor conflicts, we have a difficult time processing the information and calming our overactive brain. We tend to react with frustration and anger, but since we are so dependent on our relationships with other for our sense of self-worth, we direct this overcharged anger against ourselves. This often shows up in self-harm activities and suicidal behavior.

So what does all of this mean? First of all, let’s deal with the data from these studies. Even though Cackowski et al’s study was carried out with women, I think we can safely employ these results to men. We have a tendency to experience the same emotions but deal with them in different ways. We tend to suppress causing an increased buildup of negative energy. When we reach our boiling point, we explode more violently than women. Therefore, even though women have more suicidal attempts than men, we tend to be more successful at killing ourselves, because we use more violent means like jumping off tall building or using a gun to blow our brains out (interesting-one way to stop the over active and pain-filled brain). Women on the other hand use peaceful means such as overdosing which, by the way, leaves a possible back door to escape.

When we look at the brain scans, they are just that. It is not definitive. It just shows what parts of the brain are active. The old orbital frontal cortex is just searching vainly for solutions from past experiences. If we believe this part of the brain is “us”, then we have a problem. However, if we believe that we are something beyond the electrochemical impulses, neural pathways, and mind states, than there is hope. If we defer to the Higher-Self, we can begin to see solutions beyond the mind states and schemas of the OFC, stop all the turmoil and impose a homeostasis or balance on the insula, and nudge the dorsal striatum to let go and complete the happy pleasure route by choosing to smile at our absurd reaction to a minor conflict. We use our higher self to pat ourselves on the back and say “there, there” and we begin to see solutions where there did not appear to be any. We can then experience an amazing surge of positive power and energy to forge a new path, not only to create balance, but to carry on with the expansion and growth of our being.

Here are my five suggestion for people with BPD and anger and impulse control problems:

  1. We recognize that we have anger issues. And we thank the universe (and yes I mean thank) that we still have the ability to have an emotional response to the feeling of rejection and interpersonal disagreements. If we ever lose that, it means we have quit trying to interact and may now be vulnerable to the second and more dangerous cause of suicidal behavior – hopelessness and helplessness. We always look for something to be thankful for. It gets us in touch with our higher self.
  2. We let the people who are important in our lives know that we have a “rage” problem. We alert them that we may have to tell them from time to time that we are experiencing a rage episode and may have to excuse ourselves from a situation with a promise to come back and resolve the issue once we have ourselves back under control.
  3. When confronted with a conflict, we take a deep breath and smile (if appropriate – does not work with partners during an argument) rather than responding to our brain’s emotional reaction.
  4. Whenever we feel the conflict beginning to turn into the rage, we remove ourselves (if we can) from the situation before it blows up to unmanageable proportions and additional shame inducing behavior that will complicate our ability to resolve the conflict. If we can’t leave the scene, we may have to eat crow (amazing birds) and shut up and take it. It helps to say “yes madam” to the boss and “yes dear” to our partners.
  5. We refuse to turn the anger against ourselves. We keep it objective. We find a quiet spot and employ deep breathing and self-talk. We analyse the situation and our over-heated response. We make a plan to resolve the conflict. If we have followed steps 1 to 4, we pat ourselves on the back and say, “Well done”.
  6. If we lose it and blow up again, we are kind to ourselves and recognize that this is part of a bigger problem. We analyze the situation to see what we can do better in the future. We apologize and restore the relationship. This should be easy to do  if  we have done step 2.

 

Cackowski, Sylvia; Krause-Utz, Annegret; Van Eijk; Klohr, Julia; Daffner, Stephanie; Sobanski, Ester; and Ende, Gabriele. Anger and aggression in borderline personality disorder and attention deficit hyperactivity disorder – does stress matter? Borderline Personality Disorder Emolt Dysregul, 2017. 17.

Krauch, Marlene; Ueltzhoffer, Kai; Brunner, Romuald; Kaess, Michael; Hensel, Saskia; Herpertz, Sabinen C; and Bertsch, Katja. Heightened Salience of Anger and Aggression in Female Adolescents With Borderline Personality Disorder—A Script-Based fMRI Study. Front. Behav. Neurosci., 26 March 2018 | https://doi.org/10.3389/fnbeh.2018.00057

Borderline Personality Disorder and PTSD

shirt-tie-w-out-white-background-final-3As we have worked our way through the nine symptoms of Borderline Personality Disorder (BPD) on the DSM IV and the personality traits of the DSM 5, we have encountered a major section, and perhaps the core issue, on symptom six, namely anxiety. Deeper investigation into the relationship between anxiety disorders and BPD led us to the discovery that 90% of people with BPD suffer from one or more anxiety disorders.  In past blogs, we have looked at the impact of Generalized Anxiety, Anxiety Attacks, and Social Adjustment Disorder (SAD).    Today we want to take a look at the link between Post Traumatic Stress Disorder (PTSD) and BPD.

