New Podcast about Borderline Personality Disorder

 https://podcasts.apple.com/us/podcast/3-borderline-personality-disorder-with-david-allen-m-d/id1546807211?i=1000503914329&fbclid=IwAR3DJ5gJiYv0i--LphqaTZk67gkctxgJhjjNNisSc7AFeFjlMDLarV4A9_I

Borderline Hyper-reactivity: Compared to What?

One of my complaints about the research literature on the so called “hyper-reactivity” of patients with borderline personality disorder (BPD) is that the authors of such studies almost always look at the quality and frequency of their subjects’ responses without ever looking at what they are responding to.  Since mood instability is the most central part of the definition of the disorder, of course they will have more reactions. By definition, they’ve been selected for it!

 

Two recent studies show that patients with BPD really don’t seem as different from others as one might expect. They both provide strong evidence for my point of view. One showed that the specific reactions to interpersonally threatening stimuli of patients with BPD  is not all that different from those of anybody else.  It looked at skin conductance responses (SCR, a measure of stress) in patients and healthy controls.  The second investigated whether or not patients with other psychiatric disorders responded differently. They found that they all sort of responded the same, in spite of the fact that - once again  - the source and severity of the environmental events which triggered the patients was ignored.

Here’s some descriptions from the study abstracts.

1.   Hillmann K; Mancke F; Herpertz SC; Jungkunz M; Olsson A; Haaker J; Bertsch   K. Psychopathology. 53(2):84-94, 2020. Intact Classical Fear Conditioning to Interpersonally Threatening Stimuli in Borderline Personality Disorder.

 

Threat hypersensitivity is regarded as a central mechanism of deficient emotion regulation, a core feature of patients with borderline personality disorder (BPD). In this study, patients with BPD showed larger conditioned prolonged conditioned skin conductance responses (SCR) (a measure of stress) and subjective stress and expectancy ratings  to interpersonally non-threatening and neutral than interpersonally threatening stimuli, while interpersonally threatening stimuli elicited higher SCR compared to non-threatening or neutral stimuli in healthy controls. 

While the overall the results suggest no alterations in fear conditioning to generally aversive stimuli in BPD, it’s quite interesting than when someone in the environment is non threatening, patients with BPD react with MORE stress. One possible explanation: the people around them most of the time are more likely to attack them when most  other people would have let their guard down.

2.  Kockler TD; Santangelo PS; Limberger MF; Bohus M; Ebner-Priemer UW, Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls.
Psychiatry Research 284, 11262, 2020).

 The authors wanted to see if hyper-reactivity to stress was specific to BPD or was seen as much in other disorders. Using e-diaries, they compared patients with BPD, normal controls, patients with bulimia, and those with PTSD. The majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns, which means that the same reactivity was seen in the other disorders. The only major exception was that patients with BPD exhibited anger more frequently than any of the clinical groups or in healthy control. 

As mentioned, nothing was looked at concerning what the anger was about. So maybe anyone would be angry if exposed to whatever it was the patients with BPD had been exposed to. 

Treatment of Bipolar Disorder Goes Psychotic

 

Ever since I did my psychiatric residency training way back in 1974-1977, bipolar disorder (then called manic-depressive illness) was the easiest of the major psychiatric disorders to treat medically. There was (and is) absolutely no evidence the craziness of the patient during a manic episode or a bipolar depressive episode is amenable to any psychotherapy technique, although therapy might be important when the patient is euthymic (that is, not in a manic or depressive episode – which is most of the time) to deal with the aftermath of their having been psychotic or for other co-morbid psychological problems. Euthymic bipolar patients can have co-occurring personality disorders and anxiety disorders and anything else just like anyone. Since, when euthymic, they are in fact just like everyone else.

If you want to see what a manic patient looks like, look at this video of Charlie Sheen (https://www.youtube.com/watch?v=pipTwjwrQYQ). He actually took a show on the road but had no act. Now, cocaine can mimic mania, but he’d taken cocaine before and he never acted like this. See videos of him when he was back to his usual self to see the difference. Sheen denies he was manic, but I’m not sure I believe that.

