What is Borderline Personality Disorder (BPD)?

Borderline Personality Disorder (BPD) is characterized by difficulties regulating emotions. According to the National Alliance on Mental Illness (NAMI), patients with BPD, emotions are felt intensely and for extended periods of time with difficulty returning to a stable baseline after an emotionally triggering event. These factors can often lead to impulsivity, poor self-image, stormy relationships and intense responses to stressors. Struggles with self-regulation can result in dangerous behavior such as self-harm (i.e. cutting). It is estimated that 1.4% of US adults experiences BPD. While majority of patients are women (75%), recent studies have shown that men may be equally affected; however, they are commonly misdiagnosed with PTSD or depression.

According to the Diagnostic and Statistical Manual (DSM), patients with BPD exhibit frantic efforts to avoid real or imagined abandonment by friends or family. They may have dissociative feelings, thoughts or identity. They may lash out with inappropriate, intense or uncontrollable anger, often followed by shame or guilt. Patients will often have unstable personal relationships and alternate between extreme idealization (i.e. being “so in love”) and devaluation (i.e. hatred). Patients can have distorted and unstable self-image affecting their moods, values, opinions, goals and relationships. They sometimes engage in impulsive behaviors with possible dangerous outcomes. For example, excessive spending, unsafe sex, substance abuse and reckless driving. Patients may self-harm or threaten to self-harm including cutting, suicidal threats or attempts. Patients may also experience periods of intense depression with irritability and/or anxiety which can last hours or days. They may also experience chronic feelings of boredom or emptiness. The causes for BPD are not fully understood; however, the consensus is a combination of three factors. First, genetics. While there is no specific gene or gene profile which points to BPD, having a close family member with the disorder may place an individual at a higher risk. Second, environmental factors. Experience a traumatic event or events, such as physical or sexual abuse or neglect and/or separation from parents, may contribute to the risk factor. Third, improper brain function. Portions of the brain that control emotions and decision-making/judgement may not communicate at optimal levels in patients with BPD. There is currently no definitive testing for BPD. A patient is usually diagnosed after a comprehensive clinical interview, reviewing medical records and interviews with family and friends, if necessary.

There are a few treatments available for BPD. First, medications. Mood stabilizers and antidepressants have shown results with controlling mood swings and dysphoria. Low doses of antipsychotic medications may also help with symptoms like disorganized thoughts. Second, Dialectical Behavioral Therapy (DBT). DBT is influenced by the philosophical perspective of balancing opposites and designed for the development of new skills to manage painful emotions and decrease conflicts in relationships (Psychology Today). It promotes balance and avoiding black or white, all-or-nothing thinking. It also promotes a both-and rather and an either-or approach. It works in four key areas: 1) mindfulness (improving the ability to accept and be present in the current moment), 2) distress tolerance (increasing tolerance of negative emotions rather than trying to escape it), 3) emotion regulation (strategies to manage and change intense emotions that cause problems), and 4) interpersonal effectiveness (communication that is assertive, maintains self-respect and strengthens relationships). DBT typically consists of individual and group therapy sessions but not necessary to be done concurrently. Third, Cognitive Behavioral Therapy (CBT). CBT is a “talk therapy” designed to help patients become more aware of inaccurate or negative thinking so that challenging situations can be seen more clearly, and responses can be more effective (Mayo Clinic). Exposure therapy can also be used with CBT as it would require patients to confront situations, they would usually avoid in order to learn the appropriate responses. Patients learn to better manage stressful life situations. Lastly, short-term hospitalization may be necessary in times of extreme stress and/or impulsive or suicidal behaviors in ensure safety.