PTSD is receiving a lot of attention in the media especially in connection to military experiences. The second and perhaps more common cause of trauma involves long-term physical, and/or sexual abuse. Recent work in this area  has led some psychologists to create a subcategory called Complex PTSD (CPTSD). These intense experiences of fear create a powerful link to the Sympathetic System and to feelings of helplessness so that the traumas are difficult to resolve. In addition, the reticular system is activated putting the individual on constant high alert thereby picking out and reacting to seemingly harmless triggers from the environment.

But what about other causes of CPTSD?  Jane Leonard[1] lists the following:

  • experiencing childhood neglect
  • experiencing other types of abuse early in life
  • experiencing domestic abuse

Do these emotional experiences constitute a major insult to the body as well as the mind?

According to Leonard, People with CPTSD may exhibit these behaviors, all of which are also shared with people with BPD:

  • abusing alcohol or drugs
  • avoiding unpleasant situations by becoming “people-pleasers”
  • lashing out at minor criticisms
  • self-harm

We can see that emotional, cognitive, and behavioral similarities come into play with BPD and CPTSD, but what is the relationship if any between the causes of the two disorders? I once read in an article that bisexuals have suffered from PTSD because of the emotional and mental wounds from a thousand cuts due to their life style.  But does that really constitute CPTSD? In my opinion, PTSD and CPSTD have to include major insult to the body as well as the mind; whereas, BPD is a disorder exclusively of the mind.

Cloitre et al[2] in a study involving over three hundred subjects with complete measures of PTSD, BPD, general psychopathology, and functional impairment, concluded that four BPD symptoms separated BPD patients from PTSD, namely:

  • Frantic efforts to avoid abandonment,
  • Unstable sense of self,
  • Unstable and intense interpersonal relationships,
  • And impulsiveness.

Both groups experienced chronic feelings of emptiness. I would suggest that these symptoms have more to do with neglect and unstable home environment than actual physical or sexual injury. We would also have to consider that there may be a genetic predisposition involved in BPD, including hyper sensitivity and a need for soothing and acceptance that was denied them in childhood.

I think it is safe to say that BPD and CPTSD are different disorders; however,  we have to consider that some people may be suffering from a  combination of both, thus compounding the problem. As noted in an earlier blog, this is literally a deadly combination resulting in suicidal thoughts and an alarming number of suicide attempts.

Here are my five suggestions for Bisexuals with BPD and CPTSD:

  1. If you are one of the few who are coping with this combination of disorders, then you are a remarkable human being. Rejoice in the amazing powers of your mind and soul.
  2. If you are struggling with flashbacks from physical and sexual abuse, feelings of emptiness, and any of the above four symptoms or above four behaviors, you are in danger of an emotional crisis and you need to put supports in place.
  3. Seek professional counselling and medical treatment. There is no shame. There is no blame. According to research, begin with CPTSD therapy as these symptoms seem to be easier to deal with than BPD.
  4. Create a support group of people who love you. Do not be afraid to call upon them whenever you are experiencing emptiness and self-doubt. It’s surprising how powerful and effective a ten minute conversation can be in reestablishing our sense of self-control.
  5. If our feelings reach a crisis level , we seek physical contact with one of our support people or with a professional counselor. There is something powerful about physical and emotional connection with another human being who loves us  and understands our struggles.

[1] Leonard, Jane.  What to know about complex PTSD.  Medical News Today.  August 2018.      https://www.medicalnewstoday.com/articles/322886.php

[2] Cloitre, Marylene; Garvert, Donn W; Weiss, Brandon; Carlson, Eve B; and Bryant, Richard A. Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. Eur J Psychotraumatol. 2014.

Borderline Personality Disorder and Social Adjustment Disorder

As we have worked our way through the nine symptoms of Borderline Personality Disorder (BPD) on the DSM IV and the personality traits of the DSM 5, we have encountered a major section, and perhaps the core issue, on symptom six, anxiety. Deeper investigation into the relationship between anxiety disorders and BPD, led us to the discovery that 90% of people with BPD suffer from one or more anxiety disorders.  In past blogs, we have looked at the impact of Generalized Anxiety and Anxiety Attacks. Today we want to take a look at Social Adjustment Disorder (SAD).  

A study by Kelly et al[1] led to a startling conclusion. Patients diagnosed with BPD who scored low on overall social adjustment were over 16 times more likely to have attempted suicide than patients diagnosed with major depression. They concluded: “Recent life events may elevate suicide risk in groups already at high risk for suicide completion, whereas high levels of social adjustment may be protective against stress-related suicidal behavior.”

So what exactly is Social Adjustment Disorder? There are two factors involved in SAD – social adjustment abilities or disabilities, and adjusting to a major event. First let’s look at social adjustment. Social adjustment by definition is: “an attempt made by an individual to address the standards, values and desires of a society so as to be accepted.” People with SAD experience more stress than would normally be expected because of a history of difficulty adjusting to family and other social patterns. For example, risk may be increased by experiencing significant stress in childhood, by having a number of difficult life circumstances happening at the same time, or by experiencing a series of minor difficulties collectively over a prolonged period.

