Dialectical Behavioral Therapy

To supplement my post about borderline personality disorder (BPD), I’ll comment on a highly effective therapy developed especially for BPD. I, myself, have been through DBT and can attest to its wonderful results. DBT is a modified form of cognitive behavioral therapy (CBT). CBT focuses on addressing cognitive distortions (thoughts that assume negative reasons for a potentially neutral situation) and practicing changing the way you think about the situation. DBT focuses on accepting the way you think, but changing the way you react to the thoughts.

DBT was created by Marsha Linehan for patients with BPD, but is now used for many other disordered patients who suffer from suicidal ideation and self-harm. DBT teaches skills that a person can use to react healthily to difficult emotions.

A dialectic, in the DBT sense, can be represented as a see-saw of extremes, with a healthy center-point. For instance, two state-of-mind extremes include Emotion Mind and Rational Mind. Emotion Mind is when a person’s thoughts and actions are governed entirely by emotions. This could be good – such as when someone is in love – but it is often bad. Too much emotion can lead to inappropriate decisions, behaviors, and unhealthy thoughts.

On the other side of the see-saw, a person might be in Rational Mind. Although this sounds good (and can be good when you are performing highly rational tasks like solving puzzles), it is generally not good to think exclusively in rational mind because you miss emotional components of the situation. For instance, a person who is entirely in rational mind is unable to experience empathy or react appropriately to emotional situations (this is often a complaint made about people with Asperger’s syndrome).

You are somewhere between rational and emotional mind at all times. The middle of the see-saw is called Wise Mind. Here, you can express the right amount of emotion and rational thought to make a clear-headed decision. DBT recognizes that people are often at the extremes of this see-saw, and asks that you use “skills” to move yourself back into Wise Mind before making decisions (such as breaking up with your significant other or self-harming).

Almost every situation has a dialectic see-saw. And according to DBT, it is often best to keep yourself in the middle of the two extremes. The middle would be a compromise. Of course, sometimes compromise is the wrong decision to make (such as when you need to cut ties with an abusive relationship), but compromise is generally best.

Skills that DBT suggest are separated into categories of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Mindfulness includes: grounding yourself in a situation, for instance, recognizing where you are, what you are doing, and what is going on around you; being nonjudgmental, for instance, one of my employees assumes that when the nurses say “she is awful to work with” that they are talking about her. This is a judgmental thought. To be non-judgmental, she would have to say “well, maybe they’re not talking about me. Why am I assuming they are?”

Interpersonal effectiveness entails balancing your own needs with the needs of others, building relationships, and being in Wise Mind when approaching difficult situations.

Emotion regulation includes being mindful of what emotions you’re feeling; being aware of what you want to do – for instance isolating – and doing the opposite; doing things that make you feel good – like leisure activities – or work that makes you feel accomplished – like writing a blog post; coping ahead, for instance, if I know that I will be upset tomorrow because it’s the anniversary of my mother’s death, I can plan some distracting activities to keep myself from brooding.

Distress tolerance includes distracting yourself when you feel upset; self-soothing by taking a bath or rubbing a smooth stone; and accepting reality.

Yes, all this mindfulness stuff might sound cheesy to a lot of you, but being aware of your emotions and how you’re reacting to them is an amazing way of changing the way you behave – and changing the way you behave can eventually remove your dysfunctional thoughts, as well.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

Borderline Personality Disorder

Borderline personality disorder (BPD) is in Cluster B, but I didn’t discuss it in my Cluster B post because I think BPD deserves a post of its own. People with BPD have high impulsivity, drastic mood swings, terror of abandonment, and extremely volatile relationships. Such individuals also have self-images that vary significantly from one moment to the next.

Relationships with people with BPD can be very difficult, since these individuals have intense fear of being abandoned. They also have black-and-white thinking. Their loved ones tend to be either placed on an ivory tower or (with only small provocation) viewed a hateful, evil person. This is often seen in relationships with therapists, parents, and significant others. A person with BPD may feel an intense attachment to her therapist, to the point of crossing personal boundaries, and then feel abandoned and hateful when the therapist tries to set clearer boundaries. People with BPD often respond to environmental stimulus in extreme ways, not understanding or caring what the repercussions of their responses might be. In the example of the therapist, a patient who feels abandoned might become violent, verbally abusing the therapist or attacking her physically.

People with BPD often self-harm, and make multiple attempts at suicide. Often, the attempts at suicide can be viewed as a manipulative attempt to get attention, though sometimes the suicide is completed. (After all, the more often someone attempts, the more likely it is that completion will eventually happen.) Patients with BPD can also experience psychotic or dissociative symptoms. They might have hallucinations or paranoia.

BPD often occurs with other disorders – bipolar disorder is very common. I imagine this has a lot to do with the mood swings, impulsivity, and psychotic and dissociative symptoms. As I’ve said in previous posts, I have been diagnosed with both bipolar disorder II and BPD. I am still very skeptical of the BPD diagnosis, because all of my symptoms that fit in the BPD category can be explained by my bipolar disorder – and I don’t have the characteristic difficulty with relationships and fear of abandonment which are so strongly associated with BPD.

