The principle dimensions that have been the focus of biological research include impulsive aggression and affective instability
Issues with impulse control
Decrease central serotonergic activity (associated with increase impulsive aggression)
Diminished concentrations of serotonin in 5-HIAA in the CSF has been associated with attempted or completed suicides
Fenfluramine (drug to increase serotonin activity) creates a Blunted prolactin response (hormone produced in pituitary gland) in individuals diagnosed with BPD. These findings indicate an associate between blunted serotonergic responsiveness and impulsive aggression.
Family and twin studies of borderline personality disorder suggest that while the disorder itself may not be heritable, the prominent features of impulsivity appears to run in family.
In an ongoing study of the health and lifestyles of families with twins in the Netherlands, Trull and colleagues examined 711 pairs of siblings and 561 parents to identify the location of genetic traits that influences the manifestation of BPD. The researchers conducted a genetic linkage analysis of the families and identified chromosomal regions that could contain genes that influence the development of BPD. Trull found the strongest evidence for a genetic influence on BPD features on chromosome nine.
Prefrontal cortex, particularly prefrontal orbital cortex and adjacent ventral medial cortex, appears to play a role in aggressive behavior.
Phineas Gage example
Results of PET studies on patients meeting criteria for BPD showed decreased metabolism in prefrontal cortex, particularly orbital and adjacent ventral medial frontal cortex, associated with increased impulsive aggressive behavior.
Defined as “a predisposition to marked, rapidly reversible shifts in affective states that are extremely sensitive to meaningful environmental events”
Basically Emotional Dysregulation – which is a defining characteristic of BPD
Cholinergic system plays a role in regulating affect
Research shows that cholinergic agents appear to induce depressed mooed in normal patients and patients with depression, this effect appears even more intense in those with BPD
There is also evidence of disturbance in noradrenergic activity in effectively unstable patients with BPD
A crisis can develop when people feel they cannot control their feelings or behaviors and are having trouble coping with the demands of everyday life. Potentially this can develop into outbursts of anger, violence, intense hopelessness or self-injurious behavior. When a loved one is in crisis, it can be hard to know what to do and how to help. In this blog I talk about features of a crisis that allow for you to assess risk level. I will discuss different strategies for managing a crisis based on level of risk (high-risk vs. low to moderate risk situations). I will also give you a some de-escalation tips and ways to express “effective” compassion. Finally I will address the areas you would want to cover in creating your own crisis plan for a client, a loved one or yourself.
Safety Concerns: What can you do?
1st you need to Assess Level of Risk!
High Risk Situation:
Drive your loved one to hospital
Monitor your loved one, don’t leave them alone
Remove Lethal Means, e.g. weapons, pills, and sharp objects.
Moderate to low- risk situations:
Make contact – try to bring a feeling of calm and confidence into the situation. Practice active listening skills. Do not make judgments. Stay calm and supportive of your family member. Do not get into a shouting match however difficult their behavior, and even if you are hurt by what they are saying.
Try to learn what happen – don’t be surprised if your loved one is confused, vague or rigid: “nothing works”. Don’t get drawn into focusing on too much or too big of issues. Try to sort out one problem at a time. Acknowledge what your affected family member may be feeling or saying, let him or her know you have heard them and are trying to understand what they may be feeling.
Examine Choices – Your loved one must be involved in the problem solving. The first step is to find out what he/she has tried. Don’t rush in with the solution. Remember, solutions that are given too early, will be rejected. Guide your loved one into the solution. Examine obstacles to the plan.
Build a support network – involve anyone your loved one may be able to use as a support. Tell your loved one that talking about suicidal feelings and a thought was the right thing to do. Don’t be afraid to ask about suicidal intentions. Suicidal behaviors can be an attempt to relieve emotional pain or communicate distress
Keep your voice calm
Use short sentences
Listen to their story
Offer options instead of trying to take control
Ask ho you can help
You may want to avoid touching
Remain calm, avoid overreacting
Don’t argue or shout
Express support and concern
Keep simulation level low
Avoid eye contact
Be patient and accepting
Announce actions before initiating them
Give them space, don’t make them feel trapped.
Validated the valid versus trying to prove (or get them to see) your point.
Acknowledged the difficulties they face, as well as their current distress
Remind them that you will support them in using their skills
Identify skills that might be helpful in the situation
Coach them on using the skills
Be flexible and willing to try different approaches to the problem
Identify your own limits an communicate them clearly and non-judgmentally, as soon as possible
Reinforce, cheerlead, and encourage each small step taken toward safety, wise mind and skill use.
