Doctors Lounge - Psychiatry Answers
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Forum Name: Psychiatric Topics
|nimbeh - Wed Jan 03, 2007 11:16 am|
What are some specific traits or behaviors (not symptoms but examples of specific behaviors) that someone with bordeline PD may exhibit. And, should you ever tell someone that you think they may me borderline in their behavior and relationship with you? What is the best way to get them to see a doctor? What is the best way to interract when they are being difficult or raging at you? Especially when you are tired of leaving the house or taking the abuse? (besides leaving the realtionship) Can this disorder be helped or made better or cured? Or is it too complex and really up to me how I deal with a borderline person? Does a borderline come up with bizarre scenarios and thougths? Can I confuse this with bipolar? I want answers to the same questions about bipolar that I had about borderline. What is the main difference between borderline and bipolar? thanks.
|Dr. K. Eisele - Thu Jan 04, 2007 2:22 am|
Good questions! Whole books have been written on this subject, but I'll try to summarize it for you. Before I do, though, please understand that everyone is different and there are NO textbook cases of any disorder. The information that follows is a summary of a lecture I had the good fortune to attend.
1. Often have difficulty defining their sense of self
2. Tend to have intense, sometimes unstable, relationships
3. Often engage in self-mutilatory behaviors
5. Fear abandonment, rejection, loss of external structure
6. Very sensitive to environmental circumstances
7. Do not like sudden changes in plans
8. May experience very rapid mood swings
9. Have difficulty recognizing personal boundaries
10. Often think in terms of black and white
11. May have a pattern of undermining themselves
1. Have often lead a tortured life of abuse
2. Chronic feelings of emptiness
3. Easily bored
A couple of characteristics of the person with BPD are rather puzzling, almost universally. These are self-mutilation and difficulty recognizing boundaries. A simple way to understand what is meant by a "boundary," in this context, is the line where one person ends and another person begins.
Some patients have told me that self-mutilation is a desperate attempt to feel something, anything. The person afflicted with BPD has feelings of chronic emptiness, right? If you cut or burn your own flesh, you're likely going to feel something. The problem with physically hurting oneself (okay, there's lots of problems with it), in this context, is that the person really wants to feel something emotionally, and the physical pain that is brought about is only a temporary fix, kind of like a band-aid.
Some patients have told me that they feel so bad inside, that they cannot deal with the inconsistency of being so bad, yet physically attractive. The idea here is that they cause physical harm to themselves so they can look just as bad on the outside as they see themselves from the inside.
The issue of boundary violations is that because of their background of physical/sexual/verbal (all or any of these), they have learned from their miserable, loathsome abusers that they are nothing and always will be nothing. Therefore, there is no boundary (i.e., is a square a square if there is no line separating it from the outside?) to respect. They are simply modeling the disrespect done to them over and again.
For example, if "Missy" is physically abused, then her physical self (which is the boundary between Missy the person and the environment) is being severely disrespected. Although we are talking about a physical boundary here, it really is an emotional one, isn't it? How do you feel when you're at work or school and you suddenly discover a big hole in your pants? Kind of naked, right? At the point when a person feels embarrassment at suddenly finding themselves partially naked, it becomes an emotional issue. The person feels, rightly, as if the boundary between them and the environment has been breached.
In the case of verbal abuse, the person's self (or ego) is devalued. Missy would learn that she is stupid, bad, worthless, etc., and so much negative emphasis is placed on their internal self that a physical boundary doesn't hardly matter. Their internal self has been so disrespected so as to be nothing.
If a person feels they are nothing and there is no acknowledged boundary, they end up doing whatever is necessary to contain themselves somehow, and they end up self-mutilating because they are so bad in their own point of view (that is what they were taught, right?).
One last issue about BPD that has to be mentioned is that caregivers (e.g., nurses, therapists, psychiatrists, other physicians, family members, the list goes on and on) often do not treat them with the empathy they deserve. BPD patients are seen as "difficult patients" and their caregivers get wrapped up in that rather than seeing the forest for the trees. Instead of realizing that the BPD patient needs understanding and realizing that this person was once a tormented child, all they can see is how difficult it can be to treat them.
Most people would do whatever they had to do in order to defend a child who was being horribly abused. Those kids grow up and instead of being defended, they are again either abandoned or misunderstood, sometimes even abused again (the latter occurs most often by family, friends, intimate partners).
