Dr Allens Book for Therapists about Treatment of Borderline Personality Disorder Now Available in Paperback

Now available in paperback at http://www.amazon.com/Psychotherapy-Borderline-Patients-Integrated-Approach/dp/1138012750/ref=mt_paperback?_encoding=UTF8&me=

Personality Disorders

Personality Disorder 

"Today is the day I have dreamed of since I was diagnosed with borderline personality disorder seven years ago. The day when I can finally say I’ve beaten my demons and come through as a better and stronger person

I never dared to imagine that one day I would be free of the thoughts that have haunted my nights and invaded my waking thoughts everyday of my life since I was five years old. The crushing fear of abandonment and emptiness that has caused me to kill off everything that was ever precious to me.

My illness has caused me so much heartache and has stolen over twenty years of my life.." Katie- a patient treated for borderline personality disorder as an inpatient. To read her entire story, please click here.

Personality refers to the collection of characteristics or traits that we develop as we grow up and which make each of us an individual, with regard to our thoughts, feelings and actions. One is said to have a personality disorder when the way they feel, think and behave, hinder them from adapting well to their environment such that, they cannot live well by themselves, and in relation to others. Personality disorders are conditions in which an individual differs significantly from an average person, in terms of how they think, perceive, feel or relate to others.

Types of Personality Disorders and their Signs/ Symptoms

The following are the basic types of personality disorders and their signs/ symptoms:

 

1. Paranoid personality disorder

You are likely to:
• find it very difficult to trust other people, believing they will use you, or take advantage of you
• find it hard to confide in people, even your friends
• watch others closely, looking for signs of betrayal or hostility
• suspect that your partner is being unfaithful, with no evidence
• read threats and danger – which others don’t see – into everyday situations.

2. Schizoid personality disorder

You are likely to:
• be uninterested in forming close relationships with other people including your family
• feel that relationships interfere with your freedom and tend to cause problems
• prefer to be alone with your own thoughts
• choose to live your life without interference from others
• get little pleasure from life
• have little interest in sex or intimacy
• be emotionally cold towards others.

3. Schizotypal personality disorder

You are likely to:
• find making close relationships extremely difficult
• think and express yourself in ways that others find ‘odd’, using unusual words or phrases
• behave in ways that others find eccentric
• believe that you can read minds or that you have special powers such as a ‘sixth sense’
• feel anxious and tense with others who do not share these beliefs
• feel very anxious and paranoid in social situations.

4. Antisocial personality disorder (ASPD)

You are likely to:
• act impulsively and recklessly, often without considering the consequences for yourself or for other people
• behave dangerously and sometimes illegally
• behave in ways that are unpleasant for others
• do things – even though they may hurt people – to get what you want, putting your needs above theirs
• feel no sense of guilt if you have mistreated others
• be irritable and aggressive and get into fights easily
• be very easily bored and you may find it difficult to hold down a job for long
• believe that only the strongest survive and that you must do whatever it takes to lead a successful life, because if you don’t grab opportunities, others will
• have a criminal record
• have had a diagnosis of conduct disorder before the age of 15.

5. Borderline personality disorder (BPD)

You are likely to:
• feel that you don’t have a strong sense of who you really are, and others may describe you as very changeable
• suffer from mood swings, switching from one intense emotion to another very quickly, often with angry outbursts
• have brief psychotic episodes, hearing voices or seeing things that others don’t
• do things on impulse, which you later regret
• have episodes of harming yourself, and think about taking your own life
• have a history of stormy or broken relationships
• have a tendency to cling on to very damaging relationships, because you are terrified of being alone.

6. Histrionic personality disorder

You are likely to:
• feel very uncomfortable if you are not the centre of attention
• feel much more at ease as the ‘life and soul of the party’
• feel that you have to entertain people
• flirt or behave provocatively to ensure that you remain the centre of attention
• get a reputation for being dramatic and overemotional
• feel dependent on the approval of others
• be easily influenced by others.

