Narcissistic & Antisocial Personality in public figures: the role of mental health professionals

The norm in mental health practice has wisely been to stay out of politics for the most part, except when it comes to mental health advocacy.  

It would obviously be problematic if individual mental health experts (such as psychiatrists, psychologists, social workers, nurses, etc.) or groups representing professionals (such as specialist associations, editorial boards from journals, etc.) were to endorse or criticize political figures, with a goal to influence elections.  

But sometimes there needs to be an exception to this neutral policy.  

Mental health professionals have a great deal of experience recognizing and dealing with individuals who have behavioural and relational problems such as narcissistic and antisocial personality.  And the most valuable experience mental health professionals bring to this issue is work with patients whose partner, spouse, close friend, parent, boss, or other family member has narcissistic or antisocial traits.

Narcissistic personality traits or disorder include selfishness, self-absorption, boastfulness, need for admiration, arrogance, exploiting others, and lacking empathy.   Antisocial traits or disorder include disregard for others, frequent lying, impulsiveness and poor self-control, aggressiveness, lack of remorse, and criminal behaviours.  While we should always have an attitude of attempting to help people with these traits, it is first necessary to ensure that people with these problems are not in a position to harm others.  It is especially dangerous when a person in authority, such as a parent, boss, or political leader, has moderate or severe traits of this type.  In some ways it is comparable to allowing a small child who has behaviour problems access to a piece of dangerous machinery or weapons. 

If a patient is in a close relationship with someone having narcissistic or antisocial traits, there can be many reasons why the patient has a hard time escaping the relationship.  The relationship may be all they have known for many years.  The relationship may initially have been exciting, passionate, and positive, perhaps an escape from some other adversity, before the narcissistic and antisocial problems showed themselves.   Other people in the patient's life, including important figures such as family or church leaders, may insist or encourage that they stay.  The patient may not recognize or frame the problems in the relationship as abuse, and may instead normalize the behaviours they suffer or which they observe.  Others may be trapped in relationships of this type for economic reasons.  They may fear leaving, due to concerns not only about risk of violence, but also of social or economic isolation.  Others may experience periods of being cared for at times by their narcissistic or antisocial partner, and/or cared for by the social network which supports this relationship, despite the overall toxicity of the situation.   

Sometimes people with antisocial personality lie so often to the people around them, that everyone starts to believe the lies are actually truth, through sheer repetition.  

These factors are similar to the cognitive biases I have described in other posts -- interpersonal or group affiliations can be so strong that they keep people locked into certain choices or behaviours due to group or "status quo" loyalty, even when the experiences they are having are very harmful to themselves and others.  In such entrenched situations, people will selectively attend to data that supports the status quo, and reflexively reject information that encourages change, even if there is a very strong and compelling level of evidence.  

At present, there are important choices in global elections coming up, and a shocking proportion of people appear willing to vote for a person whose behaviour is laden with very serious and dangerous problems.  Not only are there severe narcissistic traits, shocking mean-spiritedness, and vitriolic, hateful, divisive language evident on an almost daily basis for many years, there are frank antisocial traits including criminal behaviour in multiple domains, as well as other very troubling features including an obvious lack of intellectual skills, fund of knowledge, interpersonal warmth, humour (except for mockery),  patience, balanced capacity for judgment, or intellectual curiosity.  There is often frank thought form disorder evident during orations.  Furthermore, there will be a team of other people supporting or working with this person who share similar traits, behaviours, and attitudes, in an ever more exaggerated way compared to 5-10 years ago.  

Other problems in this case include a lack of fundamental cognitive or intellectual skills, a lack of emotional self-regulation, and a lack of principles that might guide wise, effective, or compassionate decision-making.  Instead, I suspect that this person's decisions would often be guided by vindictiveness and attempted self-aggrandizement rather than the good of the country or the world.  Attachment to policies supported by particular groups, such as church groups, would only be used as a tool to advance himself.    Some individuals with narcissistic or antisocial personality can suppress or hide the narcissistic behaviours quite well, and therefore sneak into positions of power before others have a chance to detect the problems.  But in this case, there is a frank display of narcissism almost every time the person speaks, and perhaps a lack of insight or care about it.  Most disappointing and shocking to me is that there is such a large segment of the population that laps this awful behaviour up, makes excuses for it, minimizes it, or disregards it as unimportant.  

It would be quite straightforward to evaluate this person's intellectual capacity.  He is a person who boasted about passing a dementia-screening test as though he thought it was a measure of intelligence.  A simple high-school level fund of knowledge test would be interesting, even to identify places on a map of the U.S. or of the world (such as "where is Poland?" or "where is Nebraska"), or to say a little bit about the cultures or histories of different U.S. states or cities or different countries in the world.  A short quiz about how the economy works, or about even the most basic science (such as "what is gravity" or "what is electricity" or "what is the air made of") would be quite revealing.   A standarized situational judgment test, such as the Casper, often a requirement for applicants to professions requiring interaction with people as part of the work, would be really interesting in this case.   My prediction about these things is that the person in question would score a shockingly low percentile on all of these things, and if this was publicized he would as usual surely blame this somehow on the testing being unfair or stacked against him or a product of "cheating" etc.  