Most often, movies, TV and other forms of popular culture can misrepresent a person with a mental illness; however, sometimes they get it right. According to Dr David Allen (2013), there is a movie that portray a person with BPD accurately as well as understanding “the family relationship patterns” that he believes are the primary risk factors. Thirteen (2003), co-written and starring Nikki Reed, nails the family dynamics of people with BPD. Reportedly semi-autobiographical, Thirteen is the story of 13-year-old Tracy (played by Rachel Evan Wood) a junior high school student in Los Angeles, feels abandoned by her divorced, alcoholic mother, begins dabbling in substance abuse, sex, and crime after being befriended by a troubled classmate, Evie (played by Nikki Reed). Another movie that portrays BPD is Eternal Sunshine of the Spotless Mind (2004). While her diagnosis is never revealed in the film, the character, Clementine “Clem” Kruczynski (played by Kate Winslet) is a good representation of BPD’s impulsivity, substance abuse, emotional intensity, and idealization and devaluation (Virzi, 2017). A case was made for the character of Anakin Skywalker, from the Star War films Episode II Attack of the Clones (2002) and Episode III The Revenge of the Sith (2005), as an example of BPD (Virzi, 2017). Played by Hayden Christensen, Anakin has preoccupations and fears of abandonment and loss. He has sensitivity to potential slights, bursts of extreme anger, and paranoid ideation (Virzi, 2017). I can certainly see how Anakin could be an example of an person with BPD.

In conclusion, Borderline Personality Disorder is an inability to regulate emotions and can be exhibit extreme emotions from love to anger. While no specific cause is known, it is thought to be genetic, environmental, and/or improper brain function. A combination of therapy, medications and hospital stays are common treatments for BPD. Popular culture often misrepresents individuals with mental illness in their stories; however, a few movies have been shown as good examples of patients with BPD and their families. The films, Thirteen and Eternal Sunshine of the Spotless Mind, and the Star Wars character, Anakin Skywalker, are good representations of individuals with BPD.

References

Allen, David M. (July 22, 2013). Borderline Personality Disorder in the Movies. Psychology Today. https://www.psychologytoday.com/us/blog/matter-personality/201307/borderline-personality-disorder-in-the-movies. Retrieved March 3, 2020.

Mayo Clinic. Cognitive Behavioral Therapy. https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610. Retrieved March 4, 2020.

NAMI (National Alliance on Mental Illness). Borderline Personality Disorder. https://www.nami.org/learn-more/mental-health-conditions/borderline-personality-disorder. Retrieved March 1, 2020.

Psychology Today. Dialectical Behavioral Therapy. https://www.psychologytoday.com/us/therapy-types/dialectical-behavior-therapy. Retrieved March 2, 2020.

Virzi, Juliette (November 20, 2017). 10 Movies That Got BPD Symptoms (Mostly) Right. The Mighty. https://themighty.com/2017/11/movies-borderline-personality-disorder-bpd/. Retrieved March 3, 2020.

Divided We Fall: a look into church division and what we can do about it

Divided We Fall: Overcoming a History of Christian Disunity by Luder G. Whitlock Jr is a look into the history of the Christian church and how disagreements and arguments have created division among Christians throughout the centuries. He begins with biblical foundations of faith and how humans as relational beings are designed for companionship and community. He takes an in-depth look into the historical events which have shaped the different denominations as we know them today. From the Apostolic Church to the Medieval Era to the Reformation. As he discusses the differences among the denominations, he focuses on the Presbyterian Church, which he is the most familiar with. The differences are more than doctrinal differences but cultural, economic and social differences. For example, the Presbyterian Church has 10 or more denominations that have developed since the arrival in the New World. The church separated into North and South denominations during the Civil War and failed to reunite when the war was over. Some denominations are divided along heritage identity i.e. Scottish and Irish congregations. Some division simply came about over the business matters. After he discusses where the church has lost its focus, he offers solutions to refocus and return to the united church as discussed in the Bible. It all begins with love, trust, understanding, kindness and the ability to function together despite our differences.

I thoroughly enjoyed this book. I enjoyed reading the history of the church and the changes to the church as society changed. I agreed with many of his points especially his assertion that he is a Christian without the label of a denomination, “I am happy to be a mere Christian without further appellation.” I too am happy to be merely a Christian. The clarification of what denomination I may or may not belong to is unimportant. Another point he made is “the closer you are to Christ, the more some issues fade in importance.” I wholeheartedly agree. The last year I committed to reading the Bible book by book and I found myself closer to Christ and to God than I have ever been before. The denominational differences and scrabbles do not matter to me anymore. I highly recommend this amazing book. Mr. Whitlock is honest about where the church has gone wrong and acknowledges the solutions he offers will be difficult for some to do but they are necessary for unity among believers. This book has a permanent place on my bookshelf.