Anyway, about 80% of these patients could tolerate and were responsive to lithium for prevention of manic episodes. The longer they took it, the more likely it would be to also prevent depressive episodes as well. If the patient got depressed while taking lithium, antidepressants worked just great. Journal articles saying they do not were full of crap – the most important of these is discussed in this post.  Most of my patients on lithium were basically symptom free for decades, no matter if I saw them in a public clinic, an academic clinic, or a private practice environment.

 

When patients first got manic, we used antipsychotic medications to bring them down, usually in inpatient settings, because lithium takes a couple of weeks to kick in. Once lithium was on board, we discontinued the antipsychotic medication because they didn’t need it any more. The only other time we used antipsychotic medication in bipolar patients was during depressive episodes in which the patient also had delusions and hallucinations (psychotic depression). Again, the antipsychotic meds could often be discontinued after the episode was over.

 

When a patient couldn’t tolerate or was not responsive to lithium, we would then use antipsychotic medications as the only alternative back then, but always had to worry about them causing a neurological disorder (tardive dyskinesia [TD]). Until it was found that the anticonvulsants Tegretol and Depakote were good for mood stabilization – so then they became the second line drugs.

 

When the new, “second generation” antipsychotics came out, which can cause huge weight gain and diabetes in addition to TD, the drug companies started to push them. The use of lithium started to plummet. After it was found that some of them had some antidepressant effects – although usually only to augment an antidepressant – Pharma started to push them even more. Despite the major risks, use of them increased from 12% of cases to 53% of cases between 1997 and 2008.

 

Not only that, but the number of patients diagnosed with bipolar disorder inflated by more than double since 2000. Everybody and their brother who had any mood symptoms at all were misdiagnosed with it, most due to the insane idea known as “bipolar spectrum,” or as I call it, B.S. Another study in the Journal of Clinical Psychiatry that I wrote about previously  showed that 40% of patients in their sample who met clear DSM criteria for borderline personality and not for bipolar had been misdiagnosed as bipolar by a prior mental health professional, as well as 10% of all of the other patients.

Caveat emptor, which in this case means, let the patient beware!

Debate over “No Suicide Contracts” presumes Patients are All Alike

An article entitled No Suicide Contracts: Can They Work by Caroline Roberts M.D. came out in the August 2020 issue of Clinical Psychiatric News. No suicide contracts (NSC’s) had been given for years by therapists and psychiatrists to potentially suicidal patients. The contract essentially gets the patient to sign off on a statement that they will not kill themselves. Alternatively, the patient commits to calling someone if they think they might make an attempt. Some NSC’s ask them to call a suicide hot line, while others say to call the therapist.

 

For quite some time now, however, use of NSC’s has been discouraged in the literature because they may give therapists a false sense of security. There is no clear-cut evidence that they are “effective.” In some populations, such as borderline personality disorder (BPD) where the patient may want to invalidate the therapist, they might even backfire. Or patients may not keep their word because they know the therapist might commit them to a mental hospital. They might not want to go there.

 

Dr. Roberts (“She helps you to understand and does everything she can” ~ say the Beatles) makes the obvious point in her article that the answer to the question of whether NSC’s can work “is conditional on the unique combination of patient, clinician, and therapeutic relationship.” And, I might add, the unique family dynamics and history of prior treatment that each patient brings to therapy. How could anyone think that the question of whether any intervention either will or will not work does not depend on everything that has happened before, during, and after the signing of the contract – both in the patients’ lives and in their relationship with the therapist?

 

This is yet another example of the ecological fallacy, in which an entire group of people is characterized just by its average member. It’s like the old joke about a drowning victim who couldn’t possibly have died in a certain lake because its average depth is only three feet!

 

Of course, no intervention is going to be effective 100% of the time in anyone. For one thing, new things can happen to a patient in between therapy sessions. Family fights can break out or people can be dumped by lovers. A loved one might even pass away.

 

Telling a patient to call a hot line will generally be less effective than if the patient can talk to the therapist personally. The patient may think (and I agree) that therapists should care enough to be available during emergencies, and to have someone who can substitute for them if they are not available. Therapists should also know how to empathically get patients off the phone in non-emergency situations.

With patients with BPD, therapists will most likely have better results with an NSC if they have validated their patients without having fed into their false selves.

The therapist can ask patients if they are afraid they might be committed, and let them know that commitment will only be used as a last resort to save the patient’s life, and that the therapist realizes that patients can feel even worse when thrown into a mental hospital.

