We move on to the second section on impaired personality functioning – on the DSM 5 – Self-direction. The description is, “instability in goals, aspirations, values, or career plans”. We are really stuck on this one so we will just wing it. I have no experience with it as it is one of the few descriptors that I did not check off in my survey. I had a one, no problem. In addition, I could not find any research studies on the topic. Let’s take it one step at a time and hope it adds up to something that we can hang our hats on.
A Sad Story – A Case Study of One*
Please Note: I will use this section to add a personal application to all the technical stuff. It is my hope that if you have BPD you will realize that you are not alone and that if I can make it than you gotta believe that you can too.)
A was born into a single parent family with eight children. I was the ninth child and the seventh son. I later found out that everyone else’s father was not my father. When George (everyone else’s dad) left mom to raise the kids by herself, she was pregnant at the time, and her stress brought on a premature baby who never really got her feet under her. She died at about eighteen months due to infection from complications with teething. Looking for support, she had an affair and got pregnant with me. When I was born, she had a physical and mental crash. The other eight kids went into the orphanage and I went to live with my 76 year old grandmother. After several months, mom recooperated (pun intended), got her kids back and started to put her life back together again. Mom never bonded with me because I was her mortal sin, according to The Catholic Church, and God would soon take me anyway. Just about at that time my grandmother died and I lost my bond we shared. My thirteen year old sister quit school to raise me while mom tried to make a wage to feed her family. She never came to my games or school events although I excelled at both. I cannot remember my mother kissing or hugging me until my fortieth birthday.
Because of this rough beginning, I never developed a solid sense of self. I tried to please everyone in the hope that they would approve and show some form of acceptance and love towards me. I became a perfectionist believing that if I showed the world just how good I was they would have to accept me and love me. I must have a powerful constitution (HS) because I managed to survive for fifty-five years. That’s when I was forced to go into an extensive eighteen week, five hours a day, five days a week intensive, group therapy program. That’s when they nailed me with the BPD label, which was okay, because that allowed me to go on long term disability and still collect my salary. Paid vacation. Not.
I have been a student of BPD ever since which led to my quest to understand it, leading to the thirty-seven traits I have identified from the DSM 5* (aside: totally unscientific but makes sense to me. There I go, apologizing again – impairment 2 – for something that needs no apology. In fact, it’s a damn good idea. When I count them up looking back to those days just before the crash, I had a nine or ten on seventeen of the impairments and traits and an overall score of 242. Bet you can’t beat that.) Above all, I had a poorly developed and unstable self-image. Give me a ten on this one. That’s enough for now. Believe me, hang in there, it does get better as we will see in the following chapters.
Please Note: I think it’s time to leave the research and theories behind for a while and look at BPD from an emotional point of view. Feelings from the heart instead of ideas from the mind. So here goes. The play within the play whereby I’ll catch the conscious of the king (me)(Hamlet).
During one weekend, I attended a writer’s workshop that focused on owning our work and feeling good about it. One of the activities really hit home. We were to carry on a written dialogue with the child within. The voice of the higher self (adult) was expressed by writing with the dominant hand and the voice of the child with the other. The following is what I came up with:
Child: It’s dark in here.
Adult: Where are you?
Child: I don’t know. Mom left me here alone a long time ago.
Adult: I was always there with you.
Child: No you weren’t. I didn’t see you.
Adult: I was watching safely from a distance.
Child: Why didn’t you come and play with me? I was scared.
Adult: I’m not sure. I cared for you, but something seemed to be holding me back. Where was your mother?
Child: I never had a mother. There was a woman. She made my meals. We watched TV together but she was not my mother.
Adult: How do you know?
Child: She never held me. She never kissed me. She never said she loved me.
Adult: What about your father?
Child: I never had a father.
Adult No one?
Child: Just you. But you never held me, or kissed me, or said you loved me either.
Adult: But I was there. I didn’t do those things because I wanted you to be strong, to grow up to be a man. Surely you must remember my visits, those poems I wrote to you over the years?
Child: Yes, thank you. I still have all of them. I read them when I feel lonely.
Adult: I am sorry I neglected you. Please forgive me. But there is still time. Perhaps you can be the child of my mature years, like my grandson?
Child: Yes, I would like that. Do you have time to play now?
Adult: Yes I do, all the time in the world. We can have our own special time every day after lunch until before dinner. Would you like that?
Child: Oh yes! That would be fun. But not golf. I hate golf. How about tag or hide and seek? I can hide someplace in the dark and you can come and find me.
Adult: And yes, and we can both run for home…
Child: And yell HOMEFREE!!
Adult: Yes let’s do it.
Child: And you can hug me and say you love me.
Adult: Yes, I promise. I do love you, you know?
Child: I know.
The Silver Lining
What can we take from this? Most of us borderliners with BPD have had to survive with a wounded child, often because of childhood neglect or abuse. Because of what we have experienced, we now have the opportunity through the power of our Higher Self, to use these experiences to grow into conscious beings, to use our trials to give insight into what it means to awaken to the infinite possibilities of the universe. Once we deal with our problems with self-esteem and develop a positive self-concept, we will be miles ahead of the rest of the population who haven’t yet faced their demons and discovered their Higher Self. We can now revisit those days again and do some healing, and then pass this knowledge on to others.
My five suggestions for borderliners
- If you have no self-identity issues and no BPD problems – enjoy the read.
- If you are one of us who struggles with poor self-identity and poor self-image, you are not alone. We* can learn to accept ourselves just the way we are. We can seek a new foundation. We bond with ourselves. We bond the fragile ego-self with the spiritually powerful higher self (HS). We become our own parent and give ourselves a hug whenever we need one.
