16 - case study Flashcards
What are some things to note about borderline personality disorder?
- In the personality section of the DSM-5
- We don’t usually apply BPD to younger kids
- Include words with a psychodynamic origin
→ the terms aren’t always used the same way over time
→ p.ex: we used to think about psychopathology as a spectrum with neurosis (no break in reality) on one end and psychosis (break in reality, not sure what’s real and isn’t) on the other end
→ BPD is on the edge of both of these
What are the diagnostic criteria of BPD?
Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:
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 (e.g., spending, sex, substance abuse, reckless driving, binge eating)
5 - Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6 - Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7 - Chronic feelings of emptiness.
8 - Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9 - Transient, stress-related paranoid ideation or severe dissociative symptoms
Give an example of idealization and devaluation (criteria of BPD)
Idealization: “you’re the best person i’ve ever met, you could do no wrong”
Devaluation: could occur when the other person does smt unexpected or makes the individual feel slighted in some way, which leads to a big shift “you’re evil, i can’t believe you’ve done this to me”
What is an identity disturbance in BPD?
Identity disturbance: p.ex one day the person is identifying as a person who’s mainly into sports, then the next they’ve joined a religious group and that’s their main thing, but could also be about sexual orientation or gender identity, constantly changing over time
→ part of understanding who we are is knowing who we are across time and different situations, so if we’re always having different emotions in similar situations, it can be shifting and unstable
Elaborate on impulsivity, emotional instability and paranoid ideation in BPD
Impulsivity: partially about emotions, no separation between having a strong emotion and following through on the urge associated to it; all the behaviours are those that have quick and intense influences on feelings and emotions (can be effective in the short term on controlling intense affect)
Emotional instability: p.ex having many different intense emotions, not necessarily lasting for long periods, but marked by intensity (doesn’t stick around like it would in a manic episode)
Paranoid ideation: belief that people are always out to get you
What does the biosocial theory explain?
- The impact of vulnerable biology and invalidating social environments
- Similar to the diathesis-stress model
- Emotional sensitivity/reactivity (biological) + invalidating environment (social)
= pervasive emotion dysregulation
→ creates a pattern that isn’t as adaptive as we’d like it to be
→ biological: individual differences in how reactive you are to the environment and how quickly you’ll react to intense emotions triggered by the environment
→ p.ex: if faced with uncertainty, you might be quicker to react negatively than others
→ social: this is like the stress part of the d-s model
→ validation: somebody saying that your internal experience makes sense
→ invalidation: constantly getting the message that there’s smt about your internal world that is off or doesn’t make sense
→ a profoundly invalidating environment is to have been abused your entire childhood, which would undermine your sense of self
→ but also, if you’re high in sensitivity, you might also be likely to see a completely normal environment as an invalidating one
What is dialectical behaviour therapy?
- ACBT approach to address pervasive emotion dysregulation
→ it’s more behavioural than cognitive - Masha M. Linehan
- Dialectic: putting 2 opposing positions against each other
→ what often happens is we focus on only one side of a dialectic
→ Linehan found that if they’re prone to feeling invalidated (those with BPD), then it’s difficult to target trying to change smt, because if you’re trying to change smt, it can feel invalidating
→ p.ex: if your feelings are too hurt by feedback when trying to learn smt new, then there’s no possibility to learn
→ the core thought in this therapy is: you have to accept the way things are rn and the way you are rn, exactly as they are AND you have to accept that these things need to change
→ p.ex: you accept that your canoe skills aren’t good rn, but also that that needs to change
→ both halves will ring true
→ p.ex: you have to study for the exam to do well AND you have to rest to do well on the exam - Core opposites in BPD: you have to accept the way things are rn, and you have to change
What is a metaphor to explain invalidation?
- Imagine you go to watch a movie with a friend, and as you’re watching, but then as you’re breathing in, you smell smoke and tell your friend, but your friend says “i don’t think so”
- But you’re still smelling it and vocalising it, but your friend still won’t listen to you
- You look around and see a fire, and even when you tell them that there’s a fire behind you, they say they won’t turn around to look
→ this leads to more intensifying emotions, more intense maybe even violent behaviours
So when you express smt that’s internal (fire going on internally), and you’re trying to tell someone else about it, and they say “that’s not happening” it greatly intensifies the emotions - With BPD, individuals are prone to having emotional fires, and you need people to understand because the emotions are real
How can you validate the experience of someone with BPD without endorsing things that aren’t true?
