Borderline Personality Family Dynamics: The Parents, Part II

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parental role as being an impediment to their personal fulfillment.

In Part I of this post, I described the one most common major issue - gender role conficts - and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role. In Part II, I will describe the other ones.

To repeat a caveat from the previous post: All of these issues may seem very common everywhere, and indeed they are. Most families that face them do not produce emotional conflicts significant enough to create BPD pathology. Rather, the issues in families that do have been magnified significantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent.

Common issue #2 causing parental ambivalence over being parents: Untimely deaths. The loss of children, in particular, may make someone fearful over losing the others while, at the same time, may lead to parental resentment over the fears and insecurities created by the presence of the remaining ones.

For example, one grandparent of a patient in our clinic had lost 10 out of 11 children to disease; the 11th was the parent of the therapist's BPD patient. The grandmother was overprotective of the mother but at the same time avoided closeness for fear of the pain of losing yet another child. When the mother grew up and left home, the grandmother became depressed. The patient was then given up as a child to the care of the grandmother to help feel the void, and became the new focus of the grandmother's hyperconcern and insecurity. This is also an example of a parent giving up a child as a gift to a grandparent - the subject of my 10/15/2010 post.

Issues #3 and #4: Financial reverses and chronic illnesses - including severe mental illnesses. Because of the financial strains and general chaos caused by these considerations, the joy of raising children may be suddenly turned into a frightful burden, both emotionally and financially, and thereby generate parental ambivalence.

Interestingly, the presence of bipolar disorder - with which BPD is often confused these day by both incompetent psychiatrists and the public despite the fact that they do not look anything alike - in a parent may lead to the very chaos in families that generates BPD behavior in children. Children in such a family are at risk both biologically and genetically for bipolar disorder and environmentally for BPD.

Issue #5: Ambivalence over religious or cultural values concerning childbearing, child rearing and filial responsibilities may lead to parental ambivalence. Examples include:

• 1.  The Roman Catholic emphasis on large families in a day and age when children cost a small fortune to raise. This may lead parents to follow the church rules but be extremely unhappy about the results.
• 2. Children, often the eldest female in a traditional family, may be called upon to take care of younger siblings in large families. In doing so they are often forced to give up exciting adolescent activities in which their peers at school freely indulge. The result may be that they become identified with the caretaker role yet resentful of it. When they leave home and have families of their own, this history may lead them to resent their own children. 

I     I used to practice in Los Angeles where I saw many Chicano (Mexican American) patients.  I saw several females who had functioned as "mother's assistants" when they were growing up. They were the eldest sister in large families. They had to stay home and take care of their younger siblings, and frequently had to miss important social events in school such as their senior Proms. Their younger sisters, however, got to go to and do everything the olders sisters had missed. When these older sisters grew up and had their own children, this recreated the family of origin issues for them and induced ambivalence in them about their brood.



•  The eldest male in a traditional family, such as seen in some Asian cultures, may be called upon to take over the family business in a career that he may just happen to hate. The costs incurred in raising children may lead to continuing family pressure to keep the business going when he wants out. The anger of Son #1 in such a situation may be displaced onto his children.

Issue #6: Parent-child role reversals. If adults in the family become incapacitated for whatever reason, and the children are therefore called upon to take over heavy adult responsibilities prematurely, the children may become resentful in a manner analogous to the situation of the eldest female in a traditional family described above.

Such individuals often describe this state of affairs with statements such as “I never got to be a kid.” [This is not the reason, however, that Michael Jackson said that]. A similar situation occurs when parents who were infantalized by their own families of origin appear to be unable to take care of themselves. Their children then try to fill the power vacuum and take care of them before they are really equipped to do so.

Issue #7: A couple has a child to “save the marriage.” The child then becomes the reason that the parents must continue in their miserable relationship. The resentment within the marital dyad becomes symbolized by the child whose presence was supposed to make the relationship better, but instead has led to the continuation of the same old marital misery.

The child then begins to believe that the family problems are all his or her fault, and the parents do not seem to try very hard to counter this belief. Children in such a bind usually come to the conclusion that their very existence is the reason their parents seem to hate each other. They may also feel that it is their reponsibility to provide a distraction to the parents' anger at one another by drawing anger on to themselves. This is one of the functions of the spoiler role.

