There are many patients I have seen who have had some mixture of the following symptoms or experiences:
1) sudden, intense shifts of mood, often towards extreme sadness, emptiness, or rage. Often times, these sudden shifts occur in the context of a relationship event (a disappointment with someone, a conflictual conversation, a breakup, etc.)
2) very chaotic interpersonal relationships -- lots of conflict, sometimes a lot of aggression, sometimes frequent break-ups, reconciliations, break-ups, reconciliations, etc. Sometimes this is a product of the person having chosen a partner with a chaotic relationship style, but sometimes this relationship chaos occurs even with a partner who is calm
3) prominent, longstanding thoughts about suicide, even when mood is better
4) frequent self-injurious behaviour (most frequently, cutting skin with a razor), which is often done to relieve extreme emotional tension. Sometimes self-injury or suicide attempts occur as a form of non-verbal interpersonal communication or protest.
5) prominent, longstanding self-hatred
6) symptoms which "seem psychotic", such as hallucinations, paranoia, or thought disorganization of various types, but which do not have the characteristic qualities or patterns found in psychotic illness such as schizophrenia
7) pronounced confusion about identity, often with respect to gender, sexuality, or "sense of self"
8) difficulty with relationship boundaries
9) a chaotic and often very negative set of experiences with doctors, the health care system, etc.
10) hospital stays in which symptoms got worse rather than better
I have seen many for whom these symptoms were their manifestation of depression, or part of a type of bipolar disorder, and for whom these issues improved following standard treatments for mood disorder.
For others, some of these symptoms are part of a post-traumatic syndrome.
I have seen many others for whom these symptoms seemed to be part of a developmental struggle, arising with adolescence or earlier, and resolving with time, support, work, development of purpose, meaning, community, autonomy, etc. Often a fairly short-term experience of therapy has helped.
For others, these symptoms become more lasting phenomena, and may in fact become more and more entrenched with time. It is as though the person has a chaotic relationship with time itself, which feeds the symptoms, rather than relieving them.
Some of the symptoms, such as self-injury, seem to have strong addictive components. Other types of addictive behaviours (such as substance abuse) are common in this population as well.
For many of my patients, there is so much overlap between "depression" and so-called "borderline personality traits" that I don't find that there is much point being concerned with "labeling" at all, since the same things help with both.
Here are some things that I have found to be helpful in all cases (in addition my standard advice about a healthy, happy lifestyle):
1) gentle, supportive, compassionate, friendly, consistent care in a setting with clear but non-rigid boundaries
2) treatment of specific symptoms pharmacologically (e.g. antidepressants may help with mood; anticonvulsants or antipsychotics may help with anxiety, irritability, insomnia, and lability; stimulants may help with inattention, hyperactivity, or distractability)
3) avoidance of harm (e.g. I would tend to avoid prescribing potentially addictive medications, or medications that are particularly dangerous in overdose; also some types of overly confrontational, reactive, over-medicalized, suggestive, dogmatic, or "digging into the past" styles of psychotherapy can probably be overtly harmful for some people, especially if the therapy style is engaged in without the patient's full understanding or consent).
4) gentle attention to the same kind of dynamics happening in the therapy as what happens in other relationships (e.g. intense conflicts, feelings of abandonment, "chaos"), and an attempt to gently work it out rather than let the symptoms threaten the relationship
5) cognitive-therapy techniques of various types can be particularly helpful; specifically Linehan's "Dialectical Behavioural Therapy" which is a type of cognitive therapy enriched by ideas from Buddhist mindfulness. Also Linehan's ideas emphasize the idea of "validation" which I consider extremely important -- symptoms need to be calmly understood, empathized with, rather than discounted or dismissed
6) long-term dynamically-oriented psychotherapy, 1-on-1 or group (or both). There is an expanding strong evidence base that this helps a lot
7) trying neither to over-react (e.g. push for an immediate hospital visit), nor to under-react (e.g. ignore or dismiss), regarding suicidal thoughts or self-injury; but to try to be understanding and helpful in any case
8) I do not tend to recommend hospitalization, especially through an emergency admission, as a cornerstone of therapy, except I do encourage people to use the emergency rooms if they cannot survive safely through the day and they do not feel they have other resources available. I believe it is much more therapeutic for people to choose themselves whether or not to use the emergency room.
9) a good day-program, if available, can be very helpful. These are harder to find nowadays
A few references:
http://www.ncbi.nlm.nih.gov/pubmed/16437534
(a Cochrane review of psychotherapy for borderline personality)
http://www.ncbi.nlm.nih.gov/pubmed/16437535
(a Cochrane review of medication for borderline personality; this shows, as I would expect, a modest and inconsistent evidence base, which I think supports the idea of being open-minded about using pharmacological therapies, but perhaps of having modest expectations of them, and being wary of relying too heavily on medication treatments alone)
http://www.ncbi.nlm.nih.gov/pubmed/17541052
(a randomized study showing broad, large effects from psychotherapy in patients having a borderline personality diagnosis, over a 1-year period)
http://www.ncbi.nlm.nih.gov/pubmed/18347003
(a study with an 8 year follow-up! --we need more such very long-term studies-- It shows that an intensive day program approach was very helpful)
http://www.ncbi.nlm.nih.gov/pubmed/17427099
(another longer-term study showing substantial benefits from psychotherapy)
It is important to note that many with so-called "borderline personality" may have depression or other problems at the same time, and each of these problems may improve with specific types of therapy. Many studies are not considering these "comorbid" conditions, and therefore underestimate the effectiveness of various types of therapy.