Divided We Fall: Overcoming a History of Christian Disunity

is available in paperback and eBook

Selective Mutism: not just a form of shyness

Selective mutism is the inability to speak in certain situations. It usually occurs in children less than five years old; however, it is not usually noticed until a child starts school. It is often mistaken for shyness. For fans of The Big Bang Theory, selective mutism isn’t a new term. One of the main characters, Raj Koothrappali (played by Kunal Nayyar), suffered from selective mutism until he was able to overcome it at the end of season 6. My interest in selective mutism is much more personal than a character from a favorite TV show. My five year old daughter often won’t speak in social situations in which she is unfamiliar, is the center of attention or speak with adults whom are not active members of her life (i.e. my husband’s work acquaintances). So I’m curious if my daughter suffers from selective mutism and if so, what I can do to help her overcome this problem. In the course of my research, I see that selective mutism is rate. It affects less than one percent of individuals seen in mental health setting.

Causes of selective mutism can stem from an anxiety disorder, self-esteem issues or problems with speech, language and hearing. The symptoms of selective mutism includes a consistent failure to speak in specific social situations where there is an expectations for speaking. The failure to speak interferes with school, work or with social communication. The lack of speech lasts at least a month and the failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation. For example, a non-Spanish speaker not speaking in a situation in which Spanish is being spoken is not selective mutism. The failure to speak is also not due to a communication disorder (i.e. stuttering) and does not occur exclusively during the course of autism spectrum disorders, schizophrenia or other psychotic disorders. According to the Diagnostic and Statistical Manual of Mental Disorders: Fifth (DSM-V, 2013), children with selective mutism may show anxiety disorders (i.e. social phobia), excessive shyness, fear of social embarrassment and social isolation and withdrawal. Children with selective mutism may also show signs of separation anxiety, frequent tantrums, moodiness, inflexibility, slow to warm up and sleep problems.

If selective mutism is suspected, parents are advised to first, remove all pressure and expectations for the child to speak. Pressuring a child to speak when they won’t, will only add to the anxiety the child is feeling. Second, convey to the child that the parents understand he or she is scared and it is hard to get the words out but Mommy and Daddy are there to help. Third, praise the child’s efforts and accomplishments when a child speaks when they normally wouldn’t. Also support and acknowledge the difficulties and frustrations when a child refuses to speak again. Fourth, if parents are really concerned, they need to speak with their family physician or pediatrician. Beware of doctors and “experts” who see selective mutism as controlling or manipulative behavior or the result of overprotective parents. This is not the case and seek out help from those who truly understand selective mutism.

The diagnosis of selective mutism is very detail and in depth. First, the child is examined by a Speech-Language Pathologist (SLP) as well as the child’s pediatrician and a psychologist or psychiatrist. A complete background is gathered starting with the child’s educational history. The educational history includes academic reports, parent/teacher comments, and any previous testing. A hearing screening is performed to rule out any hearing inability or a middle ear infection. An oral-motor examination is performed in which the coordination and strength of the muscles in the lips, jaws and tongue is tested. The parents/caregivers are interviewed for any suspected problems, environmental factors (i.e. language stimulation), and information about the child’s amount and location of verbal expression. A family history of psychiatric, personality and or physical problems could be attributed to the child’s selective mutism. The child’s speech and language development is examined to see how well the child express himself and understands others. Lastly, a speech and language evaluation will be done to determine the child’s expressive language. This is usually done with the SLP; however, if the child will not speak, a home video of the child speaking is acceptable. A language comprehension is taken in the form of standardized test as well as verbal and non-verbal communication (i.e. pretend play or artistic expressions).

If a child is diagnosed with selective mutism, what is the course of treatment? The SLP will create a behavioral treatment program which will focus on specific speech and language problems or social anxiety issues. First, stimulus fading involves the child in a relaxed situation with someone they talk to freely and a new person is gradually introduced into the room until the child is comfortable talking in front of and with each person. Second, shaping is a structured approach to reinforce all efforts by the child to communicate until audible speech is achieved. These efforts could include gestures, mouthing, or whispers. Third, self-modeling techniques have the child watch videos of himself or herself performing the desired behavior. Self-modeling is used to facilitate self-confidence and carry over behaviors into settings in which the mutism occurs.