Two or even several of these issues can present themselves simultaneously to a family, thus increasing parental ambivalence over the presence of children almost exponentially. The whole family becomes embroiled in quite a stew, and the abuse and neglect of children that sometimes results from these conflicts becomes more understandable, although still not excusable.

Expressing empathic understanding of the family's behavior, without condoning it, is far more productive in helping a family to stop troublesome behavior patterns than raking them over the coals for their misbehavior.

Pharma Weapons of Mass Seduction: Part II

In my post of August 31, Plausible Deniability, I illustrated how Pharma-tainted psychiatrists are able to subtly make marketing points about various drugs while denying that they are doing anything of the sort.  I commented on some of the tricks that were being used.

This post will be the second in an occasional series that discuss the more subtle and insidious devises used by Pharma-connected "experts" to mislead - or should I say con - practitioners.  These "experts" are called opinion leaders by Pharma and are a major part of their psyche ops.  Their marketing departments have been scrupulously studying physician behavior - especially physician weaknesses - for decades.  I will also discuss in future posts some of the ways they have done and are doing that. 

An excellent discussion of the more obvious and better-known pharma marketing techniques can be found at http://www.abc.net.au/rn/backgroundbriefing/stories/2011/3337618.htm.  This program is from the Australian media, but the situation is much the same in the US.  I will not be focusing on those techniques much in these posts.

Pharma marketing targets all physicians, not just psychiatrists, although psychiatrists have been a leading target.  Of course, I am more familiar with the marketing of psychiatric drugs, so my main focus will be those.

Of course, it is ultimately the fault of the practitioner for not taking the time to challenge misleading ideas and to check them out with unbiased and readily available sources of scientific information such as the Medical Letter.  But that is, in a way, the point.  Pharma knows quite well that many practitioners will not have either the time or inclination to do this.  The average physician works about 60 hours per week. 

Not only that, but many are also suckers who can be easily deceived. 



BTW, did you know that 80% of antidepressant medications are prescribed by non-psychiatrists?

In this post I will discuss how Pharma-inspired or paid-off writers in psychiatric newspapers, throw-away journals, and journal supplements denigrate highly-effective drugs (antidepressants and benzodiazepines) that just happen to have gone generic, in hopes that doctors will prescribe more expensive, potentially more toxic, and less effective brand-named drugs (particularly atypical antipsychotics). 

(And yes, antidepressants and benzo's do not work for everyone, can cause severe side effects in some people, can be habit forming, may cause unpleasant withdrawal reactions, blah blah blah.  [All of these problems can be dealt with by a competent physician who follows his or her patients closely].  And a majority of patients need psychotherapy instead of or in addition to medications. No sh*t! So please don't keep writing to me to point out the obvious).

I am going to use as illustrations two articles that appeared in a newspaper called the Psychiatric Times.  I do this because two very recent articles that clearly illustrate my points appeared there, not because I want to pick on that particular publication.  In fact, Psychiatric Times tends to be rather fair in general and is one of the most pharma-critical of the publications I am talking about.

By way of definition:  Throw-away journals are official-looking medical "journals" that are mailed free of charge to all doctors who might prescribe certain drugs pushed by big Pharma.  Psychiatric Annals (Anals?) and Current Psychiatry are two examples from psychiatry. 

They are heavy on full-page and sometimes multi-page Pharma advertisements, and Pharma probably pays to produce and mail them.  The articles they contain are not peer reviewed (sent out to about three independent experts for review of the adequacy of their science prior to a decision by the journal editors about whether or not they should be published).

Journal Supplements are mini-journals mailed along with more legitimate, peer-reviewed journals (and usually having the same cover design) that consist of multiple articles which claim to review a particular topic in the field.  Most doctors are unaware that the articles in a journal supplement are not peer reviewed like the articles in their accompanying primary journal, and that the supplements are usually sponsored by one pharmaceutical company.

First, an article about anti-depressants.  I submit as evidence for my contention in the Plausible Deniability post (that the article by Sachs and others claiming that antidepressants are ineffective in bipolar depression is being used in the field to push other medications) the CME article "Understanding and Treating Bipolar Depression" by Caleb Adler, M.D. It appeared in the July, 2011 issue of Psychiatric Times. As mentioned, there are a lot more articles like this one in various publications.