Now, should you ever tell someone you think they may be borderline? I wouldn't, even though I am psychiatrist. That's because I would then be put in the position of diagnosing a psychiatric problem with someone I knw personally. That doesn't work out. For you, however, it's potentially a big problem simply because you could be wrong.
I think the best way to get someone to se a doctor is an open, honest discussion (using "I" phrases as much as possible) without delivering either a message of rejection or an ultimatum. For example, if you were to say to your friend, "get help or I'm out of here," if she/he is indeed borderline, not only will she/he freak out, but may also behave rather rashly, by self-mutilating, or manipulating by any number of different ways.
Instead, tell her/him how YOU feel when he/she does ______________. Suggest that YOU are worried about her/him and that you only want what is best for them and for both of you in the context of the relationship.
I hope I've answered your questions about borderline personality disorder. I will come back tomorrow or Friday to continue the discussion about Bipolar Disorder.
Don't hesitate to ask more questions if necessary.
|nimbeh - Thu Jan 04, 2007 10:14 am|
First, am I to use the quote button or the post reply button when replying to you? Okay, I have already several times in the past told someone close to me about their behaviours and specifically brought up borderline or bipolar and suggested they get some help. What damage have I done? She doesn't really want to have anything to do with me because she feels uncomfortable I suppose and now she critiques and judges everything about me. What can I do to correct any damage? What can I say to her to make it better? Are people like this hard to reason with? And about me. After all the time we've been together I feel like I am completely insane (I didn't used to!). Is this normal? What effect can people with these disorders have on others close to them? Also, can people be both borderline and bipolar and does it get worse with time and age? Is it best to just leave someone like this alone? How do I respond to rages and accusations and the bizarre behaviors and mood swings and personality changes?
|nimbeh - Sun Jan 07, 2007 12:50 pm|
Hey! Did you forget about me? Just wondering. I need some advice soon if possible. Thanks!
|Dr. K. Eisele - Sun Jan 07, 2007 2:39 pm|
No, I didn't forget about you. I slipped on some ice and could tolerate only a few minutes on the computer at a time. I'm okay now.
Yes, it is entirely possible to confuse Borderline Personality D/O (BPD) with Bipolar Affective Disorder (BAD). The key to distinguishing the two is to remember that BPD is a personality d/o while BAD is a mood d/o. To us a computer analogy, this means that BPD has more to do with the hard-wiring rather than the software, and vice versa for BAD. The consequence of this is that while BAD can be helped greatly with an emphasis on medicine and some psychotherapy, BPD is treated with more emphasis on psychotherapy and medicine, secondarily, for symptoms.
How you, as a layman, can tell the difference, is in the frequency of the shifting of "moods." A comparison between mood and affect is in order here:
Affect = the moment-to-moment changes in how a person feels about situations.
Notice that affect is more of an attitude. We can be angry because the new puppy is resisting potty-training, but that usually doesn't change our mood significantly. Major events in our lives can effect a change in mood, but usually the mood is slower to change.
People with BPD have affective instability, which can bring about mood instability. A huge red flag for me is a patient's proclamation that their mood changes several times/day. That would be extremely rare so as to be nearly impossible, using the definitions above. Now, if someone comes in saying that all of sudden their mood switched from happy to sad, and the sadness had persisted over a period of, at a minimum, a few days, BAD will be on my list of potential diagnoses.
Specific characteristic/behaviors is a little more difficult for BAD than for BPD. People with BAD look, act, and interact the same as people without BAD, until they experience an exacerbation of their mood d/o. I'll list some danger signs that could be seen with a shift to mania or depression.
Extreme irritability ("I am surrounded by incompetence, because I am the reason my company even exists today", when the patient is really a mail clerk)
Decreased need for sleep or complete lack of need for sleep
Impulsivity (maxes out all credit cards and cash reserves on unneeded items, may even pawn or give away possessions due to generosity, even those just purchased, may suddenly take a long trip without telling anyone, engages in very risky activities)
Increased goal-directed activity (suddenly works 18 or more hours per day without regard for physical fatigue, needs, including occupation as well as hobbies)
How to deal with a loved one with BPD? Take a deep breath and hang on. The best thing to do is frequently reassure them that you are a loved one, they are a loved one to you, and be firm. The biggest fear someone with this disorder has is rejection. They will do anything to avoid being rejected or abandoned, and many times they do the very things that push people away. Get them into therapy as quickly as possible, and support the therapy as much as you can. Don't be fooled by complaints /accusations she/he may make about others. Take the complaint/accusation seriously, but verify the veracity of such before acting.