7. Narcissistic personality disorder

You are likely to:
• believe that there are special reasons that make you different, better or more deserving than others
• have fragile self-esteem, so that you rely on others to recognise your worth and your needs
• feel upset if others ignore you and don’t give you what you feel you deserve
• resent other people’s successes
• put your own needs above other people’s, and demand they do too
• be seen as selfish and ‘above yourself’
• take advantage of other people.

8. Avoidant (or anxious) personality disorder

You are likely to:
• avoid work or social activities that mean you must be with others
• expect disapproval and criticism and be very sensitive to it
• worry constantly about being ‘found out’ and rejected
• worry about being ridiculed or shamed by others
• avoid relationships, friendships and intimacy because you fear rejection
• feel lonely and isolated, and inferior to others
• be reluctant to try new activities in case you embarrass yourself.

9. Dependent personality disorder

You are likely to:
• feel needy, weak and unable to make decisions or function properly without help or support
• allow others to assume responsibility for many areas of your life
• agree to things you feel are wrong or you dislike to avoid being alone or losing someone's support
• be afraid of being left to fend for yourself
• have low self-confidence
• see other people as being much more capable than you are
• be seen by others as much too submissive and passive.

10. Obsessive-compulsive personality disorder (OCPD)

You are likely to:
• need to keep everything in order and under control
• set unrealistically high standards for yourself and others
• think yours is the best way of making things happen
• worry when you or others might make mistakes
• expect catastrophes if things aren’t perfect
• be reluctant to spend money on yourself or others
• have a tendency to hang on to items with no obvious value.
OCPD is separate from obsessive compulsive disorder (OCD), which describes a form of behaviour rather than a type of personality.

Causes of Personality Disorder

Research suggests that a combination of the following factors may lead to the development of personality disorder:

Family circumstances

Individuals who had difficult childhood are more prone to develop personality disorders. These difficulties include: changes in the family such that children have several different parent figures, with different demands and expectations, or spending time in foster care. Many people who experience physical, sexual or emotional neglect or abuse are more vulnerable to develop some personality disorders like borderline personality disorder
Antisocial personality disorder (ASPD) has been linked to antisocial behaviour in childhood, which could be the result of high levels of stress and family problems. These might include parents not giving children enough warmth, intimacy, consistency or appropriate discipline and supervision. Children whose parents have ASPD or abusing drugs or alcohol may also be factors.

Trauma

Repeated childhood traumas (unrelated to abuse), such as being involved in major incidents or accidents, or sudden bereavement, may lead to personality disorder. It’s been suggested that early and severe trauma, in particular, can cause personality difficulties.

Genetics and inheritance

Some elements of our personality are inherited. People are born with different temperaments; for example, babies vary in how sociable they are, in the intensity of their reactions, and in the length of their attention span. Some experts believe that inheritance may play a relatively big part in the development of OCPD (obsessive compulsive) and ASPD (antisocial).

Triggers to a Personality Disorder

• using a lot of drugs or alcohol
• problems getting on with your family or partner
• money problems
  
• anxiety, depression or other mental health problems
• important events
• stressful situations
• loss, such as death of a loved one

Living with personality disorder

People with a personality disorder, just like anyone who has mental health difficulties, can be stigmatised because of their diagnosis. They can attract fear, anger and disapproval rather than compassion, support and understanding. This is both unfair and unhelpful. Personality disorder is a real problem that demands real help. We can all help by being friendly, supportive and understanding, rather than being judgemental.

How to help yourself if you have a personality disorder

• Try to unwind when stressed - have a hot bath or go for a walk.
• Make sure you get a good night’s sleep.
• Look after your physical health and what you eat. You'll feel better on a balanced diet, with lots of fruit and vegetables.
• Avoid drinking too much alcohol or using street drugs.
• Take some regular exercise. This can be as easy as getting off the bus one stop early, and walking the rest of the way can make a difference.
• Give yourself a treat (although not drugs or alcohol!) when things are difficult or you have coped at a stressful time.
• Take up an interest or hobby. This is a good way to meet others and take your mind off the day-to-day stresses that we all face.
• Talk to someone about how you are feeling.
• Learn more about the disorder. You may do this by asking professionals as many questions about the disorder as you may have and doing your own research over the internet or from relevant books.