I pointed out in the previous post that drug companies did not need the folks who authored the Sachs article to recommend anti-psychotics for bipolar depression. They have a lot of other people to do that particular job for them. ("Opinion leaders" is the term Pharma uses for such people), like the authors of articles like these.

The Times article lists a variety of treatment options for bipolar depression including various atypicals and mood stabilizers, and even mentions neurontin and lamictal - both of which have both been shown to be particularly ineffective - before mentioning, at the very last, standard antidepressants.

After focusing on the red herring of antidepressants causing switching into mania - which even the author grudgingly admits can be easily prevented with drugs like lithium that true bipolar patients should be taking anyway - it speaks of the use of antidepressants as "fairly controversial," even though they have been used successfully for over fifty years.

Then the reference to the Sachs et. al. article come in: "Nonetheless, the large STEP-BD analysis did not observe improvement in patients receiving standard antidepressants. Other meta-analyses that have purported to observe an effect may be methodologically flawed."

I do not see any mention that this part of the STEP-BD study was a study ONLY of treatment-resistant subjects, or that it used only two antidepressants for that matter.

And what is the unspoken implication of that last statement about the meta-analyses, even though it may be literally true for any given study? (The reference cited for this statement, by the way, was just another article in Psychiatric Times!) It is this: that any study which purports to show that antidepressants work is probably methodologically flawed, that's what.  There are no similar caveats attached to any of the other drugs mentioned in the review.

A lot of plausible deniability built into the wording though. Brilliant marketing.

The second article concerns benzodiazepines and is titled, "Anxiety Disorders: the Anxious Bipolar Patient" by MD's Khavital Lohano and Rif S. El-Mallakh in the September 2011 issue of Psychiatric Times.  The article correctly points out that many bipolar patients also have severe co-morbid anxiety disorders like panic disorder, which often require additional meds (an instance in which polypharmacy may sometimes be legitimate and necessary). 

In one study, 21% of bipolar patients had panic disorder - a 26 fold higher incidence than in the general population. 

Interestingly, the panic attacks in manic-depressive patients do not occur when a patient is in the manic state.  They occur when the patient is in the normal (euthymic) mood state or, more frequently, in the depressed phase of the illness.

Certain benzodiazepines are, in my experience, far and away the most effective medications for panic disorder, whether it is comorbid with something else or not.  The second most effective drugs are antidepressants. 

Of course, just as with the last article, in discussing treatment options this one goes out of its way to stress that antidepressants can induce mania, without mentioning that anti-manic drugs prevent this from ever happening.

At least antidepressants were the first class of drugs mentioned.  The second?  Antipsychotics, of course.  They are actually stated to be the second line drugs for this indication!  Without FDA approval, I might add.  And the FDA happens to be absolutely right in not approving them for this indication.

Listed third was anticonvulsants like depakote.  Interestingly, the article admits, "There are no randomized controlled trials that examine the use of anticonvulsants for the anxiety component in bipolar patients."  But, naturally, it goes on to state, "However, anticonvulsants appear to have a small effect in reducing anxiety."  Side effects were not even mentioned about either antipsychotics or anticonvulsants anywhere in this article.

Next, under "alternative agents," the article discusses the anticonvulsant gabapentin, which in my experience has very mild tranquilizer-like properties but is not FDA-approved for anxiety. 

LAST, the article finally and very briefly mentions benzodiazepines.  Get this: and I quote:  "Benzodiazepines are clearly effective in many types of anxiety disorders.  However, their use is problematic, and these agents must be prescribed cautiously."  

So what, the fact that antipsychotics can cause diabetes is not problematic and did not need to be mentioned in the article like the problems with benzo's were? Or the fact that depakote can cause polycystic ovaries in females?  No caution needed in prescribing those agents, I guess.

Even in mainstream publications and in the APA Treatment Guidelines, whenever benzodiazepines are mentioned, one almost always also sees a phrase added that is something similar to, "But of course they can be addictive."  On the other hand, when antipsychotics are mentioned, one almost never sees a phrase like, "But of course they can cause diabetes, massive weight gain, higher cholesterol, and an irreversible neurological disorder called tardive dyskinesia."