I hope this helps. Please come back and let us know how the situation progresses.
|nimbeh - Sun Jan 07, 2007 7:41 pm|
I am sorry you slipped. Did you break anything? I've told her I think she is bpd or bad. You said I shouldn't have. It has affected her. How I'm not sure but it's not a good thing. Is there something to say to her to correct this? How do I get her to see a doctor? People with this are extremely draining, aren't they? Can they make me feel crazy? Permanently? Can I ever do anything right for people with this? It seems no matter what, I'm going to hear about it. Is this a symptom? Control and manipulation if control isn't attained? So you are saying that they may push someone away first for fear of this person abandoning them? Another form of control? I've been told that people like this will never be through with you until they put you in the grave somehow unless you sever all ties. I've been told by a bipolar that they will take you down in flames. Is this close to the truth from your expereience? What influence may someone with these traits or symptoms have on me because I feel completely crazy or do you think it's just ptsd? I suppose if I thought I had been run crazy then I wouldn't realize it so I wouldn't think it. Seriously, is it possible for someone to drive someone else crazy like I'm doing you with all these questions? I'm a little excited to be talking to a psychiatrist so please be patient. Thanks, man! (afterthought) if someone told me they thought I may be bad or bpd it wouldn't bother me either because I don't think I am or if I thought I was then I might seek help or would I if I was? Understand? But when I tell her she will begin to scream holy hell and the ground begins to open up and I smell sulfur. Is this a sign of a symptom? Do you understand? I don't think I could get too deep with you. Your a shrink, right? Thanks again. Bye!
|Dr. K. Eisele - Tue Jan 09, 2007 12:50 am|
I think the best thing you could possibly do is show her that you're still there for her even though you think she has this thing called BPD. The reason why it's so difficult to tell someone this, is because a lot of folks, sadly including medical professionals, will throw that word out like it's an insult.
I can't speak for everyone, but I can say that the patients that I see with this disorder are extremely draining, for more than a couple of reasons. My patients do tend to be the sickest of the sick, because of my work setting. For those who do not understand people afflicted with BPD, and/or who have to spend a lot of time with them, they can indeed make you feel like you're the one with the problem, and hopefully, that won't be a permanent feeling.
I do believe that when someone with BPD pushes someone away it comes from two different desires, and both of them work against them, in that they end up with being rejected. On the one hand, they need to feel like they are in control, which is due to the total stripping away of their control over their own bodies during their childhood (sexual and physical abuse is common in their histories). On the other hand, they cannot stand to be rejected or abandoned because the abuser, usually someone we would normally associate with a position of trust, abandoned them by not caring for them properly, and betraying that trust so absolutely. Patients with BPD have very, very little ability to trust as a result of their history.
This kind of person does not put you in the grave unless you allow it to happen. You need to remain in control of your own emotions. Remember, when we react, our emotions are at work, but when we respond, there is thought involved as well. It is true that people in your situation have "gone down" with the person who has the BPD, but only because they reacted, not responded. Perhaps they didn't understand the difference.
It is probably not possible, with the exception of some really extreme situations, for someone to be driven crazy by another, as long as the former is sane. You may be incredibly stressed by this person's antics, but as long as you are sane, likely you are safe, as long as you remember to respond rather than react.
She definitely needs to be seen by a psychiatrist. You need to be incredibly open with her at this point. I would do all I could about getting the appointment set up before "the discussion" is to happen. If the following is true, then I think you should say it:
This way, you take the blame out of it. There's no heavy judgments attached (as there are when you say, "you're borderline!"). Even if you are absolutely convinced the problem is her doing, that doesn't make the above example untrue.
With therapy and maybe some medication, the person with BPD can get better.