Another frequent egregious and alarming behaviour in this case is something I've described before:  projection.  A rhetorical tactic almost always is to use extreme language to denounce other people, or accuse them of some horrible thing, lying all the way through, yet very often the very things he is accusing others of are obvious features of his own behaviour, character, and history.  

It is especially shocking that certain groups whose personal and group culture is devoted to devout faith, moral purity, law & order, and personal freedom, would double down in their support for this person whose behaviour is in extreme contradiction to these values.   In many religious stories or scriptures, a recurring theme has to do with people of faith being misled or enamored by dark forces--there are many stories where the faithful have lost their way, figuratively or literally, but without having insight or the willingness to change until a lot of harm had been done.  These texts encourage people to humbly reflect and be willing to refocus themselves on their values.    In this case, I think many people including those with strong, honourable moral values and faith,  have very much lost their way in their support of a dangerously unfit leader who is poised to do great harm to their country and the world, in service to himself.  

Of course, it is true that unless a detailed assessment were to be done, we could not have the confidence to make a formal psychiatric diagnosis. But in the realm of narcissism and antisocial personality, most of the actual evidence for such diagnoses comes from collateral information of the patient's behaviour.  In an actual interview, particularly a single individual interview, many people with problems of this type can present themselves in a seemingly normal way (though in this particular case I think there would be many simple ways in an interview to demonstrate some of the problems unequivocally, especially intellectual weaknesses and almost cartoon-like unsuppressed narcissism).   

In any case, this situation reminds me of trying to help a patient (i.e. a large segment of the public) who is in a dangerously abusive relationship with a partner, yet who insists on staying and who might get angry or upset at the suggestion that they could or should think about leaving.  The "patient" in this case is a group numbering 40% or more of the population in certain areas.  

The role of a mental health professional with a "patient" of this type would involve compassionate and empathic exploration of the history, help with treating symptoms of pain or suffering, but also there would need to be movement towards encouraging change or leaving the relationship, warning about the risks of staying, but with a message of hope for a better, happier, more prosperous, more peaceful future after leaving.    Here, a motivational interviewing framework would be needed, since simply encouraging or pushing for change could be very counterproductive if the person does not desire this.  Other ideas for helping include tactics similar to what is described in David McRaney's book "How Minds Change."  (see my post about this book).  

One of the most compelling agents of change or healthy persuasion in this case is to emphasize the role of ingroup members who are speaking out.  In this case, there are many examples.  When an ingroup member speaks out, people are less likely to dismiss the concerns as simply being the product of political opponents.  

Another role of mental health professionals could be to discuss the issue of narcissism, antisocial behaviour, and abusive relationships in a public setting, as an educational endeavour to help people recognize and avoid such relationships in the first place, to be informed about how to get out of such a relationship safely, and to be in a position to help others.  

I have felt that the mental health community has not spoken out appropriately about the current public figure issue I have been alluding to.  I understand the principles behind the reserve, i.e. staying neutral in politics, but this is such an intensely important issue impacting individual and public well-being that something needs to be said about it.  Also, professionals, professional organizations, and editorial boards from journals need not spell out specific opinions about a particular case or a particular person, rather they could simply speak out about recognizing narcissism, antisocial behaviour, entrenched attachment to abusive relationships, the extreme dangers to well-being involved with such situations, the psychological factors preventing change, and things we can all do about it, without spelling out any particular individuals.  

I wish there could be psychiatric journals for the month of October where the issue would be devoted to a review of the research and current state of knowledge about recognizing and dealing with narcissistic and antisocial personality traits in relationships with loved ones, bosses, or community leaders.  In the absence of this, I at least encourage people to explore the issue themselves at a library or online.  

Links: 

Garth Kroeker: How Minds Change by David McRaney: a book review and discussion

Garth Kroeker: Political polarization, propaganda, conspiracy theories, misinformation, and vaccine hesitancy: a psychiatric approach to understanding and management

Parental behaviours associated with offspring personality traits

Johnson et al. have published an interesting article in the August 2011 edition of The Canadian Journal of Psychiatry (pp. 447-456) in which they describe a nice longitudinal study of 669 families, correlating parenting behaviour with future personality traits in the offspring.

To some degree, studies of this type might seem to be re-examinations of the obvious -- that is, children of friendly, gentle, stable, involved parents are more likely to be healthy and stable themselves.  The thing is, much of this effect is arguably due to heredity rather than parenting.  The genetic factors which influence temperament, mood, personality, etc. are likely to be present in both parents and children--the impact of parenting behaviours themselves are therefore likely to be overestimated.

A good method to tease out these factors would be to study  families with adopted children, provided there is good data about psychological characteristics of the birth parents.  In general studies of this sort have led to the surprising conclusion that genetic factors are quite a bit higher than expected, and parenting factors quite a bit lower.