What you can do as a friend or relative.

As a relative, friend or companion to someone who suffers from a personality disorder, you very much get to feel the effects of the disorder especially when it takes a toll on your loved one. Many a times you might wonder what you can do to help the situation. Well, here are some ways that you can help a loved one suffering from a personality disorder:
• Emphasize the positive: a diagnosis of personality disorder doesn’t stop someone being likeable, intelligent, highly motivated or creative. Make the most of their strengths and abilities.
• Good information is crucial. If your friend or relative would find it helpful, you could be involved in discussions with mental health professionals, when they are explaining diagnoses and treatment approaches to them. You could act as their advocate and speak up and support them, making sure they get the answers they need from professional services.
• They may need your encouragement to change their behaviour. For instance, alcohol, drugs or staying in an abusive relationship can only add to their problems.
• Try not to stop them from doing things just because you think they may be unhelpful. Unless it’s something dangerous, it may be better to let them experience the consequences of their actions, so that they can learn from them.
• Telling them they are ‘immature’ or ‘inadequate’, or ‘attention-seeking’ or ‘making bad choices’ may sometimes feel justified, but it’s usually more helpful to focus on their good points and things that have gone well for them. Remember that it can be very hard to change, so try not to expect too much too soon.
• If their behaviour is difficult for you, let them know how it makes you feel, and ask them to think about how they would feel if they were treated in a similar way.
• If you treat them as if they are unable to cope, they will not learn how to make their own decisions or do things for themselves.
• Encourage them to reflect on their experiences and learn from them, rather than saying ‘I told you so’.
• Try to help identify situations that bring out the best or worst in them and follow up on this. For example, even if they are uncomfortable being close to people or in company, they may be much more relaxed and lose their inhibitions when they are discussing a subject that really interests them. So encouraging them to joining a particular society, club or class may be a way they can learn to enjoy company.

References

http://www.nhs.uk/Conditions/Personality-disorder/Pages/Definition.aspx   
http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/personalitydisorder.aspx 
http://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/useful-contacts/#.VYOnP6g3bIU

http://www.mentalhealth.org.uk/get-involved/your-stories/kaylas-story/

 

An Unwarranted Hidden Assumption in Research on Personality Disorders

One of the major reasons I became interested in family systems theory, tribalism, family myths, social psychology, and other manifestations of collectivism was because I noticed a big problem with the major forms of psychotherapy practiced on individuals: psychodynamic and cognitive-behavior therapy, and, though to a lesser extent, humanistic therapies like Gestalt therapy.  

All of these forms of individual therapies pay way too much attention to the way patients are reacting, and not nearly enough attention to what it is they are reacting to.

It’s a bit like looking at someone who is falling apart after recently having personally witnessed their entire family being beheaded by terrorists, and concluding that he or she has “poor distress tolerance coping skills.” Well, maybe not quite that bad, but you get the idea.

Some psychologists talk about something called the fundamental attribution error. According to Richard Nisbett and Lee Ross in their 1980 book, Human Inference: Strategies and Shortcomings of Social Judgment, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.”

Richard E. Nisbett, Ph.D.

Of course, internal predispositions, one's past history of learning due to environmental reinforcement, and free will are very important in determining how people are going to respond to a given situation. With people who have personality disorders in particular, however, to say that their living in a family war zone, as frequently described in this blog, is not a huge part of the problem seems to me to be the height of absurdity.

I thought of this issue recently after reading an article entitled “Ecological Momentary Assessment in Borderline Personality Disorder: A Review of Recent Findings and Methodological Challenges” (Santangelo, Bohus, & Ebner-Priemer, Journal of Personality Disorders 28 (4), pp. 555-576). 

Ecological Momentary Assessment (EMA) is a research technique designed to look at behavior and internal processes outside of the confines of what is called retrospective reporting. Retrospective reporting is the subjects' response to questionnaires about the way they normally respond in their daily lives - in hindsight.