To answer your question, yes, I am a psychiatrist.
|nimbeh - Tue Jan 09, 2007 3:02 pm|
I understand how that word could be viewed as an insult especially if someone doesn't have the ability to 'hear' things the way you mean them. I'm with you. I understand exactly how complex this can be after years of being involved. I don't feel so crazy as I distance myself. It's easy to get wrapped up in this isn't it? It's so hard not to 'react' when someone is being unreasonable and hostile and raging. Thanks for telling me that I can't be made crazy by her. It really helped. I think what has happened is that I've somehow lost myself. I became completley meshed with her way of thinking. I didn't realize what was happening. It's like I remember who I was and how I used to be but it's hard to feel that anymore. Getting her to see someone about this impossible. She's too fearful. I know that for her to admit to anything then that would mean having her whole system of beliefs her whole life completley rearranged. She doesn't understand that I wouldn't mind or think any differently of her if she did get help. In fact I would think more of her and would be able to respond instead of reacting because it would be in the open and I'm sure a specialist would tell us how to manage things. Right? I'm stubborn though, and sometimes just refuse to accomodate her episodes because she won't do anything about it or listen to me and I'm sure you know that they think it's always someone else that needs help. To her, I'm the one that needs help. How can that be if I'm the one that notices certain things and brings up her getting some help. Sound familiar? Will this thing get worse as someone gets older? Is it necessary to get treatment? If not then what can I do? Does it mean just hanging up the phone or walking away or going fishing or something? Is it best to ignore and not to engage? Does that do any good? I always just want to try to fix it and it always seems to make it worse. It's very frustrating. Everything gets twisted and distorted against me and then I seem to be the one with a problem in the end to her because I can get relly angry and call her a certain name because she refuses to listen to me. It seems she thinks she can do or say anything she wants to with no consequences. It's so hard to understand this way of thinking. It's like another person takes over her. If you answer these questions I think that will be it. What do I owe you? Thanks, Doc.
|nimbeh - Tue Jan 09, 2007 4:29 pm|
One more thing. How long can an episode last? What's the longest you've seen? If a person is left untreated for life, what is the worst outcome to be expected? Being alone, insanity, etc..?
|Dr. K. Eisele - Wed Jan 10, 2007 12:57 am|
It is absolutely necessary to get treatment. You sound frustrated to me, and you need to know that it is possible for her to be helped by therapy with or without medications. I don't know her age or how long you've been with her, but I've seen relationships destroyed under the kind of pressure that someone with Borderline Personality D/O and her/his partner can generate just by simple interactions.
There really is no way for me, probably you as well, to predict whether she will get better or worse. If she refuses to go to therapy, then you have to ask yourself if she respects you, your opinion, and your relationship. It could be that she does, but that she is too frightened. If the latter is the case, then persevere. I also recommend therapy for you, alone, if she won't go. A professional can help you to deal with the stress as well as give you valuable pointers for whatever you decide.
Another thing that stands out in what you've written is that you are the "fixer" in this relationship. It is your role to make everything okay and to smooth things over, if I've interpreted your posts correctly. You, alone, cannot fix this. She has to want to fix this as much you do. The harder you try to fix it, the less "gratitude" you'll get from her, and the more complicated things will become. It's not that she is trying to torment you. It's that something in her past went very, very wrong, and she's learned these behaviors because at some point, that is how she survived.
You mentioned that she seems to have no regard for consequences. That could be a lot of different things, but if this is part of a borderline personality disorder affliction, then you can assume that she either had to develop that as a trait for her survival, or, alternatively, that the behaviors were modeled by some role model as appropriate.
Getting really angry with her will not help. This is why you need therapy as well. It wouldn't be healthy for anyone to be in a relationship like yours and not be able to express their anger. If you decide not to engage, good for you, but expect some fireworks from her, at least temporarily. Although I dislike the analogy, a borderline "episode" is much like a two-year old's temper tantrum. The more you react, the more frequently the behavior will occur. If you simply respond, as would the ideal parent in dealing with a temper tantrum, the behavior will not be rewarding and at some point, it will no longer be worth it for her to behave that way.
There is no general or typical length of time that an "episode" will last. You would be able to answer that better than I, because past history is the best predictor of what will come.
The worst outcome I've seen is death. People with borderline personality disorder will injure themselves over and over during their lives, and although these behaviors are not always suicidal, it is nearly impossible to tell when it is suicidal. Sometimes, someone with borderline personality disorder will self-injure, and die without having had any intent to do so.
I sincerely hope you and she can avoid this outcome. BPD can be a very deadly disease. The way to avoid the worst case scenario is therapy, and possibly, medication.
You owe me nothing; I give my time to those who seek help here at The Doctor's Lounge freely.
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