 

Simple answers to complex questions are usually simple minded, as they are here, and are only employed by simpletons. 

Book Review: Saving Ourselves From Suicide: Before and After by Linda Pacha

 

This book describes ways to handle your emotions and responses if you lose someone close to you to suicide. The author herself lost her son that way a few years ago. He was away at college for the first time. He had been diagnosed by one of two therapists as having Asberger’s Disease, a mild variation of autism, and was also experiencing confusion about his sexuality. He was having trouble relating to his classmates and was the subject of a lot of gossip and innuendo. He told his mother he felt depressed but never at any point in time mentioned that he was thinking that he might want to kill himself. The story the author tells in the beginning of the book about what happened with her son during this period is both gripping and highly disturbing. The author is an excellent writer.

 

The advice she give to parents and other survivors throughout the book is spot on. She talks about all the second guessing survivors subject themselves to, all the what-ifs and if-onlys, and the difficulties in interactions with friends, family, and acquaintances. What if you are being judged?

 

She relates her experiences and gives advice on issues such as how to handle grief during the first and second years after the death.  How does one handle anniversary reactions or one’s shattered religious faith?

 

She then goes on to her views about how to spot warning signs that someone you love is heading down the path of suicide, and how people in general and parents in particular can advocate for mental health and decreasing all of the pressures on today’s adolescents.  And then she goes on to the general subject of helping others who have gone through what she did.

 

Since she is not a mental health professional herself, she wisely avoids discussing suicides that result from adverse childhood experiences like sexual or physical abuse by parents, domestic violence, chaotic parental relationships with substance abuse and/or frequent affairs, parental alienation in divorce cases, double messages in the family, and the like. The book is not at all meant for those types of parents, whose problems far exceed the loss of a loved one, as bad as that still can be for them.

 

Another point that I like to make is that people who come from an abusive or chaotic environments are way more likely to become bullies or to bully others themselves, which means that the idea that bullying is the main cause of suicide is somewhat of a red herring.  As is the idea about suicide being caused by watching TV shows like 13 Reasons Why. Watching that could conceivable affect the timing of an attempt, but is hardly the actual cause. People are not that fragile.

 

I was happy to see that she wrote about the problems created by helicopter parenting, although she doesn’t use that term. A lot of parents these days are being absurdly over-protective to the point where kids today often feel fragile and incompetent , as well as a big burden on their parents. In response, they may in some cases start to think the parents would be a whole lot better off without them. This has gotten out of hand on college campuses with all the nonsense about microaggressions and “safe spaces” and viewing other people’s opinions as traumatizing.

 

This is in general an excellent book and well worth reading.

New Podcast Interview about My Psychotherapy Paradigm

I am interviewed by Serge Prengel, LMHC about the history of and the philosophy behind my ideas about psychotherapy with patients who have personality disorders: https://relationalimplicit.com/allen-2/ 

What Ever Happened to Family Systems Psychotherapy?

 

Back beginning with the March/April 2001 issue of a magazine that was originally produced for the followers of the new family systems psychotherapy models, it changed its name from the Family Therapy Networker to the Psychotherapy Network. The magazine had started 20 years earlier in January, 1982. What happened?

 

The editor of the magazine up until his recent death was a fellow by the name of Rich Simon. In the March/April issue of the magazine in 2012 he related the fascinating history of why this happened in an essay called Still Crazy After All These Years? A Look at 30 Years of the Networker.

 

Back in the 1980’s and 1990’s there was an explosion of new ideas about how to get psychotherapy patients to change both their behaviors and their negative moods that went well beyond the three basic paradigms or schools of therapy at the time: psychodynamic, cognitive-behavioral, and emotion-focused. Something like 300 different schools came to be, although most of them were just variations on the existing schools.  The Milton Erickson Foundation in Phoenix, AZ sponsored several “Evolution of Psychotherapy” Conferences in which the leaders of the various schools came to argue with each other in front of large audiences.

 

Family Systems therapy was the most noteworthy of the new models, because it was seemingly the first to recognize that since human beings are among the most social of all organisms, perhaps looking at herd behavior might tell us more about human beings than just looking at them in isolation.

