Brief Excerpts from "The Journal of the California Alliance for the Mentally Ill"

by Joel A. Dvoskin, Ph.D., A.B.P.P.

"...Axis II is a horrible thing to be. Though DSM IV lists along Axis II a variety of personality disorders, people who are so described are treated as if their disruptive and self-destructive acts are simply evidence of moral weakness, dishonor, and perhaps evil.

For example, people diagnosed with BPD are often pejoratively called 'manipulative.' Manipulation, often, is listed on treatment plans as a problem or symptom, and patients are insulted and punished when their behavior is so described. Yet, no matter how often punished , how seldom rewarded, the behavior continues. With almost religious fervor, we clung to our ridiculous notion that ruining one's own life was somehow a scam; that our miserable, meager, and often mean-spirited attention was a sufficient reward to overwhelm the punitive and tortuous effects of these so-called manipulative behaviors. And why? Because, if we were to attribute these behaviors to mental disability, then we are the failures. On the other hand, if we call it free will, the fault is theirs.

Why would psychiatry and psychology turn so viciously against a group of people they call mentally disordered? Apparently, the greatest sin a patient or client can commit is the sin of poor response to treatment. What is apparently so wrong about these unfortunate souls is that they have yet to demonstrate the ability to get better in response to our treatment. Thus, they don't make us feel very good...With a few notable exceptions, we have given up on helping people who desperately need us to do a better job of helping them.

When people cut themselves, we dismiss this behavior as manipulation. We dismiss their despair and say that they did it for our attention:  "It is the only way I can feel calm." Our dichotomous scientific minds lead us to see things as either willful or the result of disability. I suspect a middle ground, where people with precious few alternatives for feeling better choose one that we find offensive. Like all of us, they learn to cope the best way they can...

Axis II diagnoses, when misused, can cost them voice, history, competence and hope:

Voice - we don't listen to or believe them, which makes them less honest.

History - we see their problems as current moral weakness, not the scabs of old wounds; so instead of healing, they do wrong.

Competence - we label their coping behaviors as weak, instead of resourceful, and they quit trying.

Hope - we truly don't believe they can heal, and they get worse.

by Robert L. Trestman, PhD., M.D.

"...While the severity of the disorder's symptoms and impairment of function was at any given time equal to that of the schizophrenias or bipolar disorders, it was also clear that there were profound differences in these populations and in the interventions needed. Indeed, one of the few consistencies about BPD seemed to be its apparent inconsistency.

...At the core stood our inability to understand the problem or to effectively help those suffering with BPD to address it. Following from this core were: a) A host of theories of the origin of BPD, none with substantial empirical support; b) A profound stigma associated with BPD, not only among the families and clinicians, but also among those who paid for care; c) A sense of anger and frustration directed at the victims - those with BPD - for not responding to our interventions, for not getting better; d) A sense of cynicism among many clinicians, the recipients of care, and their families."

by Kenneth R. Silk, M.D.

"...since all these people appear so different, you can begin to appreciate why it has been very difficult to pinpoint the specific particular biological or neurotransmitter disturbance in BPD. Nonetheless, it appears it is this very variety of symptoms and reactions that biological researchers will have to deal with. Perhaps clinicians and researchers alike will need to recategorize people with BPD into subgroups...

...they belong to a group, but within that group they are individuals, and unless we appreciate the individual within the group, we will not provide adequate treatment for him or her."

by John M. Oldham., M.D.

"...Concomitant with psychotherapy, pharmacotherapy can be quite helpful to individuals with BPD. Again, it is important to individualize the treatment planning, identifying the predominant symptomatology in a given individual to guide the choice of medications. Generally, there will be a predominance of one of three main types of symptoms: cognitive symptomatology, affective dysregulation, or lack of impulse control. Some patients may virtually always become symptomatic in the same way, e.g. by developing affective instability , or by becoming impulsive; others may alternate among the different symptomatic pictures. In either case, medication is tried that may help the symptoms predominating at the time. Antipsychotic medication (e.g. Haldol) in low doses may be helpful when the person with BPD is temporarily losing touch with reality (becoming paranoid, for example). Mood stabilizing medications (e.g. Prozac) may help when depression and mood swings predominate, and impulse stabilizing medications (e.g. Depakote, Prozac) may help minimize these behaviors.

BPD is a severe and persistent mental illness. It is a bio-psycho-social disorder, one that creates enormous individual, family, and social morbidity, cost, and burden. It is becoming increasingly understood, and as a result, it can more often be successfully treated."

by Marsha M. Linehan, Ph.D.

"...To date, cognitive- behavioral therapy (specifically, Dialectical Behavior Therapy or DBT) is the only treatment that has been shown in controlled clinical trials to be effective treating BPD.

DBT is based on a model suggesting that both the cause and the maintenance of BPD is rooted in biological disorder combined with environmental disorder. The fundamental biological disorder is in the emotion regulation system and may be due to genetics, intrauterine factors before birth, traumatic events in early development that permanently affect the brain, or some combination of these factors. The environmental disorder is any set of circumstances that pervasively punish, traumatize, or neglect this emotional vulnerability specifically, or the individual's emotional self generally, termed the invalidating environment. The model hypothesizes that BPD results from a transaction over time that can follow several different pathways, with the initial degree of disorder more on the biological side in some cases and more on the environmental side in others. The main point is that the final result, BPD, is due to a transaction where both the individual and the environment co-create each other over time with the individual becoming progressively more emotionally unregulated and the environment becoming progressively more invalidating.

Emotional difficulties in BPD individuals consists of two factors, emotional vulnerability plus deficits in skills needed to regulate emotions. The components of emotion vulnerability are high sensitivity to emotional stimuli, emotional intensity, and slow return to emotional baseline. 'High sensitivity' refers to the tendency to pick up emotional cues, especially negative cues, react quickly, and have a low threshold for emotional reaction. In other words, it does not take much to provoke an emotional reaction. 'Emotional intensity' refers to extreme reactions to emotional stimuli, which frequently disrupt cognitive processing and the ability to self soothe. 'Slow return to baseline' refers to reactions being long lasting, which in turn leads to narrowing of attention towards mood congruent aspects of the environment, biased memory, and biased interpretations, all of which contribute to maintaining the original mood state and a heightened state of arousal.

An important feature of DBT is the assumption that it is the emotional regulation system itself that is disordered, not only specific emotions of fear, anger, or shame. Thus, BPD individuals may also experience intense and unregulated positive emotions such as love and interest. All problematic behaviors of BPD individuals are seen as related to re-regulating out of control emotions or as natural outcomes of unregulated emotions.

...Is was the tension and ultimate resolution of this essential conflict between acceptance of the patient as he or she is in the moment versus demanding that the patient change this very moment that led to the use of dialectics in the title of the treatment. In DBT, treatment requires confrontation, commitment and patient responsibility, on the one hand, and on the other, focuses considerable therapeutic energy on accepting and validating the patient's current condition while simultaneously teaching a broad range of behavior skills..."