But this particular study is quite good.  It was longitudinal, following parents and offspring  at various ages during the offspring's childhood years (ages 6, 14, and 16), then following up in the offspring's young adulthood years (ages 22 and 33).  Most importantly, the study carefully assessed parental psychological traits and symptoms, which in my opinion would help control for inherited traits confounding the results.

This article has some problems with lack of clarity in the writing.  It was not exactly clear when the interviews were done (particularly the data from when the children were 6 years old).  Also, in the tables, various items (such as "high praise and encouragement" in Table 2) are listed twice, with different numbers!  I'm surprised that the writers and editors didn't address these things before publication.  

In any case, the results show that various positive parental behaviours led to substantially reduced risk of future psychological problems in the offspring ("reduced aggregate offspring personality disorder symptoms levels" and "elevated aggregate offspring personality resiliency").  Here are a few examples (some of these things may seem like obvious truths -- but it is important to be reminded about just how important these are):
1) speaking kindly to child
2) being calm, not reactive with child
3) attention and dedication to child
4) raised child without reliance on punishment
5) lots of time spent with child
6) shared enjoyable activities with child
7) high affection toward child
8) good communication with child
9) high praise and encouragement


A few findings might be surprising to some.  For example, "encouragement of offspring autonomy" from fathers actually was associated with a higher risk of offspring psychological problems.

Studies about parenting may seem to have limited relevance to those of us who are not parents, or who are not currently being parented.  But I believe these findings can be generalized:  in a psychodynamic sense, all relationships have at least a partial "parental" quality to them.  We all also have a "parenting role" with ourselves!  This role, and the behaviours or stance we take in this role, are undoubtedly coloured by the type of parenting we have experienced in our childhoods.

Findings of this type encourage us to change our "self-parenting":

1) Speak kindly to self!
2) Be calm and not reactive to self!
3) Be attentive and dedicated with yourself!
4) Be with yourself without reliance on punishment!
5) Spend lots of time with yourself! 
6) Share enjoyable activities with yourself!
7) Have high affection toward self!
8) Communicate well with self!
9) And give self praise and encouragement!

10) If you are accustomed to "encourage autonomy in yourself" a lot, maybe you can give this one a rest.

Multi-dimensional nature of borderline personality symptom structure

Chmielewski et al. have published an article in the September 2011 edition of the Canadian Journal of Psychiatry in which they show that borderline personality is better described as having several separate symptom dimensions.

The benefit of having several dimensions instead of one could be illustrated by way of analogy:  suppose we are talking about heart disease.   One could simply describe all patients suffering a "heart attack" according to a single severity scale, perhaps including information of the amount of pain, degree of disability afterwards, etc.  This scale could be quite useful, but it would obscure a great deal of information about the group, and reduce the efficiency of treatment.   A multi-dimensional scale would instead look at several domains separately, such as perfusion abnormalities, rhythm abnormalities, and structural abnormalities.  Abnormal perfusion might be treated specifically with bypass surgery, rhythm problems with a pacemaker, and structural problems with a valve replacement etc.   Thus the management could become more meaningfully specific.

The authors of this paper about borderline personality show that a 3-factor model fit well to describe symptoms in borderline patients; a 1-dimensional model fit much more poorly.  The 3 factors are "affective dysregulation," "behavioural dysregulation," and "disturbed relations."    Affective dysregulation would refer to high intensity and lability of negative emotion, inappropriate anger, etc.   Behavioural dysregulation would refer to self-injurious behaviour, excessive or out-of-control behaviours such as binge eating, or I might add any sort of chemical or behavioural addiction.  Disturbed relations of course refers to interpersonal relationship problems.   One could see that these three domains would each influence the others, but part of a theoretical model is to consider to what degree problems in each domain could be considered primary.  (similarly, a blocked coronary artery would be a primary perfusion problem, but could in turn cause a secondary rhythm and structural problem in the heart). 

A particularly relevant remark from the authors comes in the discussion:  "...the current pattern of associations suggests that the glue that holds the BPD construct together may largely represent the general dysfunction or misery common across all forms of psychopathology and not just BPD."  So, the authors are hinting that we could perhaps do away with the BPD construct altogether, without any loss of insight,  and instead simply describe in succinct terms what the core symptoms are.  This makes sense to me.   I do believe that some of these core symptoms are extremely important to examine and address directly.  "Affective dysregulation" would be almost automatically addressed in any therapy environment, and "relationship dysfunction" is perhaps the most frequent topic of discussion (and perhaps transferential work) done in therapy.  But the "behavioural dysregulation"domain  I think is not quite so well-addressed in much therapeutic work.  I see this domain as the most common severe problem relatively more unique to those who fit into a "borderline personality" spectrum.  It is my own view to consider this domain through a type of addiction-medicine lens, as a set of problems which are highly destructive and addictive behavioural habits, often engaged in to cope with other symptoms, but which become independent problems with time.  This is similar to any other addiction;  alcoholism, for example,  may begin as alcohol consumption intended to calm nerves, deal with boredom, or to facilitate socialization, but in time becomes more and more a separate, self-contained behavioural and physiological addiction.


