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Borderline Personality Disorder or Traumatic Stress Disorder

Borderline Personality Disorder – What if it is a traumatic stress disorder?

When most people think of Borderline Personality Disorder – they think of bad behavior.  It is someone that is very difficult to deal with, someone that you have to be on guard against, Borderline Disordersomeone who will try their best to manipulate you.
But, while that may be the outcome, just like most psychiatric disorders, it isn’t exactly their fault.

One of the problems with BPD is that since it is a “personality disorder“, there is often no recognized medical treatment.

We simply expect that the patient should self-monitor and control their behavior.  Therapy may help this, but how many of us (psychiatric patients, in general) really want to go to therapy.

Many of us have already spent hundreds of hours with a therapist – who may or may not help.  In addition, the best therapists are likely people who can “see through the bullshit” and refuse to be manipulated.  This obviously goes against the nature of someone with Borderline Personality Disorder.

In fact, the stigma is so bad that some therapists won’t even work with Borderline patients.

Co Morbid DisordersOne theory may help.  Some therapists have developed an automatic assumption that a Borderline patient is also a trauma victim.  While this co-morbid condition may not always be true, it can help some therapists feel more comfortable treating the patient.

Due to many soldiers returning from impossible battlefields in the Middle East, Post Traumatic Stress Disorder is fairly well recognized.  Remember; I am not saying that it is easily treatable, but to some extent, the stigma is less.

When therapists look at Borderline patients as truly a PTSD patient, they may be more willing to treat the disorder. And they will attempt to get to the underlying causes of abandonment, impulsive and destructive issues, loss of control and poor self-image.

While PTSD is well defined by the professional psychiatric community, a longer-term disorder currently known as complex traumatic disorder is not.  Most examples of CTSD still involve soldiers, or they may involve women who had difficult pregnancies or who were violently sexually abused, repeatedly.

However, what if you don’t fit any of those recognized categories?

There are more ways to treat traumatic stress disorders such as Cognitive Behavioral Therapy or a newer one, Dialectical Behavior TherapyDBT focuses on four major areas:

•    Regulation of emotionsPost-Traumatic Stress Disorder
•    Tolerance for distress
•    Interpersonal effectiveness
•    Mindfulness

Unlike CBT, there is no “processing” component – making it work well as an initial treatment, starting before the patient has developed coping skills.  It builds up the feeling of emotional safety so that coping skills may develop.

Differentiating between “plain” Borderline patients – and those whose behavior is brought on by traumatic experience may help to eliminate some of the stigma still associated with BPD.  It may also offer actual, more effective treatment than CBT or other approaches.

Melissa Lind

Mental Health Professionals and Suicide

Suicide – Threat of Liability for Mental Health Professionals

Suicide is the third most common cause of death for young adults – and the ninth highest for the general adult population.  This means that a large percentage of mental health professionals will have a patient that commits suicide. It may be as high as 80 percent of psychiatrists, psychologists, social workers, and other therapists, that eventually have a patient who commits suicide.

Serious Mental Health ProfessionalYou might think that professionals are insulated against emotions that come with the death of a friend or acquaintance – but they aren’t.  Many health professionals report that even when death is expected (natural causes), they spend a great deal of time going over their treatment of the patient. They try to find out if they could have done anything different, (given another treatment) in order to help.

But, what may be surprising is the number of liability lawsuits filed against mental health professionals, when a patient commits suicide.  In fact, it is the number-one cause of responsibility lawsuits brought against mental health providers.
The threat of lawsuits, and also the stigma against people working it in the mental-health profession, has led to many psychiatrists refusals to treat the chronically suicidal. The profession sees it as a failure of the doctorMental health professionals are also less likely to see additional suicidal patients after they have had a patient succeed at suicide.

When a therapist or physician is unable, or unwilling, to treat a suicidal patient – it leaves the patient in the lurch.  It produces feelings of failure and hopelessness, without a doubt, compounding the fact that they are suicidal.  It may also be difficult for an extremely suicidal patient to find a new therapist or doctor.  Many patients report that the mental health professionals suddenly “don’t have time”.

We don’t think much about the way suicide will affect those around us – and certainly the professionals are way down the list of people whose feelings are important.

Mental health professionals also report that there is a lack of training on how to deal with suicidal patients, and processing the death of a patient.  More than half of professionals surveyed also Knocking on Heavens Doorstated that they really don’t believe they can prevent a patient from committing suicide.

