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Wednesday, May 09, 2012

Comments

I'm wondering if you would feel differently if it weren't just a hit and run interview? I think one might respond VERY differently (even at a feeling level) to a borderline one has taken on as a patient or who was one's parishioner (for a minister) or even a member of one's community or work group or family. I think because borderlines, tho notoriously terrified of abandonment, are also terrified of being examined and despised. A person can act histrionic and even seductive and be full of confidences, but it is all designed to keep the feared hounds off the scent. By tossing out loade statements about lots of things, the threatening person is kept from finding the parts a person is ashamed of. Also, if a borderline e has self medicated much of their life, part of what you are reacting to is just the addled reactions and thinking of the substance impaired and the lies and self delusions of all substance abusers. Clean and sober, the person may not so discombobulate you.

"I'm wondering if you would feel differently if it weren't just a hit and run interview?"

Not always the case, but this a somewhat frequent first session experience and a strong hint that there are separation/individuation struggles. But I should add that I don't have the view of borderline level organization adopted in the DSM. That is largely a symptom description list for someone with a histrionic personality and a more severe borderline level organization. This particular interviewee had a histrionic personality, but borderline level organization can look very different depending on the the personality. For example:

http://drx.typepad.com/psychotherapyblog/2012/04/briefly.html

Once therapy gets going (if you get past a few sessions), there are many variations in the relational experience between patient and therapist.

I was actually thinking earlier this week about a post touching on what you describe related to the experience of being watched and hounded. There are some common defensive turnabouts and interesting countertransferential experiences that occur. Now that you got me thinking about it again, I should make an effort to do something with that when I've got a little extra time during the next week. And there are some other experiences that are really interesting.

Excellent post (and comment). You capture it well. As our interviews of BPD's come in a group setting, we get that added picture that is not always visible. They have trouble controlling the flow of information received and given, and it can be upsetting to them. Too man variables, too much fear.

I have come to believe over the years there is more brain part to this. I often speak as you both do above, of an intentionality to the volatile mood, keeping hounds of the scent, keeping the interviewer off balance. I am less certain now that this is intentional or a learned adaptation even at an unconscious level. I think their brains are so thoroughly in the moment, the emotional content of these few seconds so loud, that they cannot have another response. The schizophrenic hears voices, and if they are loud or constant or persuasive enough, they quickly overwhelm real sensory data. I think something similar happens with borderlines and emotions - the internal experience of the moment drowns out other inputs. It almost is like an hallucination in that respect. It is also why they can turn on a dime emotionally. The volume is high.

Observers get frustrated because events of just a few moments ago seem to have vanished, i.e. "Of course you aren't going to ceramics group with sharp objects. You cut yourself and had to go to the ER last night." And the BPD is genuinely puzzled, for she feels FINE RIGHT NOW and there is no other reality. It's not really a manipulation, though it certainly feels that way.

DBT has techniques to learn to counteract this. I have modest approval for the treatment, though I think it is overrated. In the absence of much else that works, however, that where we steer folks, though sometimes I wonder if it should be called (snark alert) Dianetics For Girls.

Speaking of which, I was amazed at the amazement when it was revealed that Marsha Linehan herself had BPD. Well, duh. I thought it was glaringly obvious