In my browsing through the literature as I was writing this post just now, I encountered a psychology master's thesis published online (by Edward Selby, M.Sc. 2007).  Here's a link:
http://etd.lib.fsu.edu/theses/available/etd-07092007-164107/unrestricted/SelbyMastersThesisFinal.pdf
Selby makes the case well that negative emotional cascades leading to behavioural dyregulation are strongly fuelled by rumination.  The events of behavioural dysregulation, such as self-injury, serve to distract one from the intense discomfort of rumination.  Here is a quote from the conclusion:
"the findings of this study provide preliminary evidence for an
emotional cascade model of dysregulated behavior. In this model high levels of rumination may cause extremely intense states of negative affect, which result in dysregulated behaviors that distract from rumination and reduce that state of negative affect. This study specifically linked rumination to drinking to cope, binge-eating behaviors, reassurance seeking, and urgency, and it is likely that rumination is linked to a variety of other deregulated behaviors. "

Rumination, of course, is another phenomenon common to much "general dysfunction or misery."  I am reminded how important it can be, as a practical therapeutic project with patients, to work on ways to move away from, or to let go of, rumination.  (see my previous post on rumination: http://garthkroeker.blogspot.com/2011/08/chronic-pain-rumination.html)  

Mindfulness actually works

So-called "mindfulness" techniques have been recommended in the treatment of a variety of problems, including chronic physical pain, emotional lability, anxiety, borderline personality symptoms, etc.

I do not think mindfulness training is a complete answer to any of these complex problems, but it could be an extremely valuable, essential component in therapy and growth.

I think now of a metaphor of a growing seedling, or a baby bird: these creatures require stable environments in order to grow. Internal and external environments may not always be stable, though. This instability may be caused by many internal and external biological, environmental, social, or psychological factors. In an unstable environment, growth cannot occur--it gets disrupted, uprooted, or drowned, over and over again, by painful waves of symptoms. Mindfulness techniques can be a way to deal with this type of pain, by taking away from the pain its power to disrupt, uproot, or drown. In itself it may not lead to psychological health, but it may permit a stable ground on which to start growing and building health.

Mindfulness on its own may not always stop pain, but it may lay the groundwork for an environment in which the causes of the pain may finally be dealt with and relieved. In this way mindfulness can be more a catalyst for change than a force of change.

Here is some research evidence:

http://www.ncbi.nlm.nih.gov/pubmed/1609875
http://www.ncbi.nlm.nih.gov/pubmed/7649463
This is a link to two of Kabat-Zinn's papers: the first describes the results of an 8-week mindfulness meditation course on anxiety symptoms in a cohort of 22 patients, and the second describes a 3-year follow-up on these same patients. The results show persistent, substantial reductions in all anxiety symptoms. The studies are weakened by the lack of placebo groups and randomization. But the initial cohort had quite chronic and severe anxiety symptoms (of average duration 6.8 years). Symptom scores declined by about 50%, which is very significant for chronic anxiety disorder patients, and represent a radical improvement in quality of life.

These papers suggest that mindfulness does not merely "increase acceptance of pain"--they suggest that mindfulness also leads to direct reduction of symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/3897551
This is a link to one of Kabat-Zinn's original papers showing substantial symptom improvement and quality-of-life improvement in 90 chronic pain patients who did a 10-week mindfulness meditation course.

http://www.ncbi.nlm.nih.gov/pubmed/15256293
This is a 2004 meta-analysis concluding that mindfulness training, for a variety of different syndromes of emotional or physical pain, has an average effect size of about 0.5, which strongly suggests a very significant clinical benefit. It does come from a potentially biased source, "the Freiburg Institute for Mindfulness Research." But the study itself appears to be well put-together.


http://www.ncbi.nlm.nih.gov/pubmed/17544212
This randomized, controlled 8 week study showed slight improvements in various symptoms among elderly subjects with chronic low back pain. Pain scores (i.e. quantified measures of subjective pain) did not actually change significantly. And quality of life scores didn't change very much either. So I think the results of this study should not be overstated.

I do think that 8 weeks is too short. Also the degree of "immersion" for a technique like this is likely to be an extremely important factor. I think 8 weeks of 6 hours per day would be much more effective. Or a 1-year study of 1-hour per day. Techniques such as meditation are similar to learning languages or musical skills, and these types of abilities require much more lengthy, immersive practice in order to develop.

In the meantime, I encourage people to inform themselves about mindfulness techniques, and consider reserving some time to develop mindfulness skills.