- We flood our self with self-love from the HS. We practice looking in the mirror and seeing the higher self within. We do this until we can look ourselves right in the eye and say “I love you”, and mean it, and feel it. It will feel like a rush as the HS accesses the pleasure center of the brain. When we do this, we bring the two identities, the mind self and the higher self, together. We enter into the awareness of the infinite power of our Self-identity as body, mind, and soul.
- We tell ourselves we love our self (body, mind and spirit) over and over again day after day after day, until all the old feelings are permanently erased. When confronted with a moment of self-doubt, we stop it. We tell ourselves that we are better than that; in fact, we are beautiful and powerful beings in complete control of our emotions and feelings. We make a conscious decision to let go of the negative feelings associated with low self-esteem, and embrace the positive feelings bathed with love from our higher self. We do not blame our negative mind self, we thank it for being diligent and assure it that things will be different from now on.
- Set aside fifteen minutes a day for meditation with a purpose; namely to become aware of and appreciate the presence of our higher self.
* (Last aside in this chapter: I like to use “we” because using “you” can really be hard on borderliners with an already a poor self-image that says that any kind of unwanted advice is criticism, and intervention is useless. “We” means we are not alone; we are in this together. You may wish to sign up to my newsletter and attend some of my webinars at lawrencejwcooper.ca. These are free services that I offer, because, like the Ancient Mariner, I feel compelled to tell my story to anyone who will listen.)
We 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:
- 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.
- 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.
- 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.
- 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.”
- 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.
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:
- 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.
- 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.
- 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.
- 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.
- 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”.
- 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
As we continue on with our investigation into Borderline Personality Disorder and its relationship to bisexuality, we arrive at symptom seven on the DSM IV: chronic feelings of emptiness. On the DSM5 it is listed under: Significant impairments in personality functioning manifest by:
“Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.”
When we seek to define emptiness, we come up with adjectives such as hopelessness, loneliness, and isolation.
In a study by Klonsky, he concluded that emptiness is characterized more by low positive affect rather than high negative affect. In layman’s terms, it is not so much having negative thoughts and feelings related to negative events, but rather just being empty of, or having a lack of, positive aspects to our lives. Klonshy came up with some interesting observations. As expected, he noted a substantial overlap between emptiness and hopelessness, a subsequent robust relationship with depression, and an important relation to suicidality. By including a sub study on self-harm through self-cutting, he noted a pattern that suggested that chronic emptiness contributes to the development of suicidal thoughts and feelings, but may not predict progression to an actual suicide attempt.
This brings out an interesting point about the progression of BPD symptoms to suicide and other self-harming activities. It would appear that there may be two aspects to poor self-image that may lead down two different paths. As we have seen in past blogs, there is a strong correlation between BPD, anxiety, depression, and suicide. Traits such as self-criticism and dissociative states may lead to chronic anxiety and down the path to suicide; whereas the emptiness trait may lead to a form of self-harm where one is attempting to create some feelings to jar them back to a functional reality. And then, because no two people are exactly alike, there are numerous combinations of traits.
Back to my case study of my “self”, I had continuous feelings of emptiness as well as self-criticism. Therefore I had one foot on the path of anxiety and suicidal thoughts but the other on the path of hopelessness. To resolve my problem, I shut down my own wants and needs and stubbornly plowed forward trying to cure and heal anyone I could get my hands on, never getting any real satisfaction for doing any good for anybody. During profound periods of emptiness, I tried to fill it up with dangerous, risk taking gay sex. It worked for me for twenty-five years until my mind became overwhelmed and crashed. Even though I had suicidal thoughts, I never really took any steps to actually doing away with myself. I just grinned and bared and waited for the shoe to fall.
Looking back here is what I should have done. My five suggestions for bisexuals with BPD and with symptoms of emptiness:
- We find some way to fill up the emptiness and the way to do that is to simply remove the veil that is keeping us from seeing that we have a higher self.
- We simply shut down the noise of our wounded ego, the woe is me voice, and open our mind to the always present presence and power of out higher self.
- We wait for the emptiness to be replaced by a sense of this presence. We will always feel a sense of joy when our higher self sends an impulse through the pleasure centers of our brain.
- Whenever we feel down we repeat this process until we sense our higher self.
- We fill up and expand our sense of fullness on a daily basis. We spend fifteen minutes a day in mediation by focusing on the power and beauty of our higher self.
 Klonsky, David E. WHAT IS EMPTINESS? CLARIFYING THE 7TH CRITERION FOR BORDERLINE PERSONALITY DISORDER. Journal of Personality Disorders, 2008.
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 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:
- 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.
- We increase our health habits like diet and exercise thereby providing the oxygen and nutrients needed by a healthy brain.
- 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.
- We check in with our doctor or mental health professional to review healthy ways to manage our stress and deal with the current problem.
- 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.
 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.
(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
- 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:
- 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.
- 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.
- 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.
- 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.
- We engage in long term anxiety control. For more details, see the last blog for suggestions to control generalized 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, 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 . 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:
- We learn to read and monitor our anxiety levels.
- We develop a strategy like deep breathing. I use a four point square visualization technique:
- Four breaths in deeper and deeper until full
- Hold for four seconds.
- Four breaths out until completely empty
- Hold for four seconds
- Repeat until experiencing a release of anxiety.
- When stress leads to conflict (internal or external) and an anxiety attack, we:
- Remove ourselves from the situation,
- Take a walk and work off the physical side effects of the anxiety.
- 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.
- If we have a period of prolonged stress, we will need to remove our self from the situation and take a maintenance break.
- 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.
 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.
(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  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:
- 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.
- 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.
- 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.
- 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.
- 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.
 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)
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)  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:
- We never give up. When life gets too hard to bear, we seek help.
- 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.
- 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.
- 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.
- 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.
 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.