Richard working hard in Paris preparing for this podcast.

Matt preparing for the podcast and NOT being jealous of Richard.

As Richard explores Europe while teaching Mirroring Hands, Matt is on the grindstone churning out some valuable content for you. (And he’s NOT at all jealous of Richard being in Europe… not at all… really… I mean Matt’s got his internet connection and stack of books in his windowless office with a broken aircon unit in 88 degree heat – He’s got to be happy with that, or he’s just not re-framing his circumstances as he should! No, absolutely not jealous of wandering down beautiful old world Parisian streets in the late afternoon or surveying French vistas of the countryside while sipping on a local Cabernet Sauvignon and sampling the local cheese and baguettes – Nope, Matt’s not jealous of that.)

 


Notes & Links:

Our Giveaway Competition! (see below)

The Sagrada Família that Richard was talking about http://www.sagradafamilia.org/en/

BPD Definition

According to the DSM-V (American Psychiatric Association, 2013), “the essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects” (p.663). To meet the diagnostic criteria for borderline personality disorder (BPD) a person must have at least 5 of the following 9 symptoms:

  1. Frantic efforts to avoid real or imagined abandonment.
  2. Unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
  3. Identity disturbance: unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance misuse, reckless driving, binge eating).
  5. Recurrent suicidal behaviour or threats, or self-mutilating behaviour.
  6. Instability of mood and marked reactivity of mood.
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger.
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Some of the typical characteristics of Borderline Personality Disorder include:

  1. Seeing things in terms of “black-and-white”, “all-or-nothing”, often polarising their opinion of others and themselves as good or bad with little tolerance for the continuum between these extremes.
  2. Potentially self-damaging impulsivity such as gambling, spending money irresponsibly, binge eating, abuse of substances, engaging in unsafe sex, or driving recklessly.
  3. Recurrent suicidal behaviour, or threats, or self-mutilation – usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility.
  4. Efforts to avoid real or imagined abandonment with intense abandonment fears and exaggerated emotions (such as anger) when faced with separation or unavoidable changes in plans.
  5. Intense anger or difficulty controlling anger, sarcasm, enduring bitterness, or verbal outbursts associated with feelings of abandonment, often followed by shame and guilt and reinforcing the feeling of being bad or evil.
  6. A feeling of impending separation or rejection leading to profound changes in self-image, affect, cognition, and behaviour – often interpreting perceived abandonment as validation that they are ‘bad’ or ‘evil’.
  7. Hypersensitivity to environmental (especially social) circumstances and resorting to impulsive actions such as self-mutilating or suicidal behaviours to cope.
  8. A pattern of unstable and intense relationships, with the propensity to oscillate between idealizing other people to devaluing them.
  9. Can have sudden and dramatic shifts in their opinion of others, who may alternately be seen as beneficent supports or as cruelly punitive.
  10. An unstable self-image or sense of self marked by sudden and dramatic shifts in self-image, characterized by shifting goals, values, aspirations, sudden changes in opinions and plans about career, sexual identity, values, and types of friends. Often self-image is based on being evil or bad, they can have a feeling that they do not exist at all.
  11. Sudden change from the role of a needy supplicant for help to a righteous avenger of past mistreatment.
  12. Emotional instability that is due to a marked reactivity of mood that reflect an extreme reactivity to interpersonal stresses.
  13. Feelings of emptiness, easily bored, may constantly be looking for something to do.

Dialectical behavior therapy (DBT) books:

DBT Skills Training Manual

Doing Dialectical Behaviour Therapy: A practical guide

Workbook for those living with a BPD loved one.

The Stop Walking on Eggshells Workbook

DDP

Dynamic Deconstructive Psychotherapy (DDP)

Professor Robert Gregory’s  Emotion Processing Hypothesis.

  1. The Emotion Processing Hypothesis postulates that BPD is a disorder of emotion processing, rather than emotion regulation.
  2. Due to interpersonal stress, BPD does not have the normal processing of emotion that is lateral to medial movement of information through the prefrontal cortex (PFC) and integration with cortical and subcortical networks.
  3. BPD demonstrates less activation of PFC and greater limbic system activation (ventral striatum, amygdala) and less integration of cortical and subcortical networks.
  4. BPD may process emotional experiences through subcortical limbic systems rather than then usual verbal/symbolic processing through lateral to medial flow of information through the temporal lobe and PFC.
  5. Emotional processing regions such as the amygdala, hippocampus, anterior cingulate gyrus and medial prefrontal cortex have shown to be in deficit in BPD.
  6. BPD display greater activation of limbic structures (amygdala, hippocampus, ventral striatum) when responding to emotional stimuli.
  7. Deactivation of anterior cingulate gyrus and the medial prefrontal cortex when exposed to strong emotional stimuli, as well as decoupling of limbic and cortical networks – resulting in a difficulty to encode emotional experience into language and identifying, labelling and acknowledging emotions.
  8. BPD have reportedly low levels of endogenous opioids and are less able to turn off the PANIC system, described by Panksepp, when hyperaroused by emotional stimuli. To alleviate the PANIC system BPD may use self-destructive or hostile actions, or self-soothing coping mechanisms to activate their ventral stratal region (the PLEASURE system according to Panksepp).
  9. In summary, people with BPD utilise limbic solutions to interpersonal problems.
  10. More severe cases of BPD may not only have emotion processing network deficits but diminished baseline tonic activity in certain brain regions.