Low-dose atypical antipsychotics for treating non-psychotic anxiety or mood symptoms

Atypical antipsychotics are frequently prescribed to treat symptoms of anxiety and depression. They can be used in the treatment of generalized anxiety, panic disorder, OCD, major depressive disorder, PTSD, bipolar disorder, personality disorders, etc. At this point, such use could be considered "off-label", since the primary use of antipsychotics is treating schizophrenia or major mood disorders with psychotic features.

But there is an expanding evidence base showing that atypicals can be useful in "off-label" situations. Here is a brief review of some of the studies:

http://www.ncbi.nlm.nih.gov/pubmed/19470174
{this is a good recent study comparing low-dose risperidone -- about 0.5 mg -- with paroxetine, for treating panic disorder over 8 weeks. The risperidone group did well, with equal or better symptom relief, also possibly faster onset. But 8 weeks is very brief -- it would be important to look at results over a year or more, and to assess the possibility of withdrawal or rebound symptoms if the medication is stopped. Also is would be important to determine if the medication is synergistic with psychological therapies, or whether it could undermine psychological therapy (there is some evidence that benzodiazepines may undermine the effectiveness of psychological therapies) }

http://www.ncbi.nlm.nih.gov/pubmed/16649823
{an open study from 2006 showing significant improvements in anxiety when low doses of risperidone, of about 1 mg, were added to an antidepressant, over an 8 week trial}

http://www.ncbi.nlm.nih.gov/pubmed/18455360
{this 2008 study shows significant improvement in generalized anxiety with 12 weeks of adjunctive quetiapine. It was not "low-dose" though -- the average dose was almost 400 mg per day. There is potential bias in this study due to conflict-of-interest, also there was no adjunctive placebo group}

http://www.ncbi.nlm.nih.gov/pubmed/16889446
{in this 2006 study. patients with a borderline personality diagnosis were given quetiapine 200-400 mg daily, for a 12 week trial. As I look at the results in the article itself, I see that the most substantial improvement was in anxiety symptoms, without much change in other symptom areas. The authors state that patients with prominent impulsive or aggressive symptoms responded best}

http://www.ncbi.nlm.nih.gov/pubmed/17110817
{in this large 2006 study (the BOLDER II study), quetiapine alone was used to treat bipolar depression. Doses were 300 mg/d, 600 mg/d, or placebo. There was significant, clinically relevant improvement in the quetiapine groups, with the 300 mg group doing best. Improvements were in anxiety symptoms, depressive symptoms, suicidal ideation, sleep, and overall quality of life.}

Here's a reference to a lengthy and detailed report from the FDA about quetiapine safety when used to treat depression or anxiety:
http://www.fda.gov/ohrms/dockets/ac/09/briefing/2009-4424b2-01-FDA.pdf


In summary, I support the use of atypical antipsychotics as adjuncts for treating various symptoms including anxiety, irritability, etc. But as with any treatment (or non-treatment), there needs to be a close review of benefits vs. risks. The risks of using antipsychotics for treating anxiety are probably underestimated, because the existing studies are of such short duration. Also the benefits over long-term use are not clearly established either.

For risk data, it would be relevant to look at groups who have taken antipsychotics for long periods of time. In this group, antipsychotic use is associated with reduced mortality rates (see the following 2009 reference from Lancet: http://www.ncbi.nlm.nih.gov/pubmed/19595447, which looks at a cohort of over 60 000 schizophrenic patients, showing reduced mortality rates in those who took antipsychotics long-term, compared to those taking shorter courses of antipsychotics, or none at all--the mortality rate was most dramatically reduced in those taking clozapine. Overall, the life expectancy of schizophrenic patients was shown to have increased over a 10-year period, alongside substantial increases in atypical antipsychotic use)

It is certainly clear to me that all other treatments for anxiety (especially behavioural therapies, lifestyle changes, other forms of psychotherapy) be optimized, in an individualized way, before medication adjuncts be used.

But I recognize that suffering from anxiety or other psychiatric symptoms can be severely debilitating, can delay or obstruct progress in relationships, work, school, quality of life, etc. The risks of non-treatment should be taken very seriously. My view of the existing evidence is that adjunctive low-dose antipsychotics can have significant benefits, which can outweigh risks for many patients with non-psychotic disorders. As with any medical treatment decision, it is important for you and your physician to regularly monitor or discuss risks vs. benefits of ongoing medication therapies, and be open to discuss new evidence which is coming out.

Omega-3 Supplementation

Omega-3 fatty acids are present in a variety of foods.

The fatty acids EPA and DHA are present mainly in fish such as salmon, herring, mackerel, anchovies, and sardines. These fatty acids, especially DHA, are probably important for brain function, and are also found in the retina of the eye.

Another omega-3 fatty acid, ALA, is present from plant sources such as canola oil, flax, and walnuts. ALA may be converted in the body to DHA.

There is some evidence that there are health benefits from diets higher in omega-3 fatty acids, or diets supplemented with extra omega-3.

Of interest for psychiatry, omega-3 supplementation may be a safe adjunct in the treatment of depression. Fish oil is probably the simplest source of extra EPA and DHA.