Here is a link to a dialectical-behavior therapy self-help site:
http://www.dbtselfhelp.com/index.html
Wednesday, January 7, 2009
Personality Disorders
The area of personality disorders is a sensitive one. Many people find this type of diagnostic labeling pejorative, judgmental, or insulting. And there are examples I have seen where professionals have applied such labels to patients in a pejorative, judgmental, or insulting manner.
Some of the professional literature on this subject is almost impossibly pedantic or arcane.
Yet on the other hand, personality disorder categories do describe the experiences of life many people have been through, or are continuing to go through.
Some of my patients readily accept the idea of having a "personality disorder", and have worked earnestly and successfully with their symptoms, using this type of diagnostic framework.
I am cautious myself about using "personality disorder" terminology. Yet I acknowledge that sometimes understanding, and speaking frankly about, these issues, permits opportunities for things to get better more efficiently and quickly.
In general I would say that "personality disorders" could be understood as collections of chronic symptoms and behaviours which have had strong, recurrent, entrenched feedback cycles involving a person's experience of relationships with other people, with society, with work, and with lifestyle. The intersection of symptoms with these relationships tends to lead to negative results, then tends to perpetuate the pattern. And this dynamic persists irrespective of whether there are prominent mood or anxiety symptoms.
In chronic psychological conditions of any type, whether it be depression, anxiety, psychosis, etc., there are similar intersections between symptoms and relationships, but my sense of the dynamic in personality disorders is that the relationship and lifestyle disruption persists independent of other psychological symptoms.
In some cases, chronic primary symptoms such as anxiety, depression, irritability, or mood lability, could cause "personality disorders" to arise, particularly if such symptoms have been present since early childhood.
Another frequently-observed or theorized cause for "personality disorder" phenomena is childhood adversity or trauma. The adversities or traumas may differ, but in most cases recurrent or ongoing trauma is most strongly associated. Different types of adversity may affect people with different inherited temperaments in different ways -- the same type of trauma may severely affect one person, while causing few lasting symptoms in another.
It is clear that, just as with most any other set of psychiatric symptoms or diagnoses, there is a significant inherited predisposition to have a "personality disorder" diagnosis. Heritability estimates are typically in the 40-50% range. To some degree these types of findings have always seemed obvious to me, it confirms that most anything that happens in life is jointly a product of genes and environment, and the proportional split of causality is often about 50/50.
Advancing understanding of this issue has led to a conceptual shift: "personality disorders" need not be considered lifelong ailments or "defects of character". It is clear that all types of psychological symptoms may change or improve with time, under the right conditions.
There are numerous categories of "personality disorder" as described in the DSM-IV and other diagnostic schemes, and in future posts I would like to discuss each of them in turn. Also there are different theoretical schemes about what "personality" even means--and I think the best research in this area shows that personality itself is better-described using categories quite different from those in the DSM-IV. Yet, I find the DSM-IV categories do describe a common variety of problems and experiences which many of my patients have been through, and so I do think that they have relevance and validity.
Some of the professional literature on this subject is almost impossibly pedantic or arcane.
Yet on the other hand, personality disorder categories do describe the experiences of life many people have been through, or are continuing to go through.
Some of my patients readily accept the idea of having a "personality disorder", and have worked earnestly and successfully with their symptoms, using this type of diagnostic framework.
I am cautious myself about using "personality disorder" terminology. Yet I acknowledge that sometimes understanding, and speaking frankly about, these issues, permits opportunities for things to get better more efficiently and quickly.
In general I would say that "personality disorders" could be understood as collections of chronic symptoms and behaviours which have had strong, recurrent, entrenched feedback cycles involving a person's experience of relationships with other people, with society, with work, and with lifestyle. The intersection of symptoms with these relationships tends to lead to negative results, then tends to perpetuate the pattern. And this dynamic persists irrespective of whether there are prominent mood or anxiety symptoms.
In chronic psychological conditions of any type, whether it be depression, anxiety, psychosis, etc., there are similar intersections between symptoms and relationships, but my sense of the dynamic in personality disorders is that the relationship and lifestyle disruption persists independent of other psychological symptoms.
In some cases, chronic primary symptoms such as anxiety, depression, irritability, or mood lability, could cause "personality disorders" to arise, particularly if such symptoms have been present since early childhood.
