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.

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

Lupus Awareness Month

Last week, I wrote about Celiac Awareness Month for May. May is also Lupus Awareness Month. Lupus is a chronic autoimmune disease that can damage any part of the body. Inflammation and damaged can occur in the skins, joints, organs, literally the entire body is under attack. It is a disease of flares and remissions. It is an immune system in overdrive. Lupus is a disease which is more pervasive and severe than people think. An estimated 1.5 million Americans are living with lupus today with more than 16,000 new cases every year. Lupus has touched my life as my cousin-in-law suffered with lupus until her death in 2013. Recently, I learned that another dear cousin-in-law has been diagnosed as well. When I learned that May is Lupus Awareness Month, I had to take the time to educate myself and hopefully others as an estimated two-thirds of people know little or nothing about lupus. Together, we can fight this disease and support those who must live with this horrible disease.

Lupus is known as the Great Imitator as symptoms closely resembles other diseases and can come and go over time, making diagnosis difficult. On average, an individual will be diagnosed within six years from the onset of symptoms. While an exact cause is unknown, scientists believe that lupus is triggered by a combination of genetics, hormones and environmental facts. Ninety percent of lupus patients are women who commonly developed symptoms between the ages of 15 and 44, although lupus can occur in children as young as infants. Lupus is NOT a form of arthritis and it is NOT contagious. Lupus affects all races and ethnicities. Although, African-Americans, Hispanics/Latinos, Asians, Pacific Islanders and Native Americans are two-three times more likely to be diagnosed than Caucasians. The difficulty in lupus is that no two cases are alike and the symptoms can vary greatly among patients. Symptoms may develop suddenly or slowly, be mild or severe, or can be temporary or permanent. Most lupus patients will experience symptoms in flare-ups and can have periods of remissions with no symptoms at all. The most common sign and symptoms are:

Fatigue and fever

Joint pain, stiffness and welling

Butterfly shaped rash on the face across the bridge of the nose and cheeks

Photosensitivity (resulting in skin lesions and rashes, fever, debilitating fatigue, and joint pain)

Raynaud’s phenomenon (fingers and toes turn white or blue when exposed to cold or during stressful periods)

Shortness of breath, chest pain

Dry eyes

Headaches, confusion and memory loss

Due to the attack on the body, lupus can lead to various complications throughout the body. Patients can develop kidney complications often characterized by generalized itching, chest pain, nausea, vomiting and edema. Lupus can affect the brain and the central nervous system characterized with headaches, dizziness, behavior changes, hallucinations, strokes and seizures. Patients can experience memory problems and difficult expressing their thoughts. Patients can also suffer from anemia, increased risk of bleeding and blood clots, and vasculitis, the inflammation of the blood vessels). Patients are susceptible to pleurisy, inflammation of the chest cavity, and pneumonia. Lupus patients are also at greatest risk for pericarditis, inflammation of heart muscle, and cardiovascular disease and heart attacks. Patients are also at greater risk for urinary tract infections, yeast infections, salmonella, herpes and shingles. There is also an increased risk for cancer. Patients can develop avascular necrosis or bone tissue death. This is caused by loss of blood supply to the bone. Tiny breaks in the bone occur until eventual bone collapse. The hip joint is the most affected and can lead to the patient needed assistance for mobility. Lupus also poses complications of preeclampsia and preterm birth in pregnancy.

Reading the list of symptoms and possible complications is scary and heartbreaking that millions of people are suffering with these conditions. Treatments have advanced which help patients control their symptoms and even achieve long periods of remission and increase the longevity of their lives. Lupus patients can expect to live a normal lifespan. On average, lupus patients will have eight prescriptions to manage the symptoms. In 2013, the FDA finally approved the first drug designed to specifically treat lupus. Due to lupus causing the body’s immunity to go into overdrive, immunosuppressant drugs such as cyclophosphamide, a chemotherapy drug, has been shown to help alleviate symptoms. NSAIDs such as ibuprofen and naproxen, have been useful treatments. Antimalarial drugs also have been shown to help with symptoms. Corticosteroids are a common course of treatment. There are also a variety of home remedies and alternative medicines which can help as well. With the help of various treatments, many lupus patients still lead full and active lives while for others it is debilitating and greatly affects their daily lives.

In recent years, more and more famous faces have been coming forward with their own stories of lupus. I’ve complied just a few to show that lupus doesn’t have to stop life as you know it. Flannery O’Connor was diagnosed with systematic lupus erythematosus in 1951. She was told by doctors that she only had five years to live. She went on to live additional fourteen years. She died in 1964 after completing more than two dozen short stories and two novels while battling lupus. More current faces of lupus include Nick Cannon who was diagnosed with lupus nephritis (inflammation of the kidneys). Selena Gomez, Paula Abdul, Toni Braxton, and Seal all have shared their stories and continue to advocate lupus research and education as well as continue their careers and enjoy their favorite activities.

Lupus is a debilitating disease which can affect everyday activities. Many people have heard of lupus but do not know what the disease can do. During this awareness month, I want to get the word out about this silent demon which wreaks havoc on an individual’s body. I hope this post brings some understand about this horrible disease. And may it also bring awareness to someone who may not have the disease and not realize it. I’ve included websites below which you can go to for further information.

For more information:

Lupus Awareness Month www.lupusawarenessmonth.org

Lupus Foundation of America www.lupus.org

Mayo Clinic http://www.mayoclinic.org/diseases-conditions/lupus/basics/definition/con-20019676

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.