The only problem with increasing fish consumption is the exposure to environmental contaminants such as mercury and PCBs. Fish oil capsules may actually have less of these contaminants than pure fish, especially if the oil has been refined to remove contaminants. In any case, I think the benefit-risk ratio is very favourable, and that 1-3 capsules per day of fish oil is quite safe. And I feel confident to recommend increased fish intake in the diet. For vegetarians, increased intake of walnuts, canola, and flax could be recommended.

http://www.ncbi.nlm.nih.gov/pubmed/18183532
(a review of the studies over the past decade looking at omega-3 supplements in mood disorders)

http://www.ncbi.nlm.nih.gov/pubmed/16741195
(a nice review from The American Journal of Psychiatry in 2006, summarizing epidemiological data associating low fish consumption with higher rates of mood disorder, and summarizing some of the treatment studies showing antidepressant effects of omega-3 supplements in depression, bipolar disorder, and borderline personality)

http://www.ncbi.nlm.nih.gov/pubmed/19156158
(this is a recent study showing beneficial effects of omega-3 supplements in children with bipolar symptoms;but it was not a randomized or controlled study)

http://www.ncbi.nlm.nih.gov/pubmed/19200125
(this is a recent local study analyzing fish oil supplements for environmental pollutant levels, such as PCBs. Based on this study, one should avoid supplements of products such as seal or shark oils, which have much higher contaminant levels.)

http://www.ncbi.nlm.nih.gov/pubmed/19139352
(one of the articles summarizing evidence that omega-3 intake reduces the incidence or progression of macular degeneration, which is a common cause of visual loss in those over 65 years of age).

http://www.ncbi.nlm.nih.gov/pubmed/19064523
(a huge study, published in 2006, involving data from over
40 000 people over 18 years of follow-up--it shows a slight reduction in cardiac disease associated with higher fish consumption, but no change in overall "major chronic disease risk". But, incredibly, and unfortunately, they did not include mood or other psychiatric disorders in their assessment of "chronic disease" outcomes. Yet, studies of this type exemplify that The American Journal of Clinical Nutrition is an excellent journal, a valuable and practical source of evidence-based health information which could guide nutritional choices).

Self-Injury

Self-injurious behaviour is common. Cutting skin is probably the most common specific behaviour, but there are many other varieties of self-injury.

There are different reasons why it might arise, or factors that might be motivating the behaviour.

Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.

Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.

Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.

Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).

Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.

Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.

In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:

1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.

2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.

The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.

3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).

Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.


4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.

In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.

Short Term Intensive Dynamic Psychotherapy

Here's yet another interesting therapy style.

A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.

Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.

I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.

Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):

First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.

The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).

The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.

Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.

The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.

The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.

Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.

The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.

The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.

One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!

In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.

The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.

There is a small but positive evidence base for the technique in the mainstream literature.

There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.

Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112

Reservoir Metaphor

We have "emotional reservoirs" of different types. Some supply "energy", others supply "calm", "happiness", or "well-being".

If the reservoirs are full, we may maintain our energy, calm, happiness, or well-being, even in times of stress. If there is a drought (such as a bad day or week, or other varieties of stress), we maintain a healthy state, even though there is environmental adversity.

If the reservoirs are dry, we become dependent upon the immediate environmental circumstances: there may be energy or happiness, but only if daily events are going well.

The combination of a "dry reservoir" and a "bad day" could be intense symptoms: an emotional crash, lost temper, sometimes thoughts of suicide.

Various psychiatric and medical conditions lead to a "dry reservoir" condition. Depression itself is depleting. "Personality disorders" could be understood as a "reservoir" problem in some cases. Chronic pain conditions of any sort can be depleting. And chronic environmental adversity, of course (e.g. ongoing abuse, oppression, etc.) can keep a "structurally intact" reservoir constantly dry.

To run wild with this metaphor a bit, I suppose there are different varieties of reservoir problems:
1) the "leaky reservoir" : good experiences are not internalized, noticed, or remembered
2) the "too small reservoir": only recent events (over days or weeks) determine the fullness of the reservoir
3) the "blocked reservoir" : there is an abundant inner supply of positivity, but symptoms persist, and the reservoir seems inaccessible

I suppose therapeutically, this reservoir notion could be worked on in several ways:
1) learning ways to "fill one's reservoir" on an ongoing basis -- so that one becomes less dependent on the immediate situation for well-being
2) "reservoir maintenance" : repairing leaks or blockages--there may be ways to consciously maintain, notice, hold onto, positive experience, instead of allowing it too "leak away" or be inaccessible.
3) discovering a reservoir that was always there, but that lay outside of awareness (here's a kind of psychoanalytic idea--though more about uncovering something positive rather than uncovering a hidden problem).