How to Disarm a Borderline: Last Part

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), Part VII (April 30), Part VIII (June 5), and Part IX (August 2). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

This post, the last one in this series, will continue to describe specific countermeasures to the usual strategies in the BPD bag of tricks used by them to distance and/or invalidate you, as well as to induce you to feel anxiously helpless, anxiously guilty, or hostile.

Today's subjects are what to do when none of the previous interventions seem to decrease the angry responses of the family member with BPD, and what to do when you yourself blow your cool and react with a nasty comment that might kick off a variable intermittent reinforcement schedule than can undo all the fine work you have done until this point..

When all the suggestions in these posts fail

The next suggestion is useful in cases in which, no matter what you say, the family member with BPD continues to escalate with more and more outrageous accusations or oppositionalism. It only works when all others have failed, and not before.  It probably can be used only once or twice. The reason for this is, in order for you to be confident in the assumption you are about to make, the Other's negative patient behavior must have already persisted in the face of your consistent efforts to be conciliatory.

The Solution? Inquire, "Why are you picking a fight with me?"  Once again, you have to refuse to get sucked into a debate about whether or not the family member with BPD is indeed picking a fight.  It will have by this point become damn obvious, and therefore you do not have to prove it.

In response to this question, people with BPD will usually do one of two things.  First, they could conceivably stop the behavior, admit that they are picking a fight, and begin to explain why they feel it necessary to do so.  In the unlikely event that this happens, hear them out!  You will probably learn something important about your relationship.  Try not to be defensive but look for the kernal of truth in what they are saying, as described in Part IV of this series.

More usually, they may suddenly stop the provocative behavior and go on to talk about some other, completely different subject, and nicely proceed as if the fight had never even happened! In this scenario, the family member with BPD suddenly drops whatever he or she was complaining about right in the middle of a heated interaction. 

This maneuver is a lot trickier than you might think.  Because of the abrupt nature of the change in subject, you may feel drawn back into continuing the previous angry discussion yourself.  This happens because the interaction that preceded the switch feels unfinished.  You should remind yourself that the Other's goal may just have been to keep an argument going, not to settle any actual complaint or win an argument.  In other words, the actual content of the argument may be something that is somewhat unimportant.

The feeling that one gets after an argument is suddenly dropped is somewhat akin to the way one feels in the following situation: you have repeatedly tried to get a talkative friend off the telephone.  You know, those conversations when you've said several times that you'd love to talk longer but you have to go, and your friend says OK after each time, but then keeps on talking as if you had not said anything at all. Finally, you raise your voice and firmly say, "I really have to go!" In response, the friend angrily says, "OK, GOODBYE!" 

The natural response is "No, wait!" even though ending the conversation had been one's goal in the first place! 

I advise you to resist the temptation to re-ignite whatever fight had been taking place before you asked the question concerning why the family member was picking a fight, and move on to whatever new and friendlier topic the Other has chosen.  Just like your partner in conversation, act as if the earlier argument had never even taken place.

The fine art of apology

The last bit of advise on disarming someone with BPD concerns the situation in which the family member with BPD gets the best of you and you react with a statement or action that invalidates or insults the patient.  Despite being well versed in the kinds of interventions described in this series of posts, you may still find yourself responding poorly to a family member's provocations. 

The person with BPD, after all, has a lifetime of experience in creating these reactions.  Unfortunately, intermittent emotional overreactions from another tend to make such a person try even harder and longer to illicit said reactions. This is due to the variable intermittant reinforcement process desribed in Part I of this series of posts.

Solution:  After you and your targeted other have calmed down, own up to your mistake and apologize for it!  Be a person of integrity. Be someone who is responsible, has a sense of right and wrong, and is the sort of person other people can look up to.

Having said that, however, an effective apology in this situation should not have the slightest hint of self-denigration attached to it.  If you put yourself down in some way, the person with BPD may then go for your jugular in response.  Basically, there are two characteristics this kind of apology should always have:

First, be good-natured about your error.  After all, you are only human.  Be able to laugh at yourself.  Say, "Gee, I sure did get frustrated with you that time."

Second and most important, apologize only for what you actually said or did, but not for the feelings that led to it.  Example: "I am sorry for sounding so critical, but I just had the feeling that you were dismissing everything I said out of hand."

This sort of statement frames the former explosive interchange as a mutual problem that the two of you need to work on solving in a constructive manner.   And after all, solving interpersonal problems is what effective metacommunication is all about.