Another disorder that often occurs with BPD is PTSD. This is most likely because people with BPD have often gone through traumatic experiences such as sexual, physical, or emotional abuse as a child.

In order to be diagnosed with BPD, an individual must have five or more of the following traits: 1) frantic efforts to avoid real or imagined abandonment; 2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; 3) identity disturbance – markedly and persistently unstable self-image or sense of self; 4) impulsivity in at least two areas that are potentially self damaging – spending, sex, substance abuse, reckless driving, binge eating; 5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; 6) Affective instability due to a marked reactivity of mood – intense dysphoria, irritability, or anxiety; 7) chronic feelings of emptiness; 8) inappropriate, intense anger or difficulty controlling anger; 9) transient, stress-related paranoid ideation or severe dissociative symptoms.

I have a former friend who has been diagnosed with BPD. She experienced most of these symptoms. One incident that really sticks out in my mind is that when we were going on a distance drive from city-to-city, we stopped at a truck stop along the way. She went into the bathroom, and I stepped into the book shop. When she found me she was frantic – she’d thought I’d abandoned her in the middle of nowhere and that she’d have no way of getting home. At the time I didn’t understand the symptoms of BPD, and I was shocked at her attack. I mean, why on earth would I abandon her in the middle of nowhere? Especially for no reason at all? I told this story to a BPD guest speaker for our class. She laughed and said that her best friend will hop behind an aisle while shopping and she’ll freak out and think he left her. Even though he’s done this many times, she still freaks out every time.

Unfortunately I lost my friend who had BPD. As I said, at the time I didn’t understand BPD. She was having a particularly hard time with her mental illness at the same time that I was having a particularly hard time with my own. We got into fight after fight after fight. Then one day she invited me to a party. I refused – I was isolating because I was very depressed. She decided that I had decided to “friend dump” her and she friend dumped me first. I’ve made several attempts to rekindle the relationship, but it is unfortunately dead.

That brings me to a point that I think is very important. BPD is highly stigmatized in our society. It’s even highly stigmatized among mental health workers – many of whom won’t take more than one BPD patient at a time. There are people who’ll say you should never be friends with someone who had BPD. I think this stigma is tragic. Every person with BPD that I have met was a wonderful person despite their problems. By understanding the symptoms of BPD, and by talking to them about how we should respond when the affected person is in a “mood,” we can have a healthy and wonderful relationship with someone who has BPD.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 10: Personality Disorders. Abnormal Psychology, sixteenth edition (pp. 328-366). Pearson Education Inc.

Personality Disorders – Cluster B

As mentioned in my opening post about personality disorders, personality disorders are split into three clusters -A, B, and C. This post will discuss cluster B. People with these disorders tend to be dramatic, emotional, and erratic.

Patients with histrionic personality disorder are characterized by self-dramatization, over-concern with attractiveness, tendency to irritability, and temper outbursts if attention-seeking is frustrated. These patients often manipulate their partners with seductive behavior, but they are also tend to be very dependent on the partners’ attention. They are generally considered self-centered, vain, shallow, and insincere. These traits are much more commonly seen in women than in men – probably because many of the characteristics (like over-concern with appearance) tend to be “women’s traits.” In fact, some argue that histrionic personality disorder is just another form of anti-social personality disorder, which is much more prevalent in men.

In order to be diagnosed with histrionic personality disorder, the patient must have 5 or more of the following traits: 1) she is uncomfortable in situations in which she is not the center of attention; 2) her interactions with others are often characterized by inappropriate sexually seductive or provocative behaviors; 3) she displays rapidly shifting and shallow expression of emotions; 4) she consistently uses physical appearance to draw attention to herself; 5) she has a style of speech that is excessively impressionistic and lacking in detail; 6) she shows self-dramatization, theatricality, and exaggerated expression of emotion; 7) she is suggestible (i.e. easily influenced by others or circumstances); 8) she considers relationships to be more intimate than they actually are.

This is one of the personality disorders that will be dispensed with if the next DSM moves towards a dimensional model of diagnosis, as mentioned in my earlier post.

Narcissistic personality disorder is characterized by grandiosity, preoccupation with receiving attention, self-promoting, and lack of empathy. There are two types: grandiosity and vulnerable narcissism. In the former, the patient is convinced of their superiority; in the latter the patient expresses superiority defensively due to a low self-esteem. Narcissistic personality disorder is observed more often in men than in women.

In order to be diagnosed with narcissistic personality disorder, the patient must meet five or more of the following traits: 1) he has a grandiose sense of self-importance (exaggerates achievements and talents, expects to be recognized as superior); 2) he is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love; 3) he believes that he is “special” and unique and can only be understood by, or should associate with, other special people; 4) he requires excessive admiration; 5) he has a sense of entitlement; 6) he is interpersonally exploitative; 7) he lacks empathy and is unwilling to recognize or identify with the feelings or needs of others; 8) he is often envious of others or believes that others are envious of him; 9) he shows arrogant, haughty behaviors.