Oddly, the complaint process against physicians has been shown to increase the risk of the physician becoming depressed. One of the consequences of this will be a worsening of the situation for mentally ill people. (Chronically suicidal patients)

This is a complicated process with no easy answers, but you should know that it is likely that all psychiatrists, therapists, social workers and other counselors probably need to be in counseling themselves.  When you find a new doctor or therapist – you might want to ask.

Even if you aren’t suicidal, you need to know that your counselor is as mentally healthy as possible, certainly healthier than you.

Melissa Lind

Mental Health Professionals Report a Lack of Training on How to Deal With Suicidal Patients

Bipolar Disorder and Adolescents

Symptoms of bipolar disorder in children and adolescents may look like other disorders

Traditionally bipolar disorder has been thought to first show in early adulthood – and more often in females.  Bipolar disorder was considered to be quite rare as few as 20 years ago, to be more exact. The first emergence came in the early 20s, mainly in females. But, our knowledge about bipolar disorder has grown rapidly in the last 20 years.

Instead of the single manic-depressive diagnosis – which included diagnostic criteria of both depressive periods, alternating with manic periods – described as “euphoria”?

Those who did not have clearly rhythmic, alternating periods of a “happy” and frantic manic phase with a classic depression period were mishandled, misdiagnosed, mistreated, or dismissed.

Bipolar ChildrenIn addition, it wasn’t really known that bipolar disorder could start in adolescence or even childhood, or that there are different types of bipolar disorder.  Today, it still isn’t “officially” recognized in the “psychiatric bible” – the Diagnostic Statistical Manual of Mental Disorders (DSM), but at least more practitioners do know that it exists.

Today, we don’t exactly know what causes bipolar disorder (only that there is a genetic link of some kind, and often some past trauma). But, we can at least identify adolescent and childhood bipolar illness.  We also recognize a variety of different types of bipolar disorder (Such as mixed manic episodes, rapid cyclers, people without a depressive phase, hypomania, dysphoria rather than euphoria and cyclothymia). We also have a “catch-all” type – Bipolar NOS or “not-otherwise-specified”.

Adolescent or childhood bipolar disorder is official known as: “early onset bipolar disorder”.  In fact, childhood bipolar disorder can be more serious than a similar disease in adults and may have slightly different symptoms.

Symptoms of bipolar illness in children can often be more severe, and the cycling period may be more frequent.  Children also have more mixed episodes.  Children also have slightly different symptoms – so even the depression phase of the cycle may not be obvious.

Pediatric patients (children and adolescents) with bipolar disorder may have:

Bipolar Disorder in Children•    Abrupt mood swings
•    Periods of hyperactivity followed by lethargy
•    Intense temper tantrums
•    Frustration
•    Defiant behavior
•    Chronic irritability

These symptoms have to appear in more than one setting (school and home) and cause “distress”.

The problem is that many of these symptoms may look like other disorders.  They might be disorders such as ADHD, childhood depression, anxiety disorder, obsessive compulsive disorder, conduct disorder, premenstrual syndrome, oppositional defiant disorder and others. The danger might come from a misdiagnosis and improper treatment.

Bipolar disorder is treated with anti-manic agents (lithium), anti-convulsants (Depakote, lamotrigine) or atypical antipsychotics (Abilify, Risperdal).  In many cases, anti-depressant won’t be needed.  Treatment for other disorders like ADHD or depression may make bipolar disorder worse. Childhood bipolar disorder is something that desperately needs treatment as the distress caused to the patient, and the family can predispose the youngster to

•    Drug or alcohol abuse
•    Stealing
•    Involvement with law enforcement
•    Poor social integration
•    Poor academic performance
•    Suicidal tendencies
•    Premature sexual behavior

The Balanced Mind has a good self-check list of symptoms that can help a parent or a teen decide if bipolar disorder might be an issue.  Self-testing is not always accurate and should be discussed with a doctor, (preferably with test results in hand).  Not all doctors accept pediatric bipolar disorder. Parents may have to seek advice from more than one mental health professional and be aware that insurance may not cover the illness.

Melissa Lind

Mental Disorders Failure to Take Medications Consistently

Don’t skip your meds – even if you are sick!

It is cold and flu season in the Northern part of the world, and though that isn’t the only time people get sick, it brings up an issue common in Bipolar disorder and other mental disorders.