 

Of course, even within systems therapy, there were quite a few widely varying ideas about how to proceed with psychotherapy clients. In the beginning, the Networker profiled the colorful characters who were coming up with them: Salvador Minuchen, Jay Haley, Murray Bowen, Mara Selvini-Palazzoli, Virginia Satir, Ivan Boszormenyi-Nagy, and Carl Whitaker.  

 

Of course, just like in all of the earlier schools, there was also plenty of nonsense within the movement. Some theorists imagined a sort of Zen perspective in which the thought that we had individual selves to call our own was an illusion. They became like extreme behaviorists, who instead of viewing humans as rats in a physical maze, viewed them as rats in a family homeostatic maze - with no ability to think for themselves. 

Others started explaining real brain diseases like schizophrenia on the basis of family double binds, which themselves were very common in the families of people without any schizophrenic members. Still others viewed the dynamics of any particular family as if they had just come into being as is, without reference to the cultural milieu in which they developed. Even Murray Bowen, who developed a three-generational model, only looked at who was enmeshed or at odds with whom, without specifying over what behaviors they were enmeshed or at odds about.

 

According to Simon, feminists started complaining that women seemed to be getting the brunt of the blame for, as well as the responsibility for changing, the family dynamics - especially when patients with histories of child abuse became brave enough to come forward. The latter issue also led to a reaction in which people were accused of having “false memories” (and which were being prompted by some therapists if the people were suggestible enough). Some elements of society were also upset with the so-called “abuse excuse” in which victims were seemingly encouraged to see themselves as permanently damaged victims who took no personal responsibility for themselves.

 

The confluence of converging forces mentioned in the masthead of this blog then started to develop with a fury. Longer-term treatments were no longer being covered by insurance, which only covered symptomatic treatment. Bogus “medical necessity” criteria were used to drastically cut down the number of sessions therapists could administer. Drugs were pushed even for diagnoses for which there was no good evidence that they worked at all. “Major Depression” became just ‘’depression.”

 

“Biological” psychiatrists who were not even aware of the latest discoveries in neuroscience pushed a disease model for everything. In fact, science has clearly showed beyond a reasonable doubt that the structure of the “plastic” human brain is in part determined by interpersonal interactions, and that most of what we do is learned and done automatically in response to environmental clues without any conscious deliberations.

 

Simon added that they did take a lot of flack after the magazine got renamed for “abandoning” systems therapy, but, “…as we saw it, we were just creating room for a bigger, more diverse “blended” family of therapeutic approaches.”

Parents who Feel Both Guilty and Angry About Their Parental Performance

I recently received an e-mail from an irate reader of my blog on Psychology Today. It was in reaction to a post I wrote about parents who were cut off by their adult children acting as if they had no idea why that happened, when in fact the majority of them (but certainly not all of them) have at least a pretty good idea. She told me I was an a**hole who was automatically calling all such parents “dicks” and “a**holes.” I of course actually made no statements like that in the piece.

Of course, if a history of child abuse is involved, which it may or may not be in such cases, parents have the responsibility for that and not their children, at least before the children grow up and have minds of their own. But this was not the subject of the post.

I wrote back to her:

Sorry if the piece sounded like I was calling the parents a**holes. I don't believe that. And of course not all families that have problems like the ones I describe [in the post] are in denial about what's going on. I view everyone in the whole family as all caught within a devilishly-difficult problem to solve that is created by a variety of external factors over at least three generations. 

I never recommend cutting off parents -  even when the parents actually were (unlike you) physically or sexually abusive - and take a lot of heat for advocating that they try to work things out for everyone's eventual benefit (not that it is at all an easy thing to do this).

I of course have no way of knowing anything about particular families like yours without ongoing in-person evaluation and therapy, so what I'm about to say may or may not apply to some degree to your situation. In some families in which parents, in the estimation of the adult children, seem to be frequently beating themselves up with guilt about their worth as parents, the kids worry that they need to fix that. And what they then do is start to piss the parents off on purpose to make them feel angry at them instead of guilty. Hatefulness as a gift of love, as it were..

That last bit referred to how, in the patient with borderline personality disorder’s spoiler role, the adult child is regulating their parents’ de-stabilizing internal conflict over having children (described in this post). When the parent starts to feel too guilty, their children make them angry. When the parents start to get to angry, they lay guilt trips on them.