People in studies using this technique are given a diary to fill out several times per day at regular, fixed intervals as they live their normal lives. They are instructed to record certain feelings and reactions they are experiencing. In the article’s abstract, it says that EMA is “characterized by a series of repeated assessments of current affective, behavioral, and contextual experiences or physiological  processes while participants engage in normal daily activities.”

As the authors reviewed the results of prior studies using this methodology in subjects with borderline personality disorder (BPD), one of those hidden assumptions I defined in a previous post just jumped out at me. The authors were inherently ignoring issues created by the fundamental attribution error. 

The definition of EMA in the article's abstract mentions “context,” by which I assume they mean the environmental context, but in the studies and in their discussion about them, the issue of environmental context seemed to be missing in action. The subjects were always asked about how they were responding, but almost never asked about what it was that they were responding to!

The authors’ literature review focused on five of the DSM’s (the official diagnostic manual of the American Psychiatric Association) criteria for BPD: 1. Affective instability. 2. Dissociation and transient paranoid ideation. 3. Interpersonal disturbances. 4. Self esteem disturbances. 5. Suicidality.

Now, one legitimate reason for doing these studies is to check on the validity of the diagnostic criteria for BPD, in which case descriptions about how the subjects’ families were behaving would be somewhat irrelevant. Since the diagnostic criteria were used to establish the diagnosis of BPD before the studies were even done, if the studies seemed to indicate that the criteria are turning out to be invalid, that would have to mean one of two things:

1.       Patients with BPD have been invariably lying through their teeth - on an impossibly consistent basis - in giving even superficial descriptions of their personal symptoms and experiences during diagnostic interviews ever since the syndrome was first recognized, or 
2.      The experimenters in the various earlier studies were lousy diagnosticians and were not applying the criteria in a valid manner.

Now, since I would assume that neither of these things was generally true, a finding that the subjects did not experience these symptoms would be most surprising. Of course, generally the subjects did experience the symptoms, although perhaps in some cases not quite in the generally accepted way. This sort of a conclusion is very close to being a tautology – that is, “a rose is a rose.”

But I digress. The authors clearly mention that some of the symptoms they are looking at occur in response to stress, but generally the subjects are not asked to describe the actual stresses to which they are responding. For instance, they say that subjects with BPD were found to be “more prone” to experience stress than controls. 

The problem with this is that it that assumes that the stressors that the controls are responding to are of equal frequency, severity, and nature as the stressors to which the subjects are responding. But no descriptions of those essential factors are presented. Perhaps if the controls were living in a more stressful environment, they would experience the stresses in a fashion more similar to that of the BPD subjects. 

Why are the subjects not also asked in their diaries to describe the stressors to which they are reacting? Is it all in their heads?  (It’s All in Your Head was the original title of my last book. Damn those academic publishers who thought that title was too colloquial). Or is it because therapists, like a lot of people these days, don’t want to look at what is actually going on in families?

Another issue is that, even if the diaries did ask about stressful interactions with intimates, and even if patients described them honestly and included their own behavior in their descriptions, the experimenters would still be in the dark about how severely stressful they were. That is because these interactions have subtexts, as I described in my post The Obvious Secret of Interpersonal Interactions Within Families. 

Words and behaviors during family interactions take on additional shades of meanings within the context of all prior interactions, and these meanings can significantly add to the stress level of the involved parties. In fact, without knowing the entire history of the patient's family interactions, the experimenter's judgments about the severity of the stress would by necessity be extremely flawed. 

As far as I know, there is only one method by which a mental health professional can obtain this data: long term psychotherapy with the involved individual. This should also include occasional conjoint sessions with the patient and family members, to get their sides of the story. The stressors of every single patient have qualities that are unique to them.

Without any descriptions of the nature of the stressors, we can not really come to valid conclusions. Of course, a possible assumption that should be made is this: people who are under severe stress are undoubtedly more likely to respond with more severe reactions than people who are under far less significant stress. 

Duh!