I intend this reservoir idea as a broad life metaphor, but there are direct analogies to be made between the "reservoir metaphor" and neurophysiology. For example, if neurotransmitter reservoirs within neurons are depleted (literally) by a drug such as reserpine, a depressed state will ensue (examples such as this are strong elements of support for neurotransmitter-based hypotheses--such as the serotonin hypothesis-- about depression). One of the problems about neuropharmacologic theory, though, is that it may focus excessively on quantities (such as "reservoir volume", or more literally, "serotonin function") while failing to attend to structure (structural change in the brain must be achieved through thoughts, actions, and relationships, not merely through changing "reservoir levels").

Antisocial Personality

Many people use the term "antisocial" in daily language to describe a feeling of not wanting to socialize, or of reclusiveness.

In DSM terminology, "antisocial personality" refers basically to a history of criminal behaviour.
So it is important to clarify what is meant by "antisocial" if it comes up in conversation.

I suppose, like all other judgmental categories characteristic of the DSM, one ought to question carefully what is considered "criminal", and whether this assessment is a product of cultural bias, prejudice, etc.

For example, a protestor advocating for civil rights in some tyrannical regime might be arrested
and labeled a criminal by some, a hero by others. These assessments might also change with the passage of time--the next generation might view the same events quite differently than we do today.

A soldier who has killed dozens of people in a battle might be considered a hero by some, a criminal by others. Depends on whose side you're on, I guess. And it depends upon one's sense of morality or fairness, regardless of whether you're on a "side" or not.

However, I do believe that there are types of behaviour, present in any population (whether the population is at peace, in a war, in states of wealth or poverty, etc.), which could be considered "antisocial".

The main "antisocial" problem in an individual that concerns me is a history of recurrent cruel or violent behaviour towards other people.

There are many other types of criminal behaviour, involving stealing, fraud, dealing drugs, etc.

And there are types of behaviour that are not "against the law", but which often accompany other antisocial problems. For example, a pattern of lying frequently in order to attain social or material goals. Or, simply, acting with no regard for, or understanding of, another person's feelings or well-being.

Once again, I suppose these phenomena need to be considered in a cultural context. If a person is lying, stealing, or engaging in forgery in order to help a persecuted person escape from a tyrannical regime, then such acts could be considered among the highest forms of altruistic heroism. Yet, for some individuals, such behaviours have been part of a daily pattern, independent of other circumstances, ever since early or middle childhood.

Another so-called antisocial trait would be a recurrent failure to take responsibility, to feel or express remorse, for actions that have caused harm to others.

Often times, antisocial behaviour has developed in childhood, and persisted through adult life. An important contributing cause is a childhood environment in which there is a lot of antisocial behaviour in the home and in the community. A history of trauma, neglect, or abuse can be risk factors. There are genetic predispositions, probably best understood by indirect influences, such as inherited tendencies towards aggressiveness, irritability, impulsiveness, difficulties perceiving or being moved by others' emotional states, etc.

Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/16291212

Antisocial behaviour has a strong subcultural influence as well, for various reasons. First of all, if a person is aggressive, they are more likely to associate with other aggressive people. In this way, violence may become more of a norm within this subculture, or even a quality to emulate or to boast about, leading to some elevation of social status within the group.

The criminal justice system deals with a lot of antisocial behaviour through the prisons. While sending a violent person to prison may protect society during the prison term, it exposes that violent person to a subcultural milieu in which all of his (or her) neighbours have also committed criminal offenses. This may perpetuate that person's "antisociality".

In psychiatric practice, I find that antisocial behaviour is very difficult to address. The main issue for me is my own feeling of safety--if the therapist does not feel safe with someone, I don't think therapy is possible.

So, I think safety is an essential prerequisite for any sort of therapy. Court-mandated therapy in a safe setting (such as a prison) may well lead to improvements in symptoms for many people with antisocial behaviour (e.g. learning about anger management, treating irritable depression, etc.). However I think that externally-mandated therapy is always likely to be very limited.

Another big problem with so-called "antisocial personality" is that this style may be what is called "ego-syntonic". That is, the individual may have no wish to "change", or have no true perception that there is any sort of "problem" with them. They may attribute their episodes of violence, etc. or their prison terms, to other people having crossed them the wrong way, or to the bad luck of having been caught. Or they may simply engage in various apparently positive social tasks motivated only by a sense of immediate material gain (e.g. they may be friendly or charming with someone only to be able to build enough trust to rob them, or sleep with them later, etc.). For ego-syntonic problems of this type, I do not think psychotherapy can be effective at all. It may in fact be just one more game that the person plays, in this case with the therapist.

There was a movie a few years ago called The Corporation (written by BC law professor Joel Bakan) which argues that corporations (big business enterprises) in our society function as antisocial individuals (the law actually considers them "persons"), and that our current system of laws actually encourages or even mandates this as a norm. A core part of this argument was based on the fact that a corporation's primary motive is maximizing profit; well-being, empathy, ecological stewardship, etc. may well be considered, but only as instruments to maximize profit, not as primary motives. This is similar to understanding the behaviour of a person with "antisocial personality" as being motivated primarily by the plan of immediate individual gain. (incidentally, I found this movie to be good, and I agree with many of its ideas, but it would have been much more effective and convincing for more people had it presented its case in a more balanced manner -- it comes off as politically very left-wing partisan, somewhat dogmatic, presents only one side of various issues, and therefore will immediately alienate and disengage others with different political views, who are likely to reflexively dismiss it, rather than accept its ideas or engage in a productive dialog).