As I said in my reply, I don’t know if that dynamic applies to the writer and her children or not. So what made me think that it might very well apply? Well, there were certain sentences in the writer’s original inquiry that seemed to indicate a lot of guilt as well as a lot of anger:

Implying guilt:

• “I have admitted and apologized for the times I was a bad parent, naming specific incidents and listening to them to tell me other times they were hurt by me. I try as hard as I can to listen, be supportive, and not be overbearing.”
•  “I don’t know that any parent who needs to be told they’re a dick would accept that from you. It made me feel defensive and hurt, all over again. Trust me, most of us a**hole parents don’t realize we’re being a**holes.”  
• “I really do not know why my kids, especially my younger daughter, hold a grudge against me.  They have never said anything that I didn’t acknowledge, apologize for, and try to make right.”   

Implying anger/defensiveness:

 

·         Calling me an a**hole for allegedly implying she might be an awful person when I hadn’t actually said anything of the sort, and accusing me of “taking sides.”

·         “If they are mad because I turned out not to be perfect, but downright human and not always the best decision maker when it came to parenting, well, I at least know I always loved them immensely and would have, & still would, die for them.”

 

You be the judge.

 

High Index of Suspicion vs. Hyper-reactivity in Borderline Personality Disorder

One of the main themes of this blog is how researchers in psychiatry continually mix up learned or conditioned responses with disease states. These include misinterpreting fMRI findings and data derived from twin studies. I have also discussed something called Error Management Theory, which predicts that if you come from a toxic and crazy environment like someone with borderline personality disorder (BPD) does, and have to learn how to react to it, it is in your interest to have a high index of suspicion about the others around you. Somehow this has turned into emotional “hyper-reactivity” as some of sort of brain pathology or abnormality.

Now comes a study that seems to be strong evidence for my point of view. (Borrolla, B., Cavicchioli, C,., Fossati, A., and Maffei, C. “Emotional Reactivity Borderline Personality Disorder: Theoretical Considerations based on Meta-Analytic Review of Laboratory Studies.” Journal of Personality Disorders 34[1], 64-87, 2020). 

The authors did a meta-analysis (combining the data from several studies) which addressed the question.

Variables measured in these studies included heart rate, respiratory heart sinus arrhythmia, skin conductance, cortisol (stress hormone) levels, startle response, blood pressure, and patient self report.

Their conclusion: the hyper-reactivity hypothesis was in general not supported. The apparent increase in reactivity in BPD could instead be attributable to their tendency to evaluate emotional  stimuli more negatively than controls. Exactly what error management theory would predict!

The study authors go on to say that amygada functioning (basically fight/flight/freeze reactions) concerns “several processes that go beyond emotional arousal (salience and novelty detection, reward learning, memory, attention modulation, decision making…” (p. 79).

Exactly. And Amen.

Measurement of Outcomes in Psychotherapy of Personality Disorders Ignores Social Context

On June 22, 2020 I received an e-mail from the International Society for the Study of Personality Disorders (ISSPD), an organization to which I belong, announcing that a group whose purpose is to define standard outcomes in research on various medical conditions came up with such a list for outcomes in psychotherapy for personality disorders.

It read:

BOSTON, Massachusetts, June 2, 2020: The International Consortium for Health Outcomes Measurement (ICHOM) announced the release of their Personality Disorders Standard Set today. 

Leading mental health researchers, practitioners, and service user representatives from across Europe, North America, Asia, and Australia have joined forces to establish and launch the first international standard for measuring treatment outcomes for adults and adolescents aged 12 and above with personality disorders. This marks an important step towards promoting data quality and availability, and strengthening mental health care for this group.

As my readers are probably aware of by now, I have been critical of outcome studies in the field for a number of reasons, not the least of which is the researchers’ obsession with what is going on inside people’s heads while ignoring what it is they are actually reacting to. The focus has been entirely on a decrease in symptoms, not on the specific behaviors of self and others and the resultant difficulties in patients’ relationships which then lead to the symptoms. The primary attribution error personified. Did the relationships of subjects improve or not? We never knew.

