Thursday, January 25, 2007

Sushi Pillows, Door, and Borderline Personality Disorder

While reading Neil Gaiman's latest blog post, I discovered Sushi Pillows! These are so cool that I think I may treat myself to a couple. They sell pillows shaped like sushi rolls, nigiri, and edamame. How cool. They all look and sound like they're great quality and they are apparently hand painted. So though they are a little bit pricey, they seem well worth it. And come on, where else are you ever going to find something like this.

I've started watching Neil Gaiman's Neverwhere. It is a miniseries that was written by Neil before he wrote the book and aired on A&E. I watched episode number 1 entitled "door". My first impression from the beginning was that it was going to be pretty bad. The quality of the film is just not what one is used to and it looks sort of low budget. Get past all that though, and it's not half bad. In fact, it's quite good. Though I'm glad I read the book first. Certain parts so far look like what I thought they would and certain parts do not. I love the actor that plays Richard Mayhew. He's quite good so far. Door is interesting, though the actress that plays her seems to overact a little bit. Croup and Vandemar are EXACTLY what I pictured and every bit as disgusting and sleazy as they seemed in the book. The Marquis de Carabas looked nothing like I pictured him and also overacts a little bit, although this is suiting to his character. I might have totally missed this in the book, but I always pictured the Marquis as an old white man, and in the show he is a young black man. Interesting, but it works. The storyline is exactly as the book so far, which is very cool. I can't wait to see what the angel looks like...his name slips my mind right now...Islington? maybe...I had a very vivid image of him while reading the book and I'm looking forward to seeing how that image translates on screen. A more thorough review to come as I finish the series.

Finally, I had my first experience with borderline personality disorder today. um...very interesting. I encountered said patient in a family session today and this person just broke during the session. I've never seen anybody snap like that. I feel kind of guilty for saying this, but I was just fascinated by it. At the same time, I felt horrible for the kid. I'd like to know a little bit more about Borderline personality disorder though, so I was wondering if anyone in the field *cough* Carl *cough* could recommend a good book on the subject. There are lots out there, just wondering if someone could point me to one of the many. My library's going to grow ridiculously with this internship. I can see it now.

Oh one other thing. While surfing through my daily reads in blog land, I found a great post about book covers and their appeals or lack their of over on Quixotic's blog along with a wonderful review of Pan's Labyrinth on Carl V.'s blog. I can't wait to see that movie!


Literacy-chic said...

Sushi pillows!! Aaaaaaah!!!!! :D

Quixotic said...

Sushi pillows do look quite fun!

I love the Neverwhere series, and remember when it was on TV originally. I had to buy it from the US on DVD recently, which bugged me immensely. Croup and Vandemar are absolutely brilliant.

Just Me said...

What would you like to know about borderline personality disorder, and what makes you think this young woman had the disorder?

My experience (and guess about what happened) is that the woman was in a situation that was stressful to begin with. Being emotionally sensitive and subject to dysregulation, she was probably triggered by something someone said, a look she got, something someone said 4 minutes before. She held it together as long as possible, but then the dysregulation took over.

For me, dysregulation is a visceral thing. It starts with a tingling in my toes, crawls up my body and churns in my stomach, grips my heart and then pounds into my head. It happens in a flash and (for me) turns into instant anger. If I do a chain analysis of the precipitating factors, I can almost always track it back to shame, or fear of being exposed (which is also shame).

If it's true she has BPD, it would be important to at least try to figure out the precipitating factors. Hard to do in many cases because many believe it may have something to do with a separation from the mother in very early childhood development. An actual or perceived separation. (An ill mother gone to a hospital for an extended period; a depressed mother "absent" though she is there; a drug-using mother not capable of being there; an untrained or incompetent mother who is there but doesn't know how important it is to really BE there; a mother with too many kids who inadvertently ignores the kid.)

When this separation is combined with a genetic predisposition to being overly sensitive, it is thought to produce a sense of terror that eventually leads to symptoms like those of BPD. A sibling in the same house with the same factors may not develop BPD because the sibling doesn't have the genetic predisposition.

Those are the theories, anyway. There are others, including that a traumatic event such as sexual abuse, a horrible car accident or other physical event (witnessing a horrible event, abuse of a parent, etc.) may cause PTSD-like symptoms that mirror those of BPD. Some theorize that BPD is just unrecognized PTSD.