The second factor is the ability to adjust to specific life circumstances. Usually stressors are temporary and we learn to adjust over a three month period. However, people with SAD will experience ongoing difficulty lasting up to six to nine months or even longer if the cause is prolonged such a divorce or being fired and not being able to find a job in our area of expertise.

Most of the symptoms listed for SAD can be evidenced by any or all of the anxiety disorders; however here are some of the more unique ones:

  • Feeling overwhelmed
  • Feeling sad, hopeless or not enjoying things you used to enjoy
  • Withdrawing from social supports
  • Avoiding important things such as going to work or paying bills
  • Suicidal thoughts or behavior

Most significantly, as noted by Kelly et al, we may be looking at the major cause of suicidal behavior, not only as related to anxiety, depression, and BPD, but perhaps the major cause overall.

The key then is to develop some strategies to get through those three to nine months. Developing healthy coping skills and learning to be resilient before hand may help during times of high stress.

Here are my five suggestions for bisexuals with Social Adjustment Disorder:

  1. We can call upon our higher self for guidance and strength. We remind our self that this distress is usually time-limited and that we can get through it. We recognize that even though these events are painful, they may also be a gateway for change, a time for awakening our higher powers, and a chance to seek a better life.
  2. We increase our health habits like diet and exercise thereby providing the oxygen and nutrients needed by a healthy brain.
  3. We rally our social supports. We develop a network of supportive people and groups to assist us in time of need. When we feel overwhelmed, we do not hesitate to use their services. There is a reason they made a commitment to help us. They love us.
  4. We check in with our doctor or mental health professional to review healthy ways to manage our stress and deal with the current problem.
  5. If we know that a stressful situation is coming up — such as a move or retirement — we prepare ourselves for it by making a plan for orderly transition. For example, if we have difficulty being alone during the Christmas season, we arrange to take part in some Christmas charities such as volunteering to work in the kitchen preparing meals on Christmas day – by the way, merry Christmas – thus taking our mind off our own problems and experiencing joy through someone else’s eyes.

[1] Thomas M. Kelly, PhD1; Paul H. Soloff, MD1; Kevin G. Lynch, PhD1; Gretchen L. Haas, PhD1; J. John Mann, MD2. Recent Life Events, Social Adjustment, and Suicide Attempts in Patients with Major Depression and Borderline Personality Disorder. Vol. 32, Iss. 6. Dec. 2000.

 Read More: https://guilfordjournals.com/doi/abs/10.1521/pedi.2000.14.4.316

Borderline Personality Disorder and Anxiety Attacks

Bisexuality

(This is part of an ongoing series linking bisexuality with Borderline Personality Disorder)

 As we have delved into factors involving the sixth symptom for Borderline Personality Disorder (BPD) on the DSM IV, and the corresponding section of the DSM 5, we seem to be getting deeper and deeper into the traits exhibited by people with BPD.  We started with episodic dysphoria which basically can be translated into problems with coping with the content of our life stories.   We then moved onto anxiety and tapped into research that indicated that BPD patients have to deal with one or more anxiety disorders.  Last week we looked at Generalized Anxiety Disorder and today we want to take a closer look at Panic Attack Disorder, or its sister, Anxiety Attack.

According to research we have quoted in past blogs, approximately 90% of people with BPD have some form of clinical anxiety dysfunction. Further research indicates that about 50% experience anxiety or panic attacks. These attacks occur frequently because of difficulty coping with sudden stresses brought on by criticism, rejection, or the threat of separation from people who are important. These reactions, if consistent and occurring over a prolonged period of time, can lead to physical symptoms such as migraines and other syndromes. Intense and prolonged anxiety attacks can be a major cause of suicidal attempts. 

An anxiety attack, according to the DSM 5, involves a period of intense fear with four or more of the following symptoms:

  • palpitations, pounding heart, or increased heart rate
  • sweating
  • trembling or shaking
  • sensations of shortness of breath or smothering
  • feeling of choking
  • chest pain or discomfort
  • nausea or abdominal distress
  • feeling dizzy, unsteady, lightheaded, or faint
  • feelings of unreality or being detached from oneself
  • fear of losing control or going crazy
  • fear of dying
  • numbness or tingling sensations
  • chills or heat sensations

Based on my own experience, my attacks involved a constriction of my breathing, including tightness in the chest, and the proverbial lump in the throat, or as mentioned above, a feeling of choking. It was like this tightness went from the chest, to my throat, culminating in a feeling of physical numbness flowing over my brain. When I tried to react to the criticism, it usually changed the level and intensity of my speech, leading to what appeared to be a high-pitched angry outburst. I also experienced that I was no longer in control of what I wanted to say or do, and that these incidences were occurring almost beyond my own mind and body.