Most importantly – SAFETY FIRST! In a crisis situation, when in doubt, back off or get out.
Creating a Crisis Plan
Patient information – name, age, mental health diagnosis, medical history, list of strengths and interest.
Family information – name of parents, list of family members, etc.
Behaviors – Things that trigger (present before behavior occurs), list of strategies that have worked in the past (Skills)
Medication – name and types of medications, dosage, prescribing physician’s name and phone number. Known allergies
Treatment Choices – List of interventions or treatment currently being used, list of interventions that have not worked in past, treatments that should be avoided, list of treatment preferences.
Professional involvement – phone numbers of crisis team! Family doctor, therapist, social worker, psychiatrist and hospitals with psychiatric units
Supports – people who patient has trusting relationship with such as neighbors, friends, family members, teacher, etc.
Safety Concerns – Access to guns, knifes or weapons, access to medication, both prescription and over the counter. Emergency contact names and phone numbers.
Resources – advocacy organizations, support groups, hot-lines.
Everyone has limits. You just have to learn what your own limits are and deal with them accordingly. – Nolan Ryan
I had the pleasure of teaching the interns at Marin Country Community mental health about how to observe and set limits with clients. It struck me how simple it seems in theory to be responsible for setting our own limits and communicating these effectively, yet many struggle with doing this. The responsibility for taking care of the therapist limits belongs to the therapist, not the patient. It is crucial that these limits be communicated in a clear, direct and timely fashion. For beginning therapist limits are often crossed before they are realized and this can be harsh lesson for both parties. Below I’ve included some bullet points on the observing-limits procedures checklist for therapist (adapted from Lienhan, 1993).
Observing- Limits Checklist – Do’s
Therapist monitors his/her own limits (on a continuing basis, with each patient separately).
Therapist communicates his/her own limits to the patient honestly and directly.
with respect to phone call timing, duration, frequency.
with respect to violations of therapist privacy
with respect to infringements of therapist property, time, etc
with respect to aggressive behavior in sessions or directed at therapist
with respect to type of treatment therapist is willing to carry out or be a part of
with respect to therapist willingness to risk patient’s suicide.
Therapist extends limits temporarily when necessary.
Therapist gets professional backup or help when therapist is at edge of limits and patient needs more
Therapist gets patient cope effectively with therapist limits when patient is not in danger because of limits
Therapist is consistently firm about own limits
Therapist combines soothing validation and problem solving with observing limits.
Therapist refuse to expand limits on temporary basis when patient clearly needs more than usual from therapist.
Therapist limits change and fluctuate in an arbitrary and/or unpredictable manner.
Therapist presents limits as good for patient rather than for the good of therapist.
This Thursday I will be speaking at the BPD Friends & Family Support & Psychoeducation Group is an open,drop-in group for friends and families with loved ones suffering from Borderline Personality Disorder (BPD) or other problems with emotional regulation, impulsive or self-harming behaviors, or interpersonal difficulties.
This Month’s Topic: Limit Setting Everyone has different limits. Observing our own personal limits is simple in theory, yet can be difficult to practice. Learn how to identify what you are willing to tolerate and what is not acceptable. Troubleshoot the factors that get in the way of setting clear limits with family or friends, and practice letting your expectations be known in clear, simple language.
Join us this Thursday evening, June 2, 2011, 7pm to 9pm for a discussion of limit setting. DBT Center of Marin
895 Sir Francis Drake Blvd.
San Anselmo, California www.dbtmarin.com
For more information, call 415-459-5206×2. Due to limited space, please park across the street at the Red Hill Shopping Center if you are able.
When someone is in pain their response toward themselves is important in determining how much suffering they will endure. Research suggests the people who demonstrate self-compassion are better able to handle stress and recover faster from difficult events. For some self-compassion comes naturally (perhaps they learn this from their parents or caregivers). For others, it seems much more difficult. Some are able to have compassion for others but unable to bring that same level of kindness toward themselves. It is believe that many struggle with self-compassion based on a notion that if they remain hard on themselves they can whip themselves into line. The belief that if one remains harshly critical of oneself they are more likely to take action has proven to be incorrect. This self critical talk actually tends to diminish confidence over time, leading to more painful feelings, and negative judgments which can get people stuck in a cycle of suffering. Dr. Neff a pioneer in the research of self-compassion has identified three components that make up self-compassion; 1. Self-kindness, 2. Common humanity and 3. Mindfulness. Self-compassion involves being open to and aware of one’s own suffering, offering kindness and understanding towards oneself, desiring the self’s well-being, taking a nonjudgmental attitude towards one’s inadequacies and failures, and framing one’s own experience in light of the common human experience.