Given the prevalence of finding long-term, ritualized and/or brutal/violent sexual abuse to be at the root of some BPD, it is certainly a possibility that your patient was in the room with her abuser in family therapy at the time of her "outburst." That's a scary possibility, but something worth thinking about.

Anyway, I want you to be really careful about what books you choose to read. Some are extremely pejorative. I think the Bible is probably Marsha Linehan's Cognitive-Behavioral Treatment of Borderline Personality Disorder. It's a very hands-on treatment-oriented book, but also has tremendous insight into the disorder.

Please let me know if you'd like to know more about this devastating, horrible, painful and troubling disorder. About the only good thing about the diagnosis is that it is one of the few that has a proven cure. With enough time, commitment, help from a qualified and committed therapist (working in an unusually attached mode) and the right therapeutic constructs, I've certainly been able to short-circuit dysregulation, to put some padding in my 'emotional bank' so hits on it don't necessarily lead to being overdrawn. I know some emotional regulation skills, have new interpersonal relationship skills and -- most of all -- am highly aware that much of my interaction with others is colored by my tendency to feel unwanted and unaccepted. I hear criticism where there is none intended, and if I factor that in, I am much happier.

Anyone who likes sushi pillows would probably make a good dialectical behavioral therapist. Whimsy is certainly part of it all.

Chris said...

Hi Just Me, Thank you so much for your response!

My client is a male and was in the room with his parents when the outburst occured. He has a very real sense of being rejected by his parents. In my opinion, the parents are very distant and send him from institution to institution, but that is because he attempts suicide every time he comes home. He's a really tough case. He says that he doesn't have a problem, yet stated in a letter very clearly his intent of suicide.

He seems to be very destructive in relationships. He's attaches quickly and then feels rejected. I know I shouldn't pick favorites, but he is one of my favorites on the unit. It's just very frustrating, because though he admits he is suicidal, he says that people need to leave him alone. In the family session, he was incapable of talking to his parents without yelling and cursing at them.

I was told by the doctor that he has BPD, but it's not written on a form because he said that insurance tends to not pay for people with BPD. That's really sad. I think they actually gave him a diagnosis of mood disorder NOS for insurance purposes.

I'd just like to know more about the disorder in general and will definitely check out Martha Linehan's book. I was so happy to hear you say there is a proven cure, because I was told by the social worker that there is not, though DBT has worked well in some cases.

Thanks again for taking the time to write this. I'm an intern at this hospital and it's only my second week. I've been studying these disorders for awhile now, and it's interesting to now be able to see them manifest. Thanks again,


Just Me said...

Well, as you probably realize or have been told, the suicide threats are real enough to take very seriously.

However, and you know I'm not a professional anything ... just my own opinion here ...

In my experience, I make threats about hurting myself when, well, when I'm hurting. I want to be able to tell people HOW MUCH it hurts. Sometimes my emotions swing so out of whack that my god, no one could ever have ever felt this bad, this hopeless, this useless, this awful. Ever. There is no solution for this kind of pain, and while I'm in this pain is the wrong time to be seeking solutions (right? because my mind tells me the only solution is to blot it out, make it stop by stopping my life. I'm clearly not rational in that state, so I shouldn't be expected to reason.)

So, talking with a suicidal patient at that point, reasoning with him about all he's got to live for, the 10 things he'd miss if he were dead ... all of this falls on deaf ears. In fact, all of this is so invalidating that it has the opposite effect of helping.

"Here I am in so much pain, so hurting that all I can think of is sweet, sweet sleep of death and he wants to talk about how I'll miss my friends? What the fuck?"

In other words, it's invalidating to try to talk him out of it.

My therapist's approach is this:

I'm sorry you are hurting so much.
Yes, I can see how much you are hurting.

You know, other people have been through what you are going through and have survived it. (This one really pisses me off, I want to think my pain is worse than anyone elses', but on the other hand, it does get through on some level.)

So what are you going to do? (I guess trying to assess if I have a plan.)