For many years after my divorce and crash, my intense feelings of rejection and abandonment caused me to retreat into a form of social hibernation, where I isolated myself from any possible  threatening social situation. However, when I got married for the second time, I could no longer avoid social conflicts, and I found I was demonstrating an extreme out-of-control reaction to minor sources of criticism. When this occurred, I had to remove myself from the house and take a long walk until the adrenaline rush subsided. However, I was left with an even bigger problem now because guilt and shame had replaced anger. She in turn would withdraw and go silent which further accentuated my feelings of rejection. These anxiety attacks would usually last no more than half an hour, but the guilt and shame would last for days. This went on until the pain of emotional separation was greater that the guilt and shame. I would then painfully reengage with her and try to work out the cause of the initial reaction. 

We have been married now for four years and, with her patience and persistence, and hours and hours of discussion, we have come to grips with my anxiety attacks and developed strategies to avoid and diffuse them before they go into the guilt and shame stage. I have finally learned to deal with these feeling of rejection and abandonment. I have come to realize that she is in for the full ten yards. She has no intention of rejecting or abandoning me. Occasionally these anxiety attacks still occur but I can resolve them by reminding myself that I am not being rejected and I do not have to fear abandonment. These issues are now resolved in minutes rather than days and they are becoming less and less frequent.

So how do we deal with these anxiety attacks? One of the ways is through medication. I now take a very low dose of a mild anti-anxiety, serotonin enhancing, drug. This relieves the intensity of the generalized anxiety feelings and provides a stop gap to a full blown anxiety attack. Needless to say, one should proceed with caution and only with a doctor or psychiatrist who is equipped to monitor the drug affects and make the necessary adjustment to the types of medication and the dosage. We are our own best guide. If it works, we will sense it. We have to watch for and monitor the side effects.

One of the side effects unfortunately, or perhaps fortunately, can be a reduced libido, which in the case of us bisexual males, this can be somewhat of a relief. I have found that I can still become aroused and engage but the urgency to perform is gone. Ejaculation, although desired and still available, is no longer the goal. I now have more control over my biological processes and seek intimacy rather that sexual release. In addition, I no longer use gay sexual encounters or fantasies as a way to reduce my anxiety thresholds.

But medication, at best, is only part of the answer.  Advocates of treatment for panic attack recommend cognitive therapy. The key is to be able to recognize the causes of the anxiety and take cognitive measures to reduce the thresholds. In other words we learn to soothe ourselves.

Here are my five suggestions for bisexuals with BPD:

  1. We learn to recognize and accept that we have borderline personality profiles and that we belong to the 50% group who have to learn to live with anxiety attacks.
  2. We explore the possibility of engaging in anti-anxiety drug therapy, but we do not go into this blind. We find a doctor or psychiatrist that we trust and who will work with us to monitor and seek the best drug with the lowest possible dosage. When a drug is prescribed, we research it and discuss our findings with our physician. We should notice a marked decrease in anxiety attacks while still functioning normally in every other way.
  3. We engage in cognitive therapy. Cognitive therapy simply means we change our thinking patterns. We can do this on our own or, if we do not feel comfortable with that, we find a therapist who will engage in Dialectical-Behavioral Therapy (more on this is future blog). If we do this on our own, here is a simple formula for dealing with disagreements with loved ones:
    • We recognize the internal source of our anxiety (usually a feeling of rejection or abandonment).
    • We deal with this inner source by self-soothing. For example: there, there now, it’s okay; we can handle this; we are loved; there will be no rejection.
    • We recognize the external source of our anxiety (usually criticism) and deal with it.  We let the person know we are having anxiety issues. We tell them how we are feeling. For example: “I am having a hard time dealing with what you just said, can you please reword that in a gentler manner”.
    • We seek external and internal resolution. We talk it through with the person we are dealing with and then talk our self through the process until the soothing takes place.
    • If it’s a loved one – we ask for a hug.  
  4. If the above process is inappropriate for the circumstances, we learn to sooth ourselves. When we feel we are being criticized, we need to deal with the feelings associated with the criticism before it leads to an anxiety attack.
    • We practice the magic square (four breaths in, hold for four seconds, four breaths out, hold for four seconds, repeat).
    • We then get through the situation the best and quickest way we can, usually by accepting the criticism and then behaving appropriately.
    • We then soothe ourselves by recognizing that we just had an anxiety attack and telling ourselves it’s natural and okay and that we handled it beautifully.
    • We go through the incident again in our minds to see how we were triggered and how we can handle the situation better in the future.
    • We give ourselves a hug.
  5. We engage in long term anxiety control. For more details, see the last blog for suggestions to control generalized anxiety.

Borderline Personality Disorder and Episodal Dysphoria


This is the ninth in a series on BPD and Bisexuality

Today we want to take a look at the sixth symptom  for Borderline Personality Disorder on the DSM IV, namely: “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)”. In the DSM 5 the symptoms are covered in pathological personality traits in the domains of negative affectivity, emotional liability, anxiousness, separation insecurity and depressively. Each of these seven traits (anxiety is the only trait specifically listed in both) deserves to be treated individually; so today we will begin with episodic dysphoria.

