Julie Miller's Mental Health Blog

Archive for February 2010

Chemical dependence is one of this country’s most expensive and destructive public health issues.  Billions of dollars are spent each year on prisons, the justice system, law enforcement, and treatment.  Treatment, of course, really being the area with the smallest amount of funding.  The loss to society of productive adults and teens and the costs to future generations because of the impact of chemical dependence on families is also enormous.  But this is all just from a public health perspective.  The true cost paid by individuals and families is immeasurable.

From a family perspective, chemical dependence can destroys the present and future.  Children raised in families with chemical dependence suffer PTSD at the same rates as combat veterans.  Children raised in these families are at extremely high risk for development of chemical dependence themselves, along with higher rates of just about any mental health issue, including depression, anxiety, personality disorders, eating disorders, pain disorders… you name it.

The “war on drugs” is really a war on Americans.  How’s that war working out, you might ask?  Chemical dependence rates continue to increase.  Illegal drug trafficking appears to increase every year across the Arizona-Mexico border, as evidenced by increased drug seizures.  Do we really think we’re actually seizing more because we’re winning the war on drugs?  Nah.  We’re seizing more because they’re sending more.  Drug seizure is considered a business cost by drug lords and drug cartels.

Why do you think Mexico losing the war against drug cartels?  So there are lots of opinions, I’m sure, but it seems fairly clear to me that export of illegal drugs to the US is so lucrative that the risk of prosecution for killing public officials, civilians, journalists, law enforcement, and the risk of being killed oneself, is far outweighed by the dough earned through the drug trade.  The fact that the market for illegal drugs in the US is enormous makes dealing drugs a lucrative career choice in Mexico. I won’t even get into the issue of guns flowing from the US to Mexico, which arms the drug cartels.

Given this complicated issue with the politics surrounding chemical dependence, it seems increased funding for chemical dependence treatment would be a big part of the solution.  Treatment is designed, inherently, to reduce the demand for drugs (illegal and legal).

Treatment for chemical dependence is available in most communities to some degree.  Often rural areas do not have treatment readily available, and these areas often have higher rates of chemical dependence than urban areas.  Chemical dependence treatment usually falls under mental health treatment and therefore is subject to lack of funding by states. (Arizona is among the rock bottom states when it comes to funding for mental health services.)

What would it be like if even some of the billions of dollars spent on the “War on Drugs” went for treatment of addicts, thereby reducing the demand for drugs in the US?  Potentially, it could be revolutionary to this country, especially for future generations.  Treatment for chemical dependence would not only reduce demand, it would also increase productivity, improve families, reduce rates of mental illness, and give future generations a real opportunity to succeed and benefit directly from the billions of dollars spent.

Treatment reduces suffering.  Treatment improves lives.  Treatment gives families a chance to raise healthy, educated, productive children.

Who’s not for treatment? Unfortunately, many man people in the US are not for treatment, as evidenced by the lack of public and political will to provide the dough to pay for it.

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Treatment for borderline personality disorder is available; I don’t care what other mental health professionals say, it’s treatable and has as good a prognosis as any other mental health issue.

Three primary issues come into play with treatment of borderline personality disorder:  1) medication; 2) therapy; 3) time.

Given that I am not a medical professional, I can’t give anything even remotely like advice on medication issues.  What I have observed is that there are often co-occurring issues with borderline personality, including depression and anxiety.  A competent psychiatric physician (MD or DO) can make an appropriate assessment, diagnosis, and recommendation for medications that might be beneficial.  There is also some research I have read that Omega-3 fish oils (fatty acids) may be beneficial for some of the impulsiveness and other issues.  It’s true – check it out online.

There are a few short-term therapies that purport to help one learn to cope with borderline personality disorder.  DBT (dialectical behavior therapy) was developed at the end of the last century as a means to help anyone learn skills to cope more effectively with the symptoms of borderline personality or issues of similar complexity.  It’s basically a combination of CBT (cognitive behavioral therapy) and mindfulness; it can be very effective.  However, it doesn’t “cure” borderline personality; it increases coping skills.