Getting back to so-called antisocial personality, I think that if therapy is to help at all, it would have to require, first, that the therapist feels safe, and second, that the person truly wishes to work, on some level, on building a sense of care, love, and altruism for others. Otherwise therapy might be quite limited, for example to offering some help reducing subjectively bothersome irritability (help which would hopefully reduce future episodes of violence, etc.).

In terms of medical records, I do think that noting a history of antisocial behaviour is relevant, for safety reasons. Persons with a history of recurrent violence, sexual assault, stealing, etc. may pose a risk to fellow patients or staff during a hospital stay.

The other means of dealing with antisocial personality involve structures other than psychiatry. The criminal justice system is currently the main other structure. I feel that reform of the prison system could be a powerful change, since I think it is harmful for dangerous individuals to be locked up among a group of other dangerous individuals, then released again into society.

I wonder if modern technology could be one example of a practical solution for some cases: for example, if a violent person such as an assaultive husband or sexual offender, is given a restraining order forbidding access to his wife, family, or ex-girlfriend, it may be much safer for society, and especially for the wife, family, ex, etc. if the offender has some kind of electronic monitoring (using GPS technology, for example) which would immediately alert the family and the police if the offender were to violate the conditions of the restraining order (e.g. by approaching within a 1 km radius). It would permit the victims to feel safe, while doing least harm to the offender (by not exposing him to the negative environment of prison). Such a strategy could be much more effective than sending the offender to prison, since everyone would be right back to square one--or worse-- the moment after the prison term ended. I think of how many tragic episodes of violence (numerous such examples from local media alone in the past few years) could have been prevented if such a system were in place.

Borderline Personality, addendum:

I continue to feel this whole subject--of borderline personality-- is a dicey one to wade into, but I didn't want to be avoiding it either.

Part of a problem I've observed is that many extremely important and valid concerns or complaints can be dismissively pathologized as part of a "personality disorder trait".

For example, negative experiences of physicians or the hospital system need not be considered part of an individual's "pathology".

In fact, I think it is more uncommon than common for anyone to have a smooth journey through any medical care system--it tends to be laden with frustration, despite hopefully encountering some good people along the way.

Negative experiences of individual caregivers or relationships within a system need not be dismissed as so-called "splitting" (a "borderline" phenomenon)--they may be accurate and insightful accounts of having encountered a negative relationship.

The experiences may be a product of having encountered poor medical care, a poor medical system, or an unhealthy set of social structures which provide inadequate help. Sometimes an individual's complaints about these negative experiences may actually be a sign of courage, a character strength, rather than of a "borderline trait".

I think a larger view of so-called "borderline phenomena" has to do with group dynamics, as opposed to individual dynamics. If expressions of concern or frustration are met with hostile, judgmental, or inconsistent reactions, this may magnify the initial concerns or frustrations, leading to a vicious cycle. Each individual in such a dynamic may be behaving "healthily", but the relationship is not working. The relationship failure may be due to an inadequate structure, a lack of mutual understanding, communicative failure, a long history of relationship problems which biases the present point of view, tiredness or frustration on either side, or an insurmountable cultural gap. This reminds me of some of the conflicts between nations that go on today, in which each nation's "point of view" is understandable and valid, but the relationship fails, sometimes in a very destructive way, sometimes leading to an "arms race." Ironically, in psychiatry, such borderline relationship dynamics may occur involving the very individuals who are trying to be relationship mediators. My point here is that sometimes it is not the individual who has a "borderline personality disorder", but the relationship, or the system, which is suffering from "borderline dynamics".

An author on the subject of borderline personality I consider important is David Dawson. Title: Relationship Management of the Borderline Patient, Brunner/Mazel, 1993

I do find him wise and frank. He challenges some of the the professionally self-indulgent dogmas about psychotherapy, psychiatric hospitalization, and psychiatric medication, dogmas which may not apply to every situation, dogmas which may well, in some cases, aggrandize the "healing power" of the system or the therapeutic process, dogmas which deserve a generous dose of humility in order to more soundly be helpful. He describes numerous dramatic "case vignettes", with much needed attention given to the consideration of process and relationship dynamics. Many of his ideas about the vignettes I disagree with, but the book could open a forum for debate and discussion.

But-- I find his style at times too cynical and lacking in gentle warmth, to affirm it strongly. In fact, Dawson's ideas I think at times have been misapplied in the medical system, used as part of a tactic to prematurely discharge some patients from hospital or from other follow-up care. Yet, I think Dawson's views are important to hear, at least as the starting point for a debate.

Borderline Personality

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

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.