Episodic refers to episodic memory which is our life story that we play over and over again in our minds. It includes major events, places, and experiences. Dysphoria on the other hand is when everything in life seems to be falling apart, like the world is working against us.  This seems to suggest that our life story itself is filled with feelings of continuous failure, shame, hopelessness and helplessness.

Speaking from my own experience, I simply ignored my life story until I could no longer hide from the pain that was always there just below the surface. For many years, I survived by will, religion, and the comfort of my marriage and family. I buried my past. All my accomplishments including numerous awards, athletic achievements, and three university degrees I simply looked at as failures because they lacked perfection and only perfection would allow me to feel proud of myself.

After I crashed, I finally looked at my roots and came to terms with the cause of my episodic diaspora. I began to see my accomplishments as amazing achievements overcoming the odds of being born in poverty to a single parent mother with nine children.  But above all, I was able to look at my self and see that I had a beautiful mind and an even more beautiful soul. I began to truly live and enjoy the life I had been given.

I was also able to accept my bisexual gender not as something that added to my shame, but as a tremendous gift allowing me to make intimate connections with both men and women. 

My five suggestions for bisexuals:

  1. We need to be more gentle with ourselves.
  2. We con rewrite our life story. We can  take a look at the events in our life with a new perspective. We can visit things that are equated with shame and and remorse and see how we did the best we could under the circumstances. There really is a silver lining.
  3. If there are areas that still stand out, we can forgive ourselves. It’s okay to make mistakes as long as we learn from them.
  4. We can learn to see ourselves as beautiful creatures with beautiful minds and beautiful souls.
  5. When we reshape our story, we can put in positive outlooks throughout the years, total self acceptance in the present, and dream about the possibilities of a bright future. 

Borderline Personality Disorder, Disinhibition, and Suicidal Behavior

img_1394-1(This is the third in the series linking Borderline Personality Disorder (BPD) with Suicidal Behavior. In the first blog, we established the link between BPD and suicidal behavior in general, and in the second blog we looked at the correlation with childhood sexual abuse.)

A study conducted by Brodsky et al [1] involving 214 inpatients diagnosed with BPD, concluded that Impulsivity was the only characteristic of borderline personality disorder that was associated with a higher number of previous suicide attempts. Could it be that impulsivity by itself, leading to risk taking, is the leading cause of suicidal behavior among those diagnosed with BPD? I think not, at least not in isolation.

So why are we splitting hairs when it comes to the causes of suicidal behavior and BPD? We know there is a link with BPD and suicide, and we know there is a link with suicide, impulsivity, and risk taking. Whether or not suicidal thoughts and behaviors are a symptom of BPD or not is not the issue. The issue is that people with BPD  are dying because of their risk taking. This is especially evident in the case of the flirtation with death through street drugs. Why are we doing that? Why are we taking risks with drugs we know are, or may be, laced with fentanyl? Why have we gay and bisexual men engaged in unsafe gay sex when it may have led to AIDS? Why such a disregard for our own lives?

Speaking from personal experience, impulsivity was not my major cause of suicidal thoughts. It was my sense of failure and hopelessness. I never made an attempt on my life but I certainly took risks that I hoped might end it for me. Perhaps, it is the combination of other affects in conjunction with impulsivity, in other words,  a kind of global personality disorder, including impulsivity, that puts us at risk not just for suicidal thoughts but for actual suicidal attempts. Perhaps it is merely not wanting to live our lives anymore because there is too much pain coupled with a desperate sense of helplessness and hopelessness.

So what can we do about it? Therapy should begin not with what has happened in the past, and not the sense of hopelessness in the present.  We have to start with finding something to be thankful for, and what a better place to start than with life itself. We have to stop viewing life through the eyes of our damaged egos and begin to see the possibilities of a life we would love to live that is being offered by our higher self. We have to close our eyes and ears to the message of hopelessness and helplessness and open ourselves up to the message of hope and love from our higher self. We should be focusing on what life can be, not what it was not. We have to learn to dream again and see the possibilities of a life of peace and contentment, a life that we would truly love to live. There is a light at the end of the tunnel; we just have to open the eyes of our higher self to see it.

Here are my five suggestions for bisexuals with BPD:

  1. We can look deep inside ourselves and find that sweet spot at the center of our being, the home of our higher self. We can do this through meditation where we seek out that especial place that is within all of us.
  2. During the day, we just stop the madness for a few minutes and enter into a state of short meditation where we seek the presence of our higher self. It will give us a moment of peace.
  3. If we stay in the moment, our higher self will begin to heal our wounds and dissolve our sorrows. It may be just a quiet knowing, or it may be an emotional charge as old feelings come to the surface and are let go. We do not try to analyse where the feeling comes from; we just acknowledge it and let it go. It’s okay for us men to cry.
  4. We begin to search for and recognize our inner voice. We choose to silence the voice of our mind and welcome the voice of our spirit. It will always say I love you in a thousand different ways.
  5. We recognize that we are in essence love and that love starts with love for our self. We tell ourselves that we are proud that we have survived the pain and we give our self a hug.