Is there a cure?  Most mental health professionals would say no; however, there is some significant work based on Freud’s original psychoanalytic work that is designed to heal the attachment wounds that bring borderline personality patterns into being.

This form of therapy goes by a couple names (with small differences in my opinion), including “Object Relations Therapy” and “Self Psychology.”  I have observed this work and have seen its effectiveness in the long-term.  It is not a short-term therapy. A terrific book entitled “Search for the Self,” by James Masterson, MD, is written for the layperson and is very effective in explaining the theory behind this kind of treatment.

In this form of therapy, attachment wounds are healed through the relationship with the therapist.  It is neither an easy nor painless form of healing.  It requires a dogged determination to heal, and persistence, sometimes over a few years.  Not 10 or 15 years, but maybe 3 or 4 (or 5).  This form of treatment requires a highly trained and highly competent therapist.

The training for this kind of therapy is specialized, and not every therapist is interested in developing the skill required.  If you are looking for a therapist to help with borderline personality issues, you will need to find someone who knows what you’re talking about when you say “object relations therapy,” and who can refer you to someone who knows how to do it.  It’s not listed in the yellow pages.

As noted in my blog post entitled “Borderline #2,” borderline personality is sometimes confused with PTSD.  Indeed, if attachment trauma (lack of childhood attachment) underlies any personality disorder, trauma IS borderline personality disorder.  Effectively, then, any form of therapy that will assist with resolving unprocessed traumatic material will be of tremendous assistance in reducing the suffering of an individual with borderline personality disorder.  These forms of treatment include EMDR (eye movement desensitization and reprocessing) and TFCBT (trauma focused cognitive behavioral therapy).

Some say “time heals all wounds.”  Some mental health professionals say borderline personality “burns out” somewhere in middle-age.  Okay, but if you ask me, who wants to wait until they’re 45 or 50 before things get better just with time?  There is also an increased risk of suicide for individuals with borderline personality disorder, so just hanging around, waiting for someone’s borderline personality issues to “burnout” are not a great plan.

Borderline personality disorder is a painful problem.  There is treatment, however, that is effective if provided by well-trained, skills mental health professionals.  Seek competent help.  Ask for referrals.  Research the issues yourself to get more information.  Help is available.

Borderline personality disorder can be .  very complicated to define.  Like with any personality disorder, the specific behavioral and emotional criteria are pervasive and chronic.

Five or more of the following criteria are required for an official diagnosis of borderline personality disorder.  An individual can also have borderline “traits” or “features” and this would require only one or more of these criteria.

A personal with borderline personality might:

  • Avoid real or imagined abandonment at almost any cost
  • Experience a pattern of alternating between intense admiration and hatred of others
  • Experience an unstable self-image or even uncertainty about his or her own identity
  • Behave impulsively in ways that hurt themselves, including spending, frequent or  unprotected sex with many partners, substance abuse, disordered eating, reckless driving, etc.
  • Think about suicide often, make repeated suicide attempts, or self-injure through cutting or burning himself or herself
  • Experience frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious, lasting for only a few hours at a time or a day or two
  • Feel a sense of emptiness on a long-term basis
  • Experience inappropriate, fierce anger or problems controlling anger
  • Experience temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality

You may relate to several things listed above, or maybe just one or two.  Many individuals, who do not meet the full criteria for a borderline personality diagnosis, experience one or two of these criteria in their personality.

There may be several possible reasons an individual may experience these conditions.  Sometimes, as discussed in the previous post, other issues may seem to be like a borderline personality feature, but if considered more carefully by the mental health professional, that particular symptom may really be part of some other condition.

I have met a client more than once who came with a label of “borderline” but who was not borderline; instead, perhaps they had PTSD (post-traumatic stress disorder; see “‘P’ is for PTSD” in upcoming posts), or bipolar disorder/manic or hypermanic phase, or even a different personality disorder such as histrionic or dependent.