Here is a video of Dr. Neff discussing Self Compassion
Some articles and blogs on the topic of self compassion
“Meaning makes a great many things endurable – perhaps everything” – Carl Jung
Questions to ponder: What is the meaning of life? What is the meaning of my life? Why are we here? What do we live for?
Importance of meaning
“Absence of meaning in life plays a crucial role in the etiology of neurosis. A neurosis must be understood, ultimately, as a suffering of a soul which has not discovered its meaning… about a third of my cases are not suffering from any clinically definable neurosis but from the senselessness and aimlessness of their lives” -Carl Jung
We (human beings) require meaning. To live without meanings, goals, values or ideals seems to provoke considerable distress. In severe form it may lead to a decision to end ones life.
Victor Frankl author of “The search for meaning” noted from his experiences in a concentration camp, the individuals without a sense of purpose were unlikely to survive.
Why do we need meaning and what is “Meaning”?
Meaning – refers to sense or coherence. It describes what is expressed by something. A search for meaning implies a search for coherence.
Purpose – refers to intention, aim, and function. When we ask about the purpose of something we are asking about its role or function. What does it do? To what end?
What is the meaning of life? Is an inquiry into cosmic meaning, about whether life fits into some overall coherent pattern.
What is the meaning of my life? Is an inquiry into terrestrial meaning. Terrestrial meaning (the meaning of my life) embraces purpose: one who possesses a sense of meaning, experiences life as having some purpose or function to be fulfilled, some overriding goal or goals to which to apply oneself.
What gives us meaning?
Altruism – Leaving the world a better place to live in, serving others, participation in charity, etc. The belief that it is good to give, to be useful to others, to make the world better for others, is a powerful source of meaning.
Dedication to a cause – Many kinds of cause may suffice: the family, the state, a political or religious cause, and a scientific venture. “It must if it is to give life meaning, lift the individual out of himself, and make him a cooperating part of a vaster scheme” – Durant
Creativity – To create something new, something that rings with novelty or beauty and harmony is a powerful antidote to a sense of meaninglessness. The creation justifies itself. It defies the question, what for?
The Hedonistic Solution – The purpose of life in this view is simply to live fully, to retain one’s sense of astonishment at the miracle of life, to plunge oneself into the natural rhythm of life, to search for pleasure in the deepest possible sense. “Life is a gift. Take it, unwrap it, appreciate it, use it and enjoy it”
Self-actualization – Another source of personal meaning is the belief that human beings should strive to actualize themselves, that they should dedicate themselves to realizing their inner potential. Self –actualization is a modern term for an ancient concept expressed by Aristotle in the 4th centenary B.C. It refers to the aim pf each being to come to realize its own being. Thus, the acorn is realized in the oak and the infant is a fully actualized adult. Abraham Maslow – self actualizing needs consist of knowledge, insight, wisdom, symmetry, congruence, integration, beauty, creativity and harmony.
Self-transcendence – Victor Frankl holds self –transcendence (a desire to strive toward something or someone outside or “above” oneself) as a key feature in the question of meaning.
The essence of our experience is change. Moment by moment life flows by, never the same moment. A thought comes to your mind and a second later it is gone. In comes another one and then that too is gone. People come and go in your life. Your fortunes go up and they go down. It is incessant: change, change, and change. No two moments ever the same.
This is the way things are. There is nothing wrong with this. Yet, most of us don’t like change and we have come up with ways for dealing with this endless flowing. We categorize experience. Trying to stick each perception into one of three mental pigeonholes: is it good, bad or neutral. Then according to which box we have placed the experience in we react with a set of fixed habitual mental responses.
If we have labeled a particular perception as “good” then we try to freeze time right there. Grab hold of the particular thought, fondle it, hold it, and we try to keep it from escaping. When this does not work, we go on an all-out effort to repeat the experience that caused the thought. This mental habit is referred to as “grasping”
When we perceive something as “bad”, we try to push it away. We try to deny it, reject it, and get rid of it any way we can. We fight against our own experience. We run from pieces of ourselves. This mental habit is referred to as “rejecting”
Between the two lies the “neutral” box. Here we place all the experiences that are neither good nor bad. We pack experiences away in the neutral box so that we can ignore it and return our attention to where the action is, namely our endless round of desire and aversion. So, this neutral box gets robbed of its fair share of attention. This mental habit is referred to as “ignoring”.