Medication - Mental DisordersOne of the biggest problems in maintaining a level mood state or semblance of “normalcy” in people with mental disorders is the failure to take medications consistently.  In a lot of instances, mentally ill persons will stop taking the medication on purpose because they are “better” and “don’t need it”.

As mentioned many times before – this is, usually, done in secret. Without consultation with professionals, friends or family members who do not find out until someone with a mental disorder has gone “off-track” and had an “episode”.

But, another cause of medication non-adherence is forgetfulness. Forgetfulness wouldn’t seem to be a big deal as many medications are “forgotten” one day and resumed the next – blood pressure medicine, birth control pills, and antibiotics etc. All with each of their own ramifications.  In the case of the forgotten anti-depressant, anti-manic agent, anti-psychotic, a different set of events comes into play.

Mentally ill people may “forget” the first day but by the second day, the thoughts of “I am OK” start to intrude.  This may lead back to the first case of non-adherence where the patient then decides to quit purposefully taking their medication – obviously without telling anyone.

Mental MindWith your illness, you may not feel like getting up.  You may not feel like eating.  You may not feel like taking your medicine – but you should.  You must.  Even when your mental illness seems secondary to a physical illness, the medicine that keeps you functioning on a semi-even level is vital.  Allowing yourself to skip, even one day can ultimately cause a “relapse”.

If you skip today because you don’t feel good, you may skip tomorrow.  If you skip today and tomorrow, because you didn’t feel good, you will probably hear the voice that always says, “I am doing OK,” because you are OK – for today.  A week or two, maybe a month or two – you won’t be OK.  You haven’t been in the past and likely you won’t in the future.

No matter why you skip your meds – don’t.

There are legitimate medical reasons not to quit without supervision – such as drug withdrawal and increases in seizure potential which are real, unpleasant, and possibly dangerous. But the biggest reason is the same as it has always been.  Eventually, it will lead you back down the path, and you won’t know until you are already out of balance.

One of the biggest challenges for a bipolar or schizophrenic (or many other) patient is to ignore the impulse to give in to “See, I’m OK and I don’t need this”.  In your rational mind, you know that you do.  You may resent it, but you know.

You may have to remind yourself of how far you have come – and remind yourself that this wasn’t the first time that you had to dig yourself out of a mess.

Remember how it was, how awful it was, and how hard it will be the next time to recover.

Melissa Lind

The medicine that keeps you functioning is vital – even if mental disorders seems secondary to physical illness!

Mental Health and Grief

Grief and Mental Health – When the Two Merge

Grief is something that we all experience at one time, or another.  The stages of grief – sometimes explained as 3, 5 or 7 different stages – are pretty well known and include shock, denial, anger, sadness, acceptance in some order.  Most people will struggle but eventually come to some resolution with no prediction as to how long that will take.

Resolution of deep sorrow can be made much more difficult when a pre-existing mental illness is imposed.  A severe loss can trigger a relapse of virtually any mental illness, even when the illness was well treated, and the patient was stable.  Patients may relapse into severe depression, bipolar episodes, panic attacks or a return of obsessive compulsive behavior.  If the patient was not well stabilized, the whole apple-cart can be upset.

Depressed and Suicidal GirlEven the most mentally healthy person can become unstable if unable to resolve the feelings caused by painGrief has been known to result in clinical depression, lasting for a long period which can lead to extreme difficulties and even death in the case of suicide.  The problem comes in a case where one becomes “stuck” at a certain point – usually during the agitation period.

There is a saying;   “depression is anger turned inward.”  The existence of anger over an extended period can cause depression.

Anger allows us to have a heightened response to a threatening situation.  Anger fuels energy, giving us a false sense of power, but over time, the brain and the body run out of that same energy.  This can result in fatigue, emotional lability, and symptoms of depression.  In some cases, depression caused by grief may be resolved with grief counseling.

In other cases, however, depression may have become severe enough that medication may be warranted.  Clinical depression is characterized by:

•    Fatigue and decreased energy
•    Cloudy thinking
•    Feelings of guilt, worthlessness or helplessness
•    Insomnia or excessive sleeping
•    Irritability
•    Loss of interest in pleasurable activities
•    Body pain or digestive problems
•    Persistent sad or empty feelings
•    Thoughts of suicide

How different is this from grief – not much.  The only difference would be in how long it lasts.  Depression carries a high risk of suicide and if symptoms last longer than what would be considered “normal” – for any reason – you should seek treatmentMental Health ChaosDepression that is severe enough to interfere with normal activities for longer than four to six weeks should be treated – even if life circumstances explained it.  Counseling may work – or you may need medication for a short period.