[1] Brodsky, Beth S.; Malone, Kevin M.; Ellis, Steven P.; Dulit, Rebecca A.; and Mann, Hohn J..

Characteristics of Borderline Personality Disorder Associated With Suicidal Behavior. Am J Psychiatry 1997; 154:1715–1719)

 

 

Borderline Personality Disorder, Childhood Sexual Abuse, and Suicidal Behavior Behavior

SHIRT & TIE [small] (final)(This is the second in the series linking BPD with Suicidal Behavior)

The DSM 4 lists “recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior” under symptom 5 for Borderline Personality Disorder; however it is listed as a separate category under Axis 6 in the DSM 5. Granted, suicidal behavior does indeed merit a separate category; however, we should be aware that people with BPD are at higher risk for suicide attempts.

Research suggests that suicidal behavior is a consistent possible threat when combined with BPD, PTSD, Clinical Depression, and Bipolar Disorder; however, it would appear that people with BPD are at a greater risk. In a study by Yen et al[1] involving 621 patients with a variety of psychological disorders, they concluded that only BPD and Childhood sexual abuse predicted suicidal behavior. The risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode. Other studies indicate that there is a definite correlation between suicide attempts and some BPD personality traits such as poor or no sense of self, hopelessness, and impulsivity.

Today, we want to look at the other aspect of the Yen et al study, namely the relationship between BPD, childhood sexual abuse, and suicidal behavior. Even though Childhood sexual abuse is not listed as a symptom, it is definitely related to suicidal behavior when combined with other BPD symptoms. Soloff et al.[2] in a study of 61 criteria-defined BPD patients concluded that with the occurrence and severity of childhood sexual abuse, patients with BPD were over 10 times more likely to attempt suicide. The study accounted for other variables such as neglect and other types of childhood trauma. It was definitely sexual abuse that seemed to be the most important determining factor.

It would appear that the risk for suicidal behavior is somehow related to negative coping mechanisms involved in BPD and that these symptoms are common in people who have suffered from childhood sexual abuse. If childhood trauma is treated and handled wisely and compassionately, the child may be able to learn to deal with the trauma and live a healthy and successful life. However, if they also have, or develop, other BPD personality traits, it can lead to self-doubt, self-blame, self-loathing and hopelessness, all symptoms of BPD and potential precursors  to suicidal behavior.

Just about everyone I know with BPD has entertained thoughts of suicide sometimes in their lives. When we are looking at diagnoses of BPD, we cannot overlook the possibility of suicidal behavior.  However, if the BPD symptoms also include childhood sexual abuse,  extra precautions need to be put in place. We can explore these possibilities as we go through the process of mental and emotional healing.

My five suggestions for bisexuals with BPD:

  1. If we ourselves have been diagnosed with BPD, and we have experienced childhood sexual abuse, we must be honest with ourselves to see if we have latent suicidal thoughts that could come to the fore if our life circumstances deteriorate.
  2. We need to build a safety net that will serve as a buffer between suicidal thoughts and suicidal attempts. We can share these thoughts with friends and loved ones on a regular basis.
  3. If our friends or loved ones demonstrate  symptoms of BPD, they are at a very high risk for suicidal behavior. We need to support them in any way we can.
  4. We should explore their history with them in a caring and loving manner and make sure they are not entertaining suicidal thoughts. If they are, we can help them build a safety net of people they love and trust. We let these people know that our loved one is at risk and together we set up a support schedule and set of activities to help them get through the rough times.
  5. If our loved one has experienced sexual abuse  and is still exhibiting symptoms of BPD, they will probably need professional help to deal with the issues involved. We can get them to commit to seeking help and then arrange for professional intervention.
[1] Yen, Shirley; Shea, Tracy M.; Sanislow, Charles A.; Grilo, Carlos M.; Skodol, Andrew E.; Gunderson, John G.; McClashan, Thomas H.; Zenarini Mary C.; and Morey, Leslie C.. Borderline Personality Disorder Criteria Associated With Prospectively Observed Suicidal Behavior. The American Journal of Psychiatry. 2004.
[2] Soloff, Paul H.; Lynch, Kevin J.; and Kelly, Thomas M.. Childhood Abuse as a Risk Factor For Suicidal Behavior in Borderline Personality Disorder. Journal of Personality Disorders. June 2002 .
Read More: https://guilfordjournals.com/doi/abs/10.1521/pedi.16.3.201.22542

 

 

Borderline Personality Disorder, Bisexuality, and Suicidal Behavior

SHIRT & TIE [small] (final)In previous blogs, we have established the highly significant link between Borderline Personality Disorder (BPD) and Bisexuality. Due to the epidemic of suicidal behavior and related drug overdose, in the next five blogs, we will try to explore the links between BPD, suicidal behavior, and risk taking. Today we want to explore the association with BPD in general.