The direct result of all this is a perpetual treadmill race to nowhere, endlessly pounding after pleasure, endlessly fleeing from pain, and endlessly ignoring 90 percent of our experiences. No matter how hard you pursue pleasure and success, there are times when you fail. No matter how fast you flee, there are times when pain catches up with you. And in between these times life may seem so boring you could scream. In the final analysis this system does not work.
“In the beginner’s mind there are many possibilities, but in the expert’s there are few.” – Zen Master Shunryo Suzuki
My meditation teacher asked for volunteers to hand out an object to each student. The volunteer carefully placed this object in my hand. This would be the start of today’s meditation. Our teacher specifically did not NAME the object although we all knew what it was based on our experience. However, the point was to be discovering this object as if we had no name or preconceptions of what it was. Exploring it with all our senses: smell, sight, hearing, touch and taste.
We refer to this as the “Raisin exercise”. It’s an exercise I have done many times both as a student and a teacher. I would say I have done this particular meditation exercise over 40 times. However, it never gets old. Every time is truly, your first time.
Besides being a practice in mindfulness it also brings to awareness how our function of “naming” or “labling” actually stops the exploration. We miss a lot this way. If we stop at the name, “oh it’s a raisin”, then we done take the time to explore deeper and the more time you spend with it the more you can discover. So in our “naming” we forget how to look, we name and move on. What are we missing by doing this?
I invite you to try the raisin exercise for yourself.
Transcript: The Raisin Exercise
Now what I would like you to do is focus on one of the objects and just imagine that you have never seen anything like it before.
Taking one of these objects and holding it in the palm of your hand, or between your finger and thumb.
Paying attention to seeing it.
Looking at it carefully, as if you had never seen such a thing before.
Turning it over between your fingers.
Exploring its texture between your fingers.
Letting your eyes explore every part of it, as if you had never seen such a thing before.
And if, while you are doing this any thoughts come to mind about “what a strange thing we are doing” or “what is the point of this” or “I don’t like these,” then just noting them as thoughts and bringing your awareness back to the object.
Explore does it make a sound, hold the object to your ear.
And now smelling the object, taking it and holding it beneath your nose, and with each inbreath, carefully noticing the smell of it.
And now taking another look at it.
And now slowly taking the object to your mouth, maybe noticing how your hand and arm know exactly where to put it, perhaps noticing your mouth watering as it comes up.
And then gently placing the object in the mouth, noticing how it is “received” without biting it, just exploring the sensations of having it in your mouth.
And when you are ready, very consciously taking a bite into it and noticing the tastes that it releases.
Slowly chewing it … noticing the saliva in the mouth, … the change in consistency of the object.
Then, when you feel ready to swallow, seeing if you can first detect the intention to swallow as it comes up, so that even this is experienced consciously before you actually swallow it.
Based on Kabat-Zinn. From Segal, Z. V., Williams, J. M. G., & Teasdale, J. D.
(2002). Mindfulness-Based Cognitive Therapy for Depression. NY: Guilford.
I just came from a meditation class and was inspired to write about the experience. A simple phrase “looking out through one’s own eyes” struck me as profound. How much of the time are we looking out of our perceptions of other people’s eyes at our selves or the world? How often do we truly experience the world through our own eyes? Can we just look, just observe without interpretations, judgments and assumptions?
In DBT one of the “what” skills of mindfulness is Observe. This skill is focused on just noticing without descriptions. This sounds simple yet is difficult to practice. Our minds automatically put labels on what we see. I like to think of having a Teflon mind, letting experiences, thoughts, feelings, come and slip right off the pan. Another image could be waves of an ocean, rising and falling or clouds passing by in the sky. The idea is not to have no thoughts, feelings or experiences but to just NOTICE. The practice is about watching neither pushing away nor clinging.
I have often used the example of training a puppy. That we have puppy mind, it is running all around in many directions, easily distracted. Yet, it can be trained. One can with practice bring the puppy back to the present moment. My teacher tonight spoke of having doggy mind. A similar analogy. He stated that our mind is throwing out sticks, lots of them and our doggy mind chases them. What would it be like to have a lion mind? Yes, I see that stick but it’s not something I will chase. I can just see it for what it is and let it pass by.
So, why is this helpful? How does being able to observe, to truly look out through one’s an own eyes going to help me? I predict some may ask this question. So much of human suffering come from non-acceptance. To say, “it shouldn’t be this way” or “if only ___, I could be happy”. These are forms of non-acceptance and freedom from suffering requires acknowledging what is. Acknowledging what is requires that we see what is, not our perception of what is, not how it should be or how we want it to be, but how it truly is. It’s about being awake and when we are awake to what is, we can let go of fighting reality, find freedom and joy.