Some Suggestions for Avoiding Bad Psychiatrists

"Letters, we get letters

We get lots and lots of letters"

(Apologies to the producers of the old Perry Como TV Show, if any are still living.  Damn I'm old!)



A blog reader sent me a very interesting e-mail with some important questions about the treatment one psychiatrist was providing her daughter.   Maybe I should start a newspaper advice column.  Or maybe not.  Anyway, I'll try my hand at it this one time.

The behavior of the doctor that she describes, assuming that the description is accurate, seems to be typical of the way a lot of bad psychiatry is administered these days. I thought readers might appreciate some tips on how to avoid it.

You can find many additional tips on how to pick a psychiatrist or a psychotherapist who deals effectively with family dysfunction in Chapter Ten of my book, How Dysfunctional Families Spur Mental Disorders.

The names in the letter have been changed to protect the innocent - or in this case, the name of a doctor who is perhaps guilty:

Dear Dr. Allen,

I just recently ran across your blog and became distressed because I fear my daughter is a victim of the over diagnoses of bipolar II. I took her to Dr. XXX because she was nearly suicidal after her father threw her out of her apartment (which he owns) because of her drug and alcohol use. She had no money saved to get an apartment, she wrecked her car and had no vehicle to go back and forth to college and work, and she was on a downward spiral. I told my daughter that I would help her get on her feet financially if she saw a psychiatrist (fearing she was suicidal). She found Dr. XXX’s name in the yellow pages and off we went.

Within 10 minutes he had her diagnosed as BP II. Perhaps we were relieved that there was a medical explanation for her state or perhaps his insistence that “of course this is BP II; I am an expert in the field and should not be questioned” but we did not get a second opinion. After 11 months of ‘treatment’ she is still not ‘normal’ which he blames on her not being compliant in his instruction about when to take medication, eat, sleep, etc. She does not want to continue with the treatments as the drugs are messing her up with extreme tiredness, swelling up like a balloon on the face and extremities, hypothyroid, there are constant blood tests, and on and on.

Dr. XXX refuses to help her wean off the medications stating that he can not do that when he knows she needs the meds and he took an oath. Who can help or how can we proceed to get her safely weaned off the numerous drugs she is currently taking (Equatro, lithium, lyrica, synthroid, zyprexa) to see if now that she is no longer abusing drugs and alcohol, if she can function normally? Should we get a second opinion? What should we do? Please help!

Best regards,

Mrs. ZZZ

Hi Mrs. ZZZ,

Obviously I can not make a diagnosis of your daughter or fairly evaluate her treatment based on an e-mail, but I can make some generalizations that relate to some of what you said. The following should in no way be interpreted as medical advice, but of course that does not mean you need to discount what I say.

First of all, if any psychiatrist makes a diagnosis with certitude after just ten minutes, it is not only time to get a second opinion, but to completely ignore the first one.

If a doctor does not really address a patient’s or the family's concerns but instead just says, “Trust me, I am an expert,” ditto.

The medications you describe would be for bipolar I, not II, and fibromyalgia, which is a wastebasket diagnosis for pain we do not understand. Also, your list includes two mood stabilizers (lithium and carbamazepine [“Equatro” – a brand named drug when a much cheaper generic is available]), as well as an anti-psychotic.

Whenever I see patients on such a bizarre mix of medications, some of which are for symptoms such as psychosis which they do not in fact have, the odds are extremely good that the patient has been highly overmedicated and misdiagnosed, and the doctor has been just throwing meds at the patient willy-nilly to see what sticks.

Blaming the patient for a failure of medications, while possibly true if the patient is not taking them as prescribed, is usually counterproductive. If a patient is not compliant, maybe it is because the meds are creating more problems than they are solving.

A doctor can not make a legitimate diagnosis of a mood disorder if a patient has been using drugs throughout the entire period in which symptoms occur – because the effects of the drugs can and often do mimic the symptoms of a mood disorder.

If a patient with a diagnosis that has been made under the above circumstances needs to be weaned off meds, he or she may have to consult with several psychiatrists before being able to find one that is willing to help the patient do that. But it is definitely worth the effort.

Last, I think that bipolar II is not a legitimate diagnosis to begin with, but I am in a distinct minority of psychiatrists on that point. 

Sincerely,

David Allen

Let the buyer beware!