Now, I doubt my ex-boyfriend had a personality disorder, but he did have quite a few of these traits – possibly exacerbated by a lifetime of alcoholism which he had only recently given up when I’d met him. In fact, at one point in our relationship, he went to a neurologist to be checked for long-term side-effects of a past concussion, and he returned with a psychological assessment which said he had “narcissistic personality traits.” At the time, I had laughed it off, but later I began to see it.

This guy thought that he was incredibly smart, good looking, and absolutely amazing at his job. He was always bragging about the quality of his work; however, I saw some of his work a couple of times and found it lacking (which I didn’t say, of course). He was always talking about the future – how he had so many offers for jobs (he was unemployed) and how he’d be making well over $300,0000 a year in no time. He surrounded himself with people that he saw as superior (yes, that includes myself – he was always bragging to everyone about how smart and beautiful I was. It was rather embarrassing and over-the-top.) He also showed a surprising lack of empathy – he felt that anxiety was a sign of weakness in others, but when he had anxiety attacks he felt it was uncontrollable rather than a weakness.

Narcissistic personality disorder is one of the disorders that would be dropped if the diagnosis switched to a dimensional rather than cluster approach.

Because there is a lot of public interest in borderline personality disorder and antisocial / psychopathy, I will mention those Cluster B disorders in another post.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 10: Personality Disorders. Abnormal Psychology, sixteenth edition (pp. 328-366). Pearson Education Inc.

The Definition of Abnormal

Well, my first week of Abnormal Psychology is through. We’ve read chapters 1-2 of our textbook, Abnormal Psychology by James N Butcher.

Chapter 1 was mainly about defining “abnormal” in the sense of “abnormal psychology.” This is a lot more difficult than you might imagine.

You could try a statistical approach, for instance. If someone’s behavior is statistically rare, then that behavior is abnormal. But lots of people have behavior that is statistically rare. For instance, I went to the Minnesota Renaissance Festival just yesterday, and enjoyed some good people-watching. The Ren Fest has a variety of people – some are just pop-culture “nerds.” Some are people who love cosplay (where you dress up as a character – either made up by you or pre-created in popular culture – and act as if you are that person). And some people honestly believe they are wizards. Should we consider any of these statistically rare behaviors due to mental illness? Well, perhaps people who really believe they are wizards, but some of those people are pagans – and should we consider people of a rare religion to be mentally ill per se?

You could also try a societal norm approach. If someone behaves outside the behavioral norm, then they are abnormal. But this, in itself does not imply mental illness. Societal norms can change from culture to culture. As an example, in some tribal cultures, the men cut themselves over and over again to “beautify” themselves with scars; but in America teens who cut are generally diagnosed with depression. Norms can also change within one culture over time. For instance, a couple decades ago homosexuality was considered a mental illness, but now it is, for the most part, accepted as “normal” behavior for certain individuals.

There is also the maladaptive approach. If someone’s behavior is injurious to himself or to society, then he is abnormal. A person with OCD who washes her hands so much that they are cracked and bleeding is maladaptive. But this approach is not full-proof either. Not everyone who commits a crime is mentally ill. Likewise, should we consider someone who donates bone marrow, blood, or a kidney mentally ill?

Many people who are mentally ill suffer. But not all. The mania state of bipolar disorder is often pleasant to the patient, but he is considered mentally ill. Also, where do we draw the line of diagnosing mental illness for those who are suffering? If someone has just lost her home or a loved one, she is suffering from grief. But isn’t grief a natural and healthy response, within limits?

Another approach is irrationality and unpredictability, but teenagers and young adults often do irrational and unpredictable things for attention or just because they’re trying to impress a girl. Mental illness? Nah.

The last approach I will discuss is dangerous behavior. But yet again, that is not always indicative of mental illness. Many people jump out of planes, bungee jump, or fight in a war. These people are not considered “abnormal.”

The DSM-5 defines mental disorder as:

“a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

What the heck does that mean?

In the end, mental illness diagnoses are subjective to the clinician. For instance, I was diagnosed with bipolar disorder II. This means that I experience abnormal highs and lows (as well as other traits). I totally agree with this diagnosis. But another psychiatrist diagnosed me with borderline personality disorder. “What?!” I said. I don’t have an intense fear of abandonment, a pattern of intense interpersonal relationships characterized by alternating states of idealization and devaluation, paranoid ideation, or disassociative symptoms. Granted, I have more than 5 other traits, which makes me diagnosable with borderline. But all of those symptoms are traits that can be explained by bipolar disorder. So why the boderline personality disorder diagnosis?

What do you think? How would you define “abnormal”?

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 1: Abnormal Psychology: An Overview. Abnormal Psychology, sixteenth edition (pp. 2-27). Pearson Education Inc.