Now if you want to know more about DDP Upstate University have a wealth of resources on their website including a training manual, work sheets and even training videos. I’d encourage you to check it out and I’ll leave the link in the show notes.  http://www.upstate.edu/psych/education/psychotherapy/dynamic_decon.php

Conversational Model

Conversational Model (CM) was developed by Robert Hobson and expanded by Russell Meares. The therapy aims to develop the client’s sense of self through a form of conversational relating. Such therapeutic relatedness helps the client develop the capacity to embody what is described as “aloneness-togetherness”. The development of such a dialectic gives the BPD client a unique sense of personal being that was formally deficient and at the root of much of the borderline pathology. The manualised form of CM is psychodynamic interpersonal therapy.

The research around the conversational model focuses on a fragmentation of a sense of self and more specifically a difference in the brain patterns of the attention and default mode networks, which it seems leads to a fragmentation of self. Now the best book I have to explain what’s going on here is called “A Dissociation Model of Borderline Personality Disorder” by Russell Meares (and I’ll put a link in the show notes) – it’s a very readable book and he has an accompanying clinicians manual called “Borderline Personality Disorder and the Conversational Model”. I wouldn’t be able to cover all the details in these books, but again, to get an appreciation of why a BPD client behaves the way they do, it’s helpful to keep in mind the network fragmentation that could be going on that manifests as a fragmentation of their emotional selves.

So one of the big ideas here is a lack of cohesion in the experience of self due to a disconnectedness between brain networks. One of the observations that confirmed such a disconnectedness involved analysing electrical patterns evoked in the brain – something called an event-related potential, and observing a major spike in activity 300 milliseconds after the presentation of a stimulus. This activity, called P3 is a major part of attention processing and is the summation of the activity of two generators that combine in syncronisation to produce the one waveform or single output. Well in BPD the two generators don’t function together – they are out of sync, and rather than 1 wave there’s two waves present in an EEG readout. One of theses P3 component relies on prefrontal circuitry for attention (which also overlaps emotional processing) and a connection to this right side of this network — to the orbitofrontal networks — is not happening in synchrony as it should. It’s possible that a failure in this connectedness or syncronisation can lead to a disruption in the development of self.

There is also evidence that this lack of P3 syncronisation is association with dissociation and may contribute to the fragmentation of a sense of self experienced in BPD. Here Russell Mears talks about the default mode network, which Richard and I have talked about in the past on the show, and how the fragmentation of a sense of self may be seen as a disturbance of the usual pattern of the default mode network. So when the DMN is on (in other words when there is no task-orientated activity happening) the hypothesis is that a fragmentation of the usual connections in the DMN fragments a sense of self in BPD.

A Dissociation Model of Borderline Personality Disorder

Borderline Personality Disorder and the Conversational Model

Mentalization Therapy (MBT)

Handbook of Mentalizing in Mental Health Practice

2 Studies:

The centrality of affective instability and identity in Borderline Personality Disorder: Evidence from network analysis: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0186695

Abstract: We argue that the series of traits characterizing Borderline Personality Disorder samples do not weigh equally. In this regard, we believe that network approaches employed recently in Personality and Psychopathology research to provide information about the differential relationships among symptoms would be useful to test our claim. To our knowledge, this approach has never been applied to personality disorders. We applied network analysis to the nine Borderline Personality Disorder traits to explore their relationships in two samples drawn from university students and clinical populations (N = 1317 and N = 96, respectively). We used the Fused Graphical Lasso, a technique that allows estimating networks from different populations separately while considering their similarities and differences. Moreover, we examined centrality indices to determine the relative importance of each symptom in each network. The general structure of the two networks was very similar in the two samples, although some differences were detected. Results indicate the centrality of mainly affective instability, identity, and effort to avoid abandonment aspects in Borderline Personality Disorder. Results are consistent with the new DSM Alternative Model for Personality Disorders. We discuss them in terms of implications for therapy.

Abnormalities in gray matter volume in patients with borderline personality disorder and their relation to lifetime depression: A VBM study: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191946
Abstract
Background: Structural imaging studies of borderline personality disorder (BPD) have found regions of reduced cortical volume, but these have varied considerably across studies. Reduced hippocampus and amygdala volume have also been a regular finding in studies using conventional volumetric measurement. How far comorbid major depression, which is common in BPD and can also affect in brain structure, influences the findings is not clear.

Conclusions: According to this study, BPD is characterized by a restricted pattern of cortical volume reduction involving the dorsolateral frontal cortex and the medial frontal cortex, both areas of potential relevance for the clinical features of the disorder. Previous findings concerning reduced hippocampus and amygdala volume in the disorder are not supported. Brain structural findings in BPD do not appear to be explainable on the basis of history of associated lifetime major depression.

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