Borderline Personality Disorder and Anxiety


(This is the second in the series on exploring mood and anxiety dysfunctional traits for  Borderline Personality Disorder (BPD) on the DSM 5, and symptom six on the DSM IV . In the last issue, we looked at episodal dysphoria; today, we will take a look at generalized anxiety.)

In a study involving ninety-two hospitalized patients diagnosed with BPD[1]Grambalet et al. concluded that BPD patients were significantly more likely than the people in the control groups to suffer from a wide range of anxiety disorders including: panic disorder, social phobia, generalized anxiety disorder, mixed anxiety/depression disorder, adjustment disorder, and post traumatic stress disorder. In addition, one in five patients had two or more of these disorders. Excessive levels of anxiety correlated with reduced quality of life in mental, social, and work domains.

Each of these anxiety disorders deserves to be examined in isolation, keeping in mind that we may have two or more disorders functioning at any given time. Today we want to take a look at generalized anxiety disorder.

Ninety percent  of people with BDP have clinically high rates of anxiety[2] . Generalized anxiety makes it difficult for us to maintain our ability to function in our home and work environments, thus increasing the risk of suicide and self-injury. I remember a friend of mine explaining why she had taken the whole bottle of clonazepam, an antipsychotic medication, thus ending up once again in the psych ward at the University Hospital. She said she did it because she could no longer stand the constant feeling of anxiety. As in the case of my friend, I have noticed that many suicide attempts are due to extended anxiety attacks rather than the more commonly held belief that they are due to depression. 

I am sure that this story of anxiety resonates with most of us with BPD; we all know that we  have constant anxiety issues in trying to survive and thrive in our own corners of the world. Like most of us with BPD, I have had to learn to live with a constant form of generalized anxiety. Some days are worse than others, depending on the stress levels. Sometimes during the day, usually after teaching my classes in psychology, I will stop for a moment and realize just how tense my body is. I have learned to read the signs and diffuse my anxiety episodes, usually by engaging in deep breathing exercises. At other times, the anxiety will create the sensation of having an elephant on my chest. This anxiety is physical as well as mental. Once this level of anxiety occurs, my brain and body will slip into the sympathetic system thus increasing the sugar levels for the energy needed to flee or fight,  salt levels to raise my blood pressure to get the sugar to my muscles, and driving the administrator section of my brain to concentrate on the unknown threat rather than being able to rationally go about the business of living.     At these times, I have to take a walk while concentrating on breathing,  consciously engaging and forcing my mind to take control again, easing my brain into the parasympathetic system, and thus allowing my body and brain to burn off the excess energy.

Living with BPD means living with anxiety. We cannot eliminate it, but we can control it. We can take control of our minds and bodies, eliminate the anxiety, and then deal with the cause of the stress. If the stress is a normal part of our daily lives, we simply monitor and proceed. If the anxiety becomes uncomfortable, we take a break and reduce the anxiety levels and then get back to work. If we are going through a period of prolonged stress, we need to build in breaks and maintenance days off.  If the anxiety leads to crisis, we engage in crisis management. We get help. We take whatever medication is necessary until the crisis has past. For some of us, we will need to stay on medication for the rest of our lives. In other words, we learn to read the anxiety levels in our brain and body and then take the necessary steps to reduce the anxiety so we can function normally at home, and at work.

My five suggestion for dealing with BPD:

  1. We learn to read and monitor our anxiety levels.
  2. We develop a strategy like deep breathing. I use a four point square visualization technique:
    1. Four breaths in deeper and deeper until full
    1. Hold for four seconds.
    1. Four breaths out until completely empty
    1. Hold for four seconds
    1. Repeat until experiencing a release of anxiety.
  3. When stress leads to conflict (internal or external) and an anxiety attack, we:
    1. Remove ourselves from the situation,
    1. Take a walk and work off the physical side effects of the anxiety.
    1. Return to the situation and work on it until there we feel it has been resolved. This will usually be experienced in a washed out feeling accompanied by peace and joy.
  4. If we have a period of prolonged stress, we will need to remove our self from the situation and take a maintenance break.
  5. If we are experiencing extreme anxiety over a significant length of time, measured in months or years, we may have to make major life changes.

[1] Grambal, A;  Prasko, J; Kamaradove, D; Latalova, K;Holubova, M;Sedlackova,Z.; and Hruby, R..    Quality of life in borderline patients comorbid with anxiety spectrum disorders – a cross-sectional study. Dovepress. 2016.

[2] Harned, Melanie s.; Valenstein, Helen R..  Treatment of borderline personality disorder and co-occurring anxiety disorders. F1000Prime Rep. v.5; 2013.

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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.