Not that symptom relief isn’t important. It’s difficult to function at all, let alone focus on difficult issues, in the midst of panic or rage attacks. Self injurious behavior is also a huge problem.  I put most of my psychotherapy patients who had borderline personality disorder on meds so these symptoms were controlled in many of them – and, I might add, much more quickly and effectively than through psychotherapy or mindfulness training. In fact, the type of therapy I used (Unified Therapy) can not be done at all without some control of such symptoms, because the therapy focuses on the anxiety-producing issues with which I think patients must deal. 

However, symptoms are not at the heart of the disorder. Personality disorders are clearly and obviously (at least to me) disorders of interpersonal relationships that include a wide variety of family members and romantic partners. These relationships involve issues that are often somewhat unique to each person (the ecological fallacy is widespread in this research). Those are what need to change in order for  symptomatic improvement to last very long. And if any of them have changed after therapy, none of the changes have been measured in typical psychotherapy outcome research.

So I was anxious to see if the new data sets announced in ISSPD’s e-mail might include some of the actual problems which create personality disorder symptoms. Of course, they did not. The circle that is at the top of this post shows the areas under consideration and what tests are supposed to be used to measure them. Here’s a list of the measurements. The numbers refer to the ones in the circle  next to the name of each subsection:

The standard set

The ICHOM Standard Set for Personality Disorders is the result of hard work by a group of leading psychiatrists, psychologists, mental health experts, measurement experts, and lived experience experts. It represents the outcomes that matter most to adults and adolescents with personality disorders. We urge all providers around the world to start measuring these outcomes to better understand how to improve the lives of their service users.

1.        Defined by Emotional Distress/Emotional Pain

2.       Defined by Affective Lability/Emotional Dysregulation

3.       Defined by Self-harm/Self-injury

4.      Defined by Overt Aggression

5.       Defined by Global/Daily Functioning/Disability

6.       Tracked via the Level of Personality Functioning Scale - Brief Form 2.0

7.       Tracked via the Recovering Quality of Life - 10-Item Version

8.       Tracked via the Difficulties in Emotion Regulation Scale - 16-Item Version

9.      Tracked via the Columbia Suicide Severity Rating Scale - Screener/Recent - Self-Report

10.   Tracked via the Modified Overt Aggression Scale

11.     Tracked via the WHO Disability Assessment Schedule 2.0 - 12-Item Version

12.    Tracked via the KIDSCREEN-10 Index in Adolescent Specialist Services

13.    Tracked via the PROMIS Short Form v2.0 - Social Isolation 4a

Almost all of these outcomes are to be measured in terms of how often subjects experienced difficulties during a wide variety of activities or how often they felt bad, but nothing about whether any changes had taken place in the subjects’ lives which might account for the reasons behind any such pre-existing problems. Subjects are asked if they are having difficulties which such things as getting started with everyday activities or doing things they found rewarding. They are asked if they can enjoy themselves.

They are asked if they feel lonely or in control of their lives, but not about why. They are also asked if they feel that the people around them are causing distress, but absolutely nothing was asked about what the interpersonal problems creating the distress actually were exactly or whether or not they had been effectively addressed in therapy.

In the circle are three general life areas which I thought might expand the outcome horizon in the desired direction: Interpersonal and social functioning, sense of belonging, and health related quality of life. So I looked at the outcome measures ICHOM was recommending. Once again, the same issues reared their ugly heads.

Interpersonal and social functioning was tracked via the WHO Disability Assessment Schedule 2.0 - 12-Item Version. Sample questions: In the past 30 days, how much difficulty did you have in: learning a new task, joining in community activities, dealing with people you do not know, maintaining a friendship, and in your day to day work.  Once again, how much but nothing about what the specific difficulty involved were and why, and nothing about family or love relationships. 

Gee, and here I was naive enough to think that interpersonal functioning requires the participation of at least two people!

Sense of belonging was tracked with the  PROMIS Short Form v2.0 - Social Isolation 4a. Sample questions: How often have you experienced feeling left out or isolated from others? Again, nothing about isolated from whom or why or what is creating any continuing such problems.

Health related quality of life was tracked with Recovering Quality of Life - 10-Item Version: Sample questions: how often did you have trouble with such things as trusting others, enjoying what you are doing, feeling confident in oneself. Nothing about which relationships or even which areas of life these feelings occurred within, or what was happening which might have led to these feelings.

Truly, the science here continues to leave much to be desired.