It’s also helpful to think of borderline personality, along with any other personality, traits or features, as relating to problems with attachment, sometimes called “attachment trauma.”

Consider the first criteria listed above:  “avoid real or imagined abandonment at almost any cost.”  This is a fairly common symptom experienced by individuals from dysfunctional families in which they were abandoned (physically, emotionally, etc.) by important caregivers.  The degree to which a person is abandoned as an infant or child is very likely the degree to which they will avoid a recreation of that experience as an adult.

Given this perspective, one can perhaps understand the chronic, long-term, pervasive nature of a personality disorder like borderline personality.  The more chaotic the attachment experience as an infant or child, the more chaotic the attachment style will be as an adult, leading to frantic attempts to avoid abandonment, a highly volatile relationship style (“I hate you/don’t leave me”), difficulty regulating one’s own emotions (including attempts to do so in self-destructive ways), and difficulty with a solid sense of self.

Other symptoms often co-occur with borderline personality issues, including depression, anxiety, dissociation, addictions (chemical or “process” like spending, sex, gambling, relationships, etc.), eating disorders, etc. This is no simple problem, and treatment can be slow and complicated.

Next time, I’ll talk about treatment options.

“She’s borderline.”

“What a borderline.”

Ever hear these, or other such statements?  Many people today are familiar with the label “borderline” and use it indiscriminately.  I’ve heard even mental health professionals say such things with an attitude of disdain.

So what does “borderline” really mean?  It is a clinical diagnosis, officially “Borderline Personality Disorder,” and can easily be confused with other conditions like PTSD, bipolar, or other personality disorders.  It sometimes is used in a very dismissive manner, because “everyone knows you can’t treat borderline personality disorder.”

I couldn’t disagree more.  Of course borderline personality disorder is treatable.  Even if we don’t all agree on the cause of borderline personality (genetic?  attachment trauma?), we can treat these issues with therapy, medications, behavior modification, education, etc.

Could it be that the dismissive mental health professional attitude about borderline personality comes from frustration?  Many borderline personality behaviors do defy rational thought processes.  “I hate you, don’t leave me” is an example.  Black and white thinking.  Volatile personal relationships. Exquisite sensitivity to rejection or abandonment, even if it is imagined.  It isn’t easy to continue to express compassion for an individual who tests and pushes away and accuses and blames and angrily rejects and tearfully returns.

Borderline personality disorder is a terrible mental illness that causes horrific suffering for the individual, their family and friends.  The behavioral expression of the underlying trauma (or genetic vulnerability) can be unpredictible and mystifying, but it is no less deserving of compassion than any other mental health issue.  If an individual diagnosed with borderline personality is dismissed by a mental health professional who believes it’s a terrible pain to have a “borderline client” and “it can’t be fixed anyway,” the client will continue to suffer without hope of recovery. Plus, what if that “borderline client” really is suffering from something else, not borderline personality?

Having seen many individuals in treatment who have had personality testing, I have learned that what I had previously heard others talk about as as borderline personality could actually be diagnosed with another personality disorder, or with PTSD or bipolar, etc.  I’ve learned to look a little more closely and not make assumptions.

There is hope for anyone suffering with borderline personality disorder.  The treatment is available, and mental health professionals are responsible for learning how to treat this disorder, or referring to someone who can treat the individual.

From Mental Health Simplified at http://anxiety.mentalhealthsimplified.com:

“There are several types of anxiety disorders. They include:

  • panic attack or panic disorder (sudden anxiety that occurs without warning) with or without agoraphobia (fear of open spaces; not being able to leave your home)
  • specific phobias (many types of intense fear reactions of specific objects or situations, such as fear of spiders, flying, or heights)
  • social anxiety or social phobia (fear of being embarrassed in social situations)
  • generalized anxiety disorder (general feeling of anxiety most of the time)
  • obsessive-compulsive disorder (unwanted thoughts or behaviors that are repetitive and unnecessary)
  • post-traumatic stress disorder (anxiety associated with and that occurs after a stressful life event)”

If you have any of these concerns, help is available.  Each interferes, some more and some less, in daily life and achieving your goals.