New Year’s Eve has always been a time for reflecting on the past and more importantly looking forward to the future. It’s a time where people assess the changes they want (or need) to make for the coming year. However people tend to overestimate their ability to resist temptations and create new patterns of behavior. One way to fail proof your resolutions for a new and improved you, is to understand and learn from past mistakes. Understanding why you didn’t succeed at your goal can be just as important as understanding what made you successful in other endeavors. In DBT we analyze problematic behaviors through the use of a chain analysis, with the intention of seeing the links in the chain where one can intervene with a new coping skills instead of relying on old ineffective habits that we want to change. The purpose of the chain is to see what thoughts, feelings, behaviors and events are related to our target behavior. This can be very specific to the individual.
For example: If the target (problematic) behavior is overeating it is useful to know what kinds of prompting events (triggers) set one up to overeat. These promoting events can be internal (thoughts and feelings) or external. If we know that overeating is a way to temporary find self soothing then it would be important to develop new ways to self soothe (i.e taking a warm bath, listening to music, talking to a friend). If we find that overeating is a response to skipping meals then reduces our vulnerability would consist of making a plan to eat smaller meals though out the day.
Although it is true that our habits and specific patterns of behavior are quite individual, some common universal mistakes can be made when trying to implement behavioral change.
It’s a new year and you’re eager to kick some ass! Yet you don’t want to set yourself up for failure. How to avoid launching into a marathon only to collapse in the first mile is to break goals down into small achievable steps. Set realistic expectations. Choose a plan of action that doesn’t require a lifestyle 180.
Write your goals down.
Keep track of your progress and set daily reminders. We humans are forgetful creatures. Put your resolutions in a place where you will be able to see them frequently.
Visualise yourself doing whatever it takes to achieve you resolution as this will help you believe you can do it and see it through.
Reward yourself for successes.
Acknowledged that changing patterns of behavior is challenging, don’t let set backs discourage you from continuing working toward your goals. Be persistent. Don’t give up!
Have support and stated your intentions to others. Accountability can be highly motivating.
Stories and metaphors can be helpful in understanding ideas. This is a story taken from Marsha Linehan’s skills manual that I tell to clients often and many find helpful:
A man bought a new house and decided that he was going to have a very beautiful lawn. He worked on it every week, doing everything the gardening books told him to do. His biggest problem was that the lawn always seemed to have dandelions growing where he didn’t want them. The first time he found dandelions, he pulled them out. But, atlas, they grew back. He went to his local gardening store and bought weed killer. This worked for some time, but after summer rains, alas, he found dandelions again. He worked and pulled and killed dandelions all summer. The next summer he thought he would have no dandelions at all, since none grew over the winter. But, then, all of the sudden, he had dandelions all over again. This time he decided the problem was with the type of grass. So he spent a fortune and had all new sod put down. This worked for some time and he was very happy. Just as he started to relax, a dandelion came up. A friend told him it was due to the dandelions in the lawns of his neighbors. So he went on a campaign to get all his neighbors to kill all their dandelions. By the third year, he was exasperated. He still had dandelions. So, after consulting every local expert and garden book, he decided to write the U.S. Department of Agriculture for advice. Surely the experts could help him. After waiting several months, he finally got a letter back. He was so excited. Help at last!!!!! He tore open the letter and read the following: “Dear Sir: We have considered your problem and have consulted all of our experts. After careful consideration, we think we can give you very good advice. Our advice is that you learn to love those dandelions.” (Linhean, 1993, p.94)
What are the dandelions in your life?
This story can serve as an illustration of resistance and move one toward cultivating acceptance. Fighting reality or ourselves doesn’t create change, it usually gets us caught/stuck. Another helpful story I use comes from John Kabit Zinn, Ph.D. book “Full Catastrophe Living”. The story goes something like this:
They say there is a clever way to catch monkeys. A hunter can cut a hole into a coconut just big enough for a monkey to put his hand through. Placing two smaller holes in the other end and a wire through, one can secure the coconut to the base of a tree. They then place a banana inside the coconut, hide and wait. The monkey comes down the tree, puts his hand in and grabs hold of the banana. The hole is made so the monkey’s hand can go in but the fist cannot get out. The monkey is caught! All the monkey has to do to be free is Let Go. However, it seems most monkeys don’t let go.
Despite our intelligence our minds can do the same thing. When do you get caught in monkey mind? Struggling, stuck and refusing to let go… the first step toward freedom is noticing that we are grasping/clinging on. Then we can move toward letting go, acceptance and freedom.