At first glance, there appears to be a conflict between the DSM 4 and the DSM 5 on the inclusion of Suicidal Behavior as a symptom for BPD. The DSM4 includes it as the fifth symptom, “recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.”  However, it only appears in the DSM5 under the broader title of Disinhibition – Topic B – Risk Taking – which includes “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.”

First, let’s be clear about the connection between suicidal behavior and BPD. Black et al (2018) [1] discovered that at least three-quarters of people diagnosed with BPD have attempted suicide, and approximately 10% have died tragically. These are truly significant figures. If we recall that patients have to have five significant traits for diagnosis, even if one of these was suicidal behavior, there is still enough evidence that BPD people are definitely at risk. Borderline sufferers (and believe me, we do suffer) at greatest risk include those with prior attempts, an accompanying major depressive disorder, or a substance use disorder. Each of these by themselves are a major concern for suicide, but taken together with BPD, they seem to create the perfect storm. Other BPD personality traits that are associated with Suicidal Behavior are hopelessness, impulsivity, and a turbulent early life. They further conclude that clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates attention seeking or a call for help. According to Black et.al, this behavior is a genuine attempt to end life.

I think to clearly understand the thoughts and emotions that lead to suicide, we have to take a closer look at the definition above that includes gestures, threats and self-mutilation. For today, let’s take a closer look at gestures and threats. From my personal experience, almost everyone with BPD has entertained thoughts of suicide sometime in their life. In my own case, I struggled with the usual feelings of helplessness and self-loathing, especially when connected to my bisexual desires. It was not until I decided to inform my wife about my struggles, and the subsequent divorce, that I entertained suicidal thoughts, but unlike 75% of my fellow BPD sufferers,  I still could not pull the trigger. Instead, I engaged in all kinds of reckless behavior with the thought that I would welcome death if it happened. I also  made threats to myself and informed others that I was having suicidal thoughts but never reached the point of an actual attempt.  So what is the difference between thoughts and actions?

Again we need to look at the old formula – beliefs beget thoughts, thoughts beget feelings, and feelings beget actions. In my case, I think I shared the same beliefs with my suicide- attempting brothers and sisters. We believed that we were failures; we hated ourselves; and we no longer wanted to live out our painful lives. I think we probably shared the same thought patterns. That leaves feelings as the major component in the difference between thinking suicidal thoughts and actually carrying them out. And again, I think we probably shared the same feelings, but it was the depth of the feelings that made a difference. For these souls, hopelessness became despair; self-loathing became indifference; wanting to end the pain became the only solution, which was, of course,  the final solution. In my case, I was willing to ride it out, not believing that any good could come out on my life, but simply deciding to go through the motions and continuing in high risk behavior. Fortunately, in my case, time, the ultimate healer, eventually made the pain more bearable, and I waited around on this planet long enough that I began to sense that perhaps life was not so bad after all.

In my review of the literature, I have found some of the causes of the deeper feelings of hopelessness. The links between suicidal behavior and other factors such as childhood sexual abuse, depression, and substance abuse will be clearly defined in future blogs. For the time being, I think it is safe to say that BPD has several causal or at least correlational factors that may lead to suicidal behavior. We need to take steps that might help these people go through their life and death struggles.

Here are my five suggestions for bisexuals with BPD:

  1. We never give up. When life gets too hard to bear, we seek help.
  2. While we are still functioning, we find a kindred spirit, preferably someone who has been there, or we make a pact with a fellow sufferer that we will not go ahead with the final solution until we have sat down and talked and cried together one last time. Just expressing the negative feelings is the first step to accepting them as part of our lives that are painful but not necessarily hopeless.
  3. If there is no light at the end of the tunnel, we create one, be it ever so small, such as we wait for some event in the future that we can look forward to such as a graduation or our grandson’s birthday, something that we can celebrate.
  4. We begin to rebuild our belief system by finding and focusing on some positives in our life such as, perhaps, our creative abilities. I knew I was a good writer, and writing poetry was a way for me to survive the night and wake up the next day and start over again.
  5. We recognize that we have a higher self that is powerful and beautiful. And when life is just too difficult, we spend a few moments seeking out the person within, and we cry together.

 

[1] Black, Donald W.; Blum, Nancee; Pfohl, Bruce; and Hale, Nancy. Suicidal Behavior in Borderline Personality Disorder: Prevalence, Risk Factors, Prediction, and Prevention.  Journal of Personality Disorders > Vol. 18, Issue 3. 2018.

 

Borderline Personality Disorder and Relationships

SHIRT & TIE [small] (final)(This is the fifth in the series on the relationship between bisexuality and Borderline Personality Disorder [BPD].)