So you're just going to drive over to the coast right after leaving here? Who's going to pick up your son at daycare? (Using practical things vs. 'your little son will miss you so much!') (Then I have to go into, well I guess I could get him and take him home and THEN leave to go do it.)

So who's going to watch him when you leave?

Anyway. And then there's the part about "I would be pissed off at you if you killed yourself. It would really hurt. You are someone important in my life, and if you did that to yourself I would just hurt so much."

I think the threats are to get comfort. I think rewarding my threats with comfort simply conditions me to make them more.

However, rewarding my threats with validation of my pain (vs. "oh you poor little thing you must be so sad, the world sucks to treat you so bad, I will take care of you!") and frank discussion of the issues can take me far away from it.

And as we talk about practicalities, my heart rate slows, my nose dries, my tears slow, my emotions come back into regulation.

He can do this on the phone for me, too. He helps me re-regulate my emotions until I realize I don't want to hurt myself.

He will attach to you quickly if you are there for him. However, if you are rotating in and then will leave in a matter of weeks, you MUST TELL HIM THAT up front. "I have three weeks on this unit, and I want to be here for you as much as I can for three weeks, but I want you to know that when that is up I will be leaving because of my schedule -- not because of anything we talk about between now and then, not because of anything you say or don't say."

You have to get him clear on that or you will destroy him. He will think it is his fault you abandoned him. He will hurt.

One more thing about the dx.

It is inappropriate to diagnose any young person -- probably under the age of 20-22 -- with borderline personality disorder (pretty much with any personality disorder). Why? Because the criteria for having such a disorder involves it having longstanding and persistent characteristics.

Look up the symptoms/characteristics of borderline personality disorder, and you will see that many describe exactly those that also define "teenager," including mood swings, unstable interpersonal relationships, unstable sense of self, impulsivity, difficulty controlling anger. What makes it a personality disorder is the persistence of it BEYOND young adulthood.

So this poor young man has been labeled by one doctor who can't even be intellectually honest about his opinion because of insurance practices. (By the way, my insurance company has been more than generous about paying for DBT and DBT skills training on an outpatient basis. I think they don't want to pay for it on an inpatient one!!).

He has an intern with very little experience who is earnest but uneducated about his disorder trying to "treat" him.

He may have his abuser sitting in the room with him.

No wonder the poor little shit is angry. I would be, too.

Chris said...

Thanks again. It's great to get the perspective from someone who has experienced this firsthand. I'm not actually running the family session, I'm just sitting in with the therapist who is and helping out whenever I can. I agree with you 100% about the diagnosis. I didn't think you were supposed to give a teenager any kind of personality disorder diagnosis. I thought that was only at age 18 and I believe that's correct according to the DSM.

I feel so bad for this guy. What you're saying makes total sense, but unfortunately due to the nature of the unit, it's so difficult to get things done. The only individual counseling we offer is during family sessions and his family is a giant trigger for him. They're all assholes in my opinion. His family is a couple of rich lawyers who just place him from institution to institution.

I'm not allowed to do any individual counseling on the unit, but I try to get around that and talk with him at least. And we get along great there. He just doesn't want to open up in groups. He gets very defensive.

I think he would benefit greatly from a therapist so that he could talk to someone without his parents or a bunch of other people being around. But he refuses to go to a therapist and says that it's bullshit and he doesn't need one. Yet like you said, his suicide attempts are not threats, they're real. The mental health system in Louisiana is just so screwed up. It's so hard to get anything done. Hopefully I can help to reform that one day.

Carl V. said...

Have you ever watched the old Dr. Who episodes with Tom Baker as the doctor? My brother and I saw these on PBS when we were kids and fell in love with them. What does this have to do with your post? Well, Neverwhere has those exact same production values. As such I didn't have any problem with the way they looked and it actually made me feel very nostalgic for my childhood.

I'll wait for your full review to talk about what I thought of all the characters, etc. I too am glad I read the book first, which sprung out of Neil's own frustration with the way the story was told on DVD. It is really fun overall, look forward to talking about it more. (I will be leaving a long, raving comment then so I apologize ahead of time.)

Linda said...

My husband suffers from borderline personality disorder. It can often be very difficult to deal with him because he will just snap like you explained your patient did. One helpful website I came across while trying to find out more about BPD is I hope this is helpful!