You can contact me through my website and I can help you find an appropriate referral for your area.  Psychiatrists and therapists can treat anxiety disorders, and generally speaking are very nice people.  If you find a psychiatrist or therapist you don’t like, keep looking.  You have the right to be treated by someone you feel comfortable with.

When an individual is “triggered” and anxiety results, how can they cope?  If their nervous system is set to high most of the time, it doesn’t take much of a trigger to set up a panic attack or high levels of anxiety that can interfere with functioning.  It’s kind of like a cup that is almost full having to accept a small amount more of liquid, and then overflowing, even though the added amount was relatively small.  If the cup weren’t already overflowing, the small amount added wouldn’t have caused the liquid to overflow.

One solution for some is to lower the level of liquid in the cup to begin with.  That way, when an average amount of liquid is added (like some kind of stress from the day), the cup doesn’t overflow.

So how do you lower the level of liquid?  While it may sound like a cliche’ and therefore may be dismissed easily, if one can manage the fullness of the cup, one may be able to stay ahead of overwhelming anxiety.  Managing the fullness of the cup is basically stress management, keeping the level in the cup low.  Breathe.  Practice “here-and-now” orientation (aka “mindfulness”).  Avoid catastrophizing (the “what ifs”).  Self-soothe with healthy behaviors (exercise, meditation, relaxation exercises, using your support system, etc.).  Breathe.  Taking oneself to a safe or peaceful place in one’s mind.  Doing something fun.  Getting a massage (or pedicure, manicure, facial, or whatever feels soothing).  All of these behaviors can keep the level of stress in one’s life lower, keeping down levels of anxiety as well.

Not all of these ideas work for everyone.  But something can work for you.  Explore.  Experiment.  Pay attention to how your body feels when you are doing something, anything, and make note.  If you’re eating while driving and talking on the phone (bad idea right?), notice how your body feels.  Hang up the phone and pay attention.  Pull over and put down the hamburger and fries.  Are your muscles tight or relaxed?  Is your stomach churning, or calm?  Your body will tell you the truth if you will pay attention.

Pet your dog, and notice how your body feels.  Or pet the cat.  Feed the fish.  Watch your child playing.  Just notice what the experience is like for your body.  Notice what it’s like when your body feels calm.  When it feels hungry.  When it feels satisfied.

Pay attention.

Anxiety can be that feeling that something has to happen now.  Now.  It is “life or death” (even if it truly isn’t).  There’s an urgency, a pressure, an unavoidable rush forward into something, anything, to get relief from the pressure.  The brain is hijacked and thinking is difficult.  Patience is next to impossible.  Blood flows to the extremities for either fight or flight, and the brain just doesn’t get enough blood flow to come up with something besides the inevitable running away, duking it out, or succumbing to some (often unhealthy) self-soothing behavior.

Relate to this?  Notice what happens the next time you don’t act on that feeling of anxiety, or craving, or whatever urgent   What if you did something else?  Or just nothing at all?  How long would it take for that urgent feeling to pass?  Maybe something else is going on – it’s not just anxiety.  Sadness?  Anger?  Frustration?  Shame? Just notice.  If it had a color, what color would it be?  If it had a temperature, what temperature would it be?  If it could hold water, how much would it hold?  If it had a shape, what shape would it be?  If it had a texture, what texture would it be?  On a scale of 0 to 1o, with 0 being completely calm or neutral, and 10 being the most intense you could imagine, where would you put that feeling right now?

And then notice if, when, it shifts.  It will.  Will it get worse?  Maybe.  Will it turn from black to red?  Maybe.  Will it move from my stomach to my chest?  Maybe.  But it will shift.  It is not a permanent, static condition.

Just notice.