In previous blogs, we have established a link between BPD and bisexuality. We have looked at two symptoms for BPD on the DSM4: symptom 1 –  fear of abandonment, and symptom 3 – identity disturbance or poor self-concept.  Today we want to look at the second symptom which is “a pattern of unstable interpersonal relationships characterized by alternating between extremes of idealization and devaluation”. The DSM5 describes it as, “Intense, unstable, and conflicted close relationships … alternating between over involvement and withdrawal”.  From my review of the literature, it appears that difficulty in interpersonal relationships may be connected to problems with the mechanisms involved with bonding. This goes back to childhood issues such as abuse or neglect.

The relations between parental bonding and attachment constructs and borderline personality disorder features were examined by Nichol et al in 2002[1].  In a sample of 393 18-year-old’s, low parental bonding and attachment scores were associated with borderline features including insecure, anxious, or ambivalent attachment, and a perception of a relative lack of caring from one’s mother.

So what is happening biologically for people with BPD.  Bartz et al investigated the effects of intranasal oxytocin (OXT) on trust and cooperation in borderline personality disorder (BPD)[2]. Their data suggests that OXT does not facilitate trust and pro-social behavior in BPD’s but may actually impede it. They suggest that this may be due to possible neurochemical differences in the OXT system.

So where does this difference originate and how does it occur? First of all, we have to view OXT not only as a hormone generated by the pituitary gland but also as a neuromodulator. In plain English, that means that OXT affects the functions of the brain. This is usually done through the excitement or suppression of neurotransmitters.  In other words, OXT works differently in people with BPD by suppressing rather than exciting the transfer of messages within the brain and from the brain to the rest of the body.

We know that OXT is involved in bonding and that bonding to one’s mate creates aversion to any other potential sexual partner. When we look at aversion, we can get some clues from the rats and wolves[3].  In the case of wolves, one experience with tainted mutton made them swear off sheep for the rest of their lives. We all have experienced a nauseating sensation after an intense emotional experience and what could be more emotional than feeling rejected by one’s own mother? Could it be that when the outflow of OXT between mother and child during early childhood is accompanied by rejection that it literally leaves a bad taste in the mouth of the child by affecting the digestive system?

So how does this apply to our sexuality? We  know that sexual attraction usually involves a release of OXT. We also know that OXT can result in aversion and even nausea when presented with an opportunity for sex with members of the opposite sex for gays and lesbians and that some heterosexuals experience similar reactions about have same sex experiences. Could this indeed be the workings of OXT?

Gays, lesbians, and heterosexuals usually have no trouble bonding, and it is the work of the bond that creates the sense of aversion, and it is the aversion that creates the emotional reaction. What about bisexuals? Because we have difficulty bonding we also have no aversion mechanisms. Therefore, we can have sex with either men or women without experiencing overpowering negative emotion. We still have the OXT rush but not biologically imprinted restrictions. We have no difficulty devouring the delirious meal set before us.

What I am suggesting is the people with BPD have difficulty forming lasting relationships because we have difficulty bonding. The OXT release has the opposite effect, we simply associate it with rejection and have an aversion to bonding itself. We enjoy sex for the sake of sex but reject the bonding that goes with it. We burn our bridges and walk away from potentially painful experiences.  That does not mean, however, that we cannot have lasting relationships. It just means that we have to work harder to form stronger and more encompassing emotional and mental bonds in spite of the negative flow of OXT.

My five suggestions for bisexuals.

  1. We don’t give up on the bond. We can still  form mental and emotional bonds by creating and repeating feelings of love for our partners .
  2. If we feel emotional aversion, we can accept it, face it, and understand where it is coming from. We can then choose to recreate a feeling of love. Every time we do this, it reinforces our love bond.
  3. We do not let our aversion feelings interfere with our sex life. We focus on the physical and emotional pleasure and use this experience to again reinforce our love bond.
  4. We keep focusing on the positive aspects of our relationship and consciously build our mental-emotional bond.
  5. We do little things to show our partner we love them. Flowers and chocolate works for women and a good back rub does wonders for a man (by the way men like chocolate too, and women like back rubs).

 

 

[1] Angela D. Nickell, Carol J. Waudby, Timothy J. Trull, (2002). Attachment, Parental Bonding and Borderline Personality Disorder Features in Young Adults. Journal of Personality Disorders: Vol. 16, No. 2, pp. 148-159. https://doi.org/10.1521/pedi.16.2.148.22544

 

[2] Bartz, Jennifer; Simeon, Daphine; Hamilton, Holly; Kim, Suah; Crystal, Sarah; Braun, Ashley; Vicens, Victor; and Hollander, Eric. Oxytocin can hinder trust and cooperation in borderline personality disorder. Social Cognitive and Affective Neuroscience, Volume 6, Issue 5, 1 October 2011, Pages 556–563, https://doi.org/10.1093/scan/nsq085

 

[3] Gustavson, Carl R.; Sweeney, Michael; and Garcia,John. Prey-lithium aversions. I: coyotes and wolves 1. Behavior Biology, Vol 17, 1976.