If you have some known mental disorder, stay in contact with your mental health professional.  Most – and I did not say “all”, but most mental health patients find it difficult to self-assess, some find it difficult to be openly honest.  The only way to ensure that an episode of grief is resolved without severe consequences of going “off track” is to allow someone else to help assess your mental state.

Whether you are or are not a mental health patient, know that grief can cause mental illness and can worsen an existing illness – even if only for a short time.  It is not something to be dismissed or ignored as the risks are high.

Melissa Lind

Depression is Anger Turned Inward

Cutting – An Actual Mental Disorder

Non-Suicidal Self-Injury

A lot of people are shocked and horrified at the thought of self-mutilation and for many years “cutting” was categorized only as a symptom of Borderline Personality DisorderBPD, as you may know, has symptoms of unstable personal relationships, impulsivity, and extreme mood changes (different from Bipolar disorder as they can change on a dime and swing wildly).

The new issue of the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition or DSM-5, includes it as a separate diagnosis of Non-Suicidal Self-Injury (NSSI).  Research has suggested that NSSI can occur independently of BPD but is also often a co-existing or co-morbid illness, occurring alongside BPD, Bipolar Disorder, one of the many anxiety disorders or with other disorders such as anorexia or bulimia.

Cutting DisorderI am the mother of pre-adolescent children – who are beginning to believe they know all about people who act “weird” or do “weird” things (their words, not mine).  My daughter has recently talked about the “EMO” kids – which as a dumb mom, I had to figure out was a social group of kids who were “emotionally dark.”  She includes in her description of an “EMO” as “you know, like kids who are cutters.”  It is stereotypical to think that they all wear black clothing and heavy eyeliner – as some may – but many do not.

Some people who have the disorder would never be suspected of such – but then we are also sometimes surprised when someone who seems to have everything commits suicide, only to find that under the polished exterior was extreme anguish.  Often, cutting will be dismissed as a “stage” and it may be a “stage” – but often it is not.  Many patients – have arms or hips full of patterned scars – proving that it is often a condition all to itself.

Cutting Disorder - Mental IllnessSelf-mutilation most often starts in the early teen years when adolescent emotions are at their height – but often extends well into adulthood.  The majority of “cutters” are female – but not all.  There is often a co-existing mental illness and may have a family history component – but also often occurs following events of abuse – including sexual, physical or emotional abuse.  Sudden life changes such as unemployment or divorce – and isolation may trigger an occurrence.

People who “cut” often express a desire to “feel” as if they cannot truly attach to their own emotions.  Others will say they “cut” to kill the pain – this is because the act of producing pain also causes the body to release endorphins (the body’s natural painkiller) that makes them feel better.  Unfortunately, even though the action may induce temporary euphoria – it is often followed by guilt and a return of the negative feelings.

NSSI is defined as:

• 5 or more days of intentional self-inflicted damage to the surface of the body without suicidal intent – in the past year.
Patients must be intending to:
o Seek relief from negative feelings or thoughts and/or
o Resolve interpersonal problems and/or
o Induce a positive emotional state
• The behavior must be associated with 1 of:
o Interpersonal problems
o Negative thoughts or feelings
o Premeditation
o Ruminating on injury (obsession)

NSSI includes not only “cutting” but also burning, hitting or punching, head banging, biting, non-aesthetic piercing or carving of skin (tattoos and body piercing don’t apply), pulling out hair or other “topical” mutilation.  If a patient has expressed suicidal thoughts or shows suicidal tendencies – it is not classified as NSSI as the intent of a person with NSSI is not to commit suicide.
NSSI should be first viewed as a serious medical condition that truly requires treatment.  It may be resolved by treating an existing co-morbid psychiatric condition – but likely it will also require psychotherapy to resolve some of the underlying issues.

Definition of Self-injury/cutting (Mayo Clinic)

Cutting and Self-Harm: Warning Signs and Treatment (WebMD)

If you see signs of NSSI or “cutting” in a child, teen, or adult that you know – encourage them to seek help.

Melissa Lind (WriterMelle)

An Actual Mental Disorder – Cutting