I realize that my daughter may not have selective mutism and I have plenty I can do myself to help build her confidence to speak to those she may not be familiar with. I realize that my daughter is a chatterbox at home and in public with people within earshot but the moment she is the center of attention, she clams up. And it’s completely normal. I also realize that shyness is hereditary as I remember being unable to speak freely with people I did not know or even family members I saw often. The fear of saying the wrong thing or even saying it incorrectly, kept me from speaking. Selective mutism is a form of an anxiety disorder and with behavioral treatments, a child can overcome it. It is important to remember to not to pressure a child to speak when they are anxious.  Encourage but do not force. Help build the child’s confidence and he or she may surprise you and speak freely. If in doubt, speak with your child’s doctor for further help.

Resources

American Speech Language Hearing Association: http://www.asha.org/public/speech/disorders/SelectiveMutism/

Selective Mutism Center: http://www.selectivemutismcenter.org/aboutus/whatisselectivemutism

Alcoholism: a disease which touches so many

I have a love-hate relationship with alcohol. I am not a big drinker. I do enjoy a rare cocktail. My favorite drink is Rum and Coke but I don’t seek out the alcohol and often times I will turn down a drink. I am a child of alcoholics. My mom is a recovering alcohol who has seen her life turned upside down because of her drinking. She has come a long way and is currently working to help others end their alcoholism. My dad has not been able to end his drinking. Despite his consistent reassurances that he has, I know when someone is drunk by their voice. Because of this, we do not have a relationship. Alcoholism is a chronic and progressive disease with involves problems controlling drinking, the preoccupation with alcohol and the continued use of alcohol despite health issues. Alcoholism isn’t just a drinking problem. It becomes a life or death problem.

The symptoms of alcoholism are:

• Unable to control amount of alcohol. An alcoholic can’t have just one beer or one glass of wine. They will drink until the whole case or bottle is gone and often without realizing that they have drank so much. 
• Strong need to drink. This need is constant and irresistible urge. Thoughts of getting a drink consume everyday activities and the person will not have relief until he or she has a drink in the hand. 
• Develop tolerance which leads to the need of more alcohol to feel the same effect.
• Physical withdrawal symptoms when not drinking (i.e. nausea, sweating, and shaking)
• Experience blackouts
• Keeps alcohol in unusual places (i.e. in the bathroom, in the car, or at work)
• Legal problems, relationship issues, unemployment or financial issues due to drinking
• Loss of interest in activities and hobbies that you once loved. 

The causes of alcoholism have been researched and debated. The consensus is that alcoholism has genetic, psychological, social and environment components. It makes sense that someone who has parents and even grandparents who were alcoholics can be predisposed.  Is it a solely genetic or a combinations of the components? I think alcoholism a mixture of the social and environment components with interaction with the mental state of an individual. The risk factors of alcoholism are: 1) steady drinking overtime due to stress or an escape mechanism, 2) age at which someone begins drinking. The earlier someone starts, the higher the risk of alcoholism, 3) family history, and 4) social and cultural factors, if drinking is a part of parties and other gatherings, an individual would be more likely to drink.

The health complications from alcoholism are widespread. The most common health issue is the development of various liver aliments such as liver disease, cirrhosis and fatty liver. Alcoholism also can lead to digestive problems such as gastritis and pancreatitis. It can contribute to various heart ailments such as enlarged heart, heart failure, high blood pressure and stroke. There are hosts of other complications that alcohol can contribute to: diabetes complications (i.e. hypoglycemia), sexual and reproductive issues (erectile dysfunction in men and menstruation issue in women), eye problems, birth defects (i.e. mental retardation, organ defects, facial malformations, and impaired growth), neurological complications (i.e. dementia and short term memory loss), weakened immune system and a higher risk of cancer. Of course, death. Alcohol related deaths are the third leading cause in the U.S. In 2012, 31% of driving fatalities were alcohol related.

For me, alcohol isn’t worth it. The host of health and social problems that can arise is just not worth the alcohol. I suppose it is easy for me to avoid alcohol for various reasons: 1) majority of alcohol is not gluten-free (although manufacturers are now coming out with gluten-free options, 2) I simply don’t like how alcohol tastes or how it makes me feel and 3) alcohol is very expensive. I understand that for some people, the pull of alcohol is often too great. If you or someone you know needs help with alcohol, there are countless of organizations which can help. Alcoholics Anonymous (www.aa.org) is the most well-known. Look for your local organizations for more information and help. The first step is begins with you.

Sundown syndrome: end of the day confusion

Sundown Syndrome or “sundowning” is a state of confusion that occurs at the end of the day and into the night and can lead to pacing or wandering. Sundowning has been compared to Seasonal Affective Disorder which is a common depression caused by less exposure to natural light and usually occurs with the onset of winter. Sundowning occurs in approximately 20% of Alzheimer’s patients and usually peaks in the middle stages and lessens as the disease progresses (Webmd.com). Although Alzheimer’s patients are more susceptible to sundowning, changes in blood pressure, glucose levels after eating as well as individuals with macular degeneration can experience sundowning.

The exact cause of sundown syndrome is unknown (Mayo Clinic). However, studies have suggested that it may occur due to changes in the brain’s circadian patterns. The cluster of nerves which keeps the body’s 24 hour clock has been altered or damaged. Another study done with mice has shown that it may occur due to a change in the brain’s chemistry from the younger mice to the older mice (Webmd.com). A few factors may aggravate the occurrence of sundown syndrome are: fatigue, low lighting, increased shadows, disruption of the body’s internal clock and the difficultly separating reality from dreams (Mayo Clinic). With the inability to understand what he/she is seeing, he/she will often misinterpret what is there. For instance, one story I came across in my research tells the story of a man who thought he was being robbed at home because the sunlight coming through the blinds created stick figures on his walls. He would repeatedly call the police.

The symptoms of sundown syndrome may vary from patient to patient. Majority of patients will experience: confusion, anxiety, aggression, forgetfulness, delirium, agitations, ignoring directions, restlessness and trouble sleeping (Mayo Clinic and Webmd.com). A patient who experiences these symptoms may be compelled to wander or pace and may yell and become combative. Many physical ailments may lead to a patient being more susceptible to sundowning. Severe constipation, poor nourishment, pain, an infection and too many medications.

There are some tips for reducing the occurrence of sundown syndrome (suggested by the Mayo Clinic and Webmd.com):

Activities:

Plan activities for during the day to optimize exposure to the sun and to encourage nighttime sleepiness

Avoid daytime napping

Try to maintain a predictable routine for bedtime, waking, meals and other activities

In the evening, reduce background noise and stimulating activities (i.e. TV viewing)

Healthy Diet:

Limit caffeine and sugar to morning hours

Eat an early dinner

Light snacks before bedtime

Medical Advice:

Check for any conditions which may be contributing factors (i.e. UTIs, sleep apnea)

Regularly check medications to make sure still needed

Good sleeping environment:

Use a night light to reduce agitation that occurs when surroundings are dark or unfamiliar

Play gentle music in the evening or relaxing sounds of nature (i.e. waves) to promote sleepiness

Change bedrooms if needed

Calm reassurance:

Gently remind the patient where he/she is and what time it is.

When in a strange or new setting, bring familiar items (i.e. pictures) to help with relaxation

Due to the stress it puts on caregivers, sundown syndrome is a common cause of caregiver burnout. It is a difficult situation to take care of an individual with Alzheimer’s. My Grandma Ruby suffered from Alzheimer’s disease and it was heartbreaking to see her unable to recognize where she was or who she was with. I’m not sure if she suffered from sundown syndrome but she probably did. Sundown syndrome in combination with other disorders can be terrifying for the sufferer as well as stressful on a caregiver. I think following the above suggestions from the Mayo Clinic and other medical sources can help lessen the effects of sundowning as well as the stress and anxiety it can cause.