- There’s a trick here: think that “it makes so much sense that you feel deep fear about the squirrel in front of you because…”
- 3 becauses
1) Because you’re afraid of them
2) Because they can go in your pants
3) Because they’re pretty fast
→ with kids for example, they might come home talking about their friend drama every day, the validating thing is to pick out the value and needs that they’re trying to fulfill
→ p.ex: “it makes sense that you’re upset about your friend group not getting along cause you know what a good friend group can be”
→ what happens after the validation is the individual can actually then problem-solve
What are some strategies a person with BPD can do at home whenever they feel an emotional fire?
- Stop drop and roll: first putting an emotional fire out either with cold or sleep; second, not making any major decisions in the next 24 - 48 hours, especially decisions that you can’t take back (not using any substances, not causing any harm); third, try to find another person or picture or pet to make eye contact with, which can help you get out of your head and distract yourself
-
Opposite action: every emotion has an action, and an opposite action (p.ex: love makes you move toward someone, jealousy makes you hold onto someone tighter, etc.)
→ so, if you’re feeling sad and want to stay in bed (action to the emotion), you have to engage in the opposite action, which is to be active
→ p.ex: opposite action of attraction would be finding the icks in someone
When is it okay to engage in an action related to an emotion?
→ if the emotion fits the fact, then it’s okay to engage in the action, but if it doesn’t fit the fact or wouldn’t achieve a goal you want to get to, (running away from a fear p.ex) then it would be best to engage in the opposite action (but also to accept the emotions as well)
What is the difference between envy and jealousy?
- If there’s proximity and similarity to someone, you’re likely to feel envy when they have smt that you don’t; this shows you what you’re valuing
- Jealousy has to do with relationships: there’s a valued relationship between 2 people and there’s a third party that seems to be threatening the relationship
→ jealousy is very common in siblings in relation to their parents
→ can be a true or false alarm (real or not real threat) which can lead to actions which aren’t always effective but are urges to the person - Opposite actions would be “in what ways am i not similar to this person” or on purpose not checking partner’s phone
What are some safe actions we can suggest to someone with BPD instead of self-distructive behaviours?
- Instead of hurting yourself, hold an ice cube in one hand and squeeze it; numbing and distracting
- Write on yourself with a red pen instead of cutting; draw exactly where you would cut; draw stitches on with a black marker
- Snap a rubber band on your wrist when you feel like hurting yourself
- Cry
What is a way for individuals with BPD to distract themselves?
- By paying attention to someone else
–> Do smt for someone else: call a friend and ask if they need help with anything or if they’re doing okay; give money to a homeless person; participate in activities to help others - Take your attention off yourself: go outside and people watch (how they dress, how they talk, count the number of buttons on their shirt; count the number of people with blue eyes)
What is the most likely situation if a 15yo comes to see you and talks about sometimes hearing things that aren’t there or voices?
- We could ask them when they hear them, where they hear them, how they’re interpreting the experience, how is it making them feel, how often would it be happening
→ with children or teens, by far the most common diagnosis would be NO diagnosis
→ BUT reporting auditory hallucinations in teens is not uncommon
What are the KSADS?
Kiddie Schedule for Affective Disorders and Schizophrenia
- This will help us get insight on what it is they’re hearing exactly
→ p.ex: you could be having an auditory hallucination and know that other people wouldn’t be able to hear it, which shows us good insight, whereas the opposite would tell us lower insight since we can’t really hear other people’s thoughts
Examining the prevalence of child auditory-verbal hallucinations in both clinical and non-clinical groups, a recent meta-analysis found rates to be between __ and __%, mostly occurring during late childhood or early adolescence.
5 - 16%
→ 16% is pretty high for endorsing hallucinations
→ but so far, the vast majority of these kids won’t go on to developing any form of psychosis (kinda like tics, they come and they pass)
What are some phenomenological characteristics of AVH we’d ask about?
- Localisation: inside the head or through the ears
- Explanation of origin: external or inside the head
- Loudness
- Controllability: how much do you feel you can control the voice
- Voices speaking in the third person
- Number of different voices
- Frequency
How could we explain procrastination?
- We often hear one explanation for procrastination and we grab onto it
- But we have to do a functional analysis for it cause it can be lots of things
- It can be due to a lack of motivation
→ emotion and motivation are linked - our feelings push us to do things
→ one thing that increases motivation is being closer to the deadline p.ex
→ so it might look like procrastination
→ the previous circumstances were such that there was no pushing motivator - Other functions of procrastination can be that if you start a task, and that it gives you a feeling of uncertainty, you might wanna put that off because starting the task could be a trigger for that feeling
→ might hold a belief that “if I can’t do this extremely well then i might as well not do it at all”
What can we say about perfectionism?
→ kind of like idealization in relationships
→ having really high standards for others
→ self-oriented perfectionism or external oriented perfectionism
→ falls into eating disorders often times
→ “if I don’t achieve this very high standard then I’ll be rejected, i won’t be good enough, etc.”