Another frequently-observed or theorized cause for "personality disorder" phenomena is childhood adversity or trauma. The adversities or traumas may differ, but in most cases recurrent or ongoing trauma is most strongly associated. Different types of adversity may affect people with different inherited temperaments in different ways -- the same type of trauma may severely affect one person, while causing few lasting symptoms in another.
It is clear that, just as with most any other set of psychiatric symptoms or diagnoses, there is a significant inherited predisposition to have a "personality disorder" diagnosis. Heritability estimates are typically in the 40-50% range. To some degree these types of findings have always seemed obvious to me, it confirms that most anything that happens in life is jointly a product of genes and environment, and the proportional split of causality is often about 50/50.
Advancing understanding of this issue has led to a conceptual shift: "personality disorders" need not be considered lifelong ailments or "defects of character". It is clear that all types of psychological symptoms may change or improve with time, under the right conditions.
There are numerous categories of "personality disorder" as described in the DSM-IV and other diagnostic schemes, and in future posts I would like to discuss each of them in turn. Also there are different theoretical schemes about what "personality" even means--and I think the best research in this area shows that personality itself is better-described using categories quite different from those in the DSM-IV. Yet, I find the DSM-IV categories do describe a common variety of problems and experiences which many of my patients have been through, and so I do think that they have relevance and validity.
Monday, January 5, 2009
Transcendental Meditation for ADHD
Today I encountered an interesting article in the journal
Current Issues in Education, Volume 10, No. 2, 2008
It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.
Some of the authors appear to have good backgrounds in research and scholarship.
Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.
The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).
But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.
And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.
Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.
I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.
Current Issues in Education, Volume 10, No. 2, 2008
It is about teaching a meditation technique ("transcendental meditation") to children with ADHD, and measuring changes in their symptoms over time. The study shows a significant beneficial effect in numerous symptom clusters, including anxiety and mood.
Some of the authors appear to have good backgrounds in research and scholarship.
Looking up a different author, and checking out some of the other stuff on the internet about TM made me concerned about the level of religious dogma in this area, bolstered by numerous claims (many of which I think are overvalued) about "scientific evidence", also with many claims about TM being part of something morally advanced, yet I note various registered trademarks among the jargon used, together with an insistence that one has to learn the technique from a specially-trained instructor, and an insistence that one cannot learn the technique in other ways. One would think that a purely altruistic set of motives would lead to such ideas being shared more freely and humbly.
The study is substantially weakened by the fact that there is no "placebo control group", hence the findings likely exaggerate the specific benefit of TM (it may be possible, for example, that any other quiet technique taught to children for 10 minutes twice a day, might have led to symptom improvements).
But it is my hunch that meditative techniques can be helpful to improve contentment, and to reduce negative symptoms, for many people. Also, I do agree with the authors' point in this article, that there are different types of meditation, and that some types suit people better than others. Some of my patients have tried meditating, and found it unhelpful. It may be worthwhile in these cases to give a different style of meditating a try. TM apparently does not aim for "mental control"--and therefore it may be more suited for people whose minds and thoughts are hard to "control". "Control" as a meditative goal may just lead to frustration.
And I do--with some reservation--agree that having a meditation teacher or class may be necessary to learn the technique optimally, just like learning to swim or play the violin may require a teacher or class. Yet, I think it is fair to make use of other resources, including books and the internet. I am always wary of salesmanship or charlatanism in these areas, where people are charging a substantial fee while using various elements of persuasion to get you to sign up for something.
Another big area in meditation for treating psychiatric or medical problems is so-called "mindfulness-based meditation". There is an accumulating evidence base for this, and I encourage people to learn more about it. Interestingly, one of the pioneers in using these techniques in medicine first used it for successfully treating chronic physical pain.
I will be on the lookout for other pieces of objective evidence on this issue, as I find meditation interesting, probably beneficial, and at least harmless, provided the practice doesn't lead someone to be swept into some kind of cult-like subculture. I would agree with the statement that if everyone quietly meditated daily in some way, we would probably have a fair bit less violence and conflict in the world.
Wednesday, December 17, 2008
Social Learning Therapy
Here's another style of therapy probably under-utilized:
This is based on Bandura's work on social learning theory and self-efficacy.
The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).
A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.
For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.
If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.
I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.
Here are a few links to some sites dealing with Bandura's theories:
http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
http://www.des.emory.edu/mfp/bandurabio.html
(a nice biographical sketch of Bandura and his ideas)
An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.
I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):
http://www.mentalhealth.tv/index.php?mod=page&page=Home
This is based on Bandura's work on social learning theory and self-efficacy.
The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).
A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.
For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.
If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.
I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.
Here are a few links to some sites dealing with Bandura's theories:
http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
http://www.des.emory.edu/mfp/bandurabio.html
(a nice biographical sketch of Bandura and his ideas)
An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.
I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):
http://www.mentalhealth.tv/index.php?mod=page&page=Home
Relaxation Training
Here's another example of a therapy style that is probably under-emphasized.
Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/18843744
As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.
Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.
There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.
The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.
Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/18843744
As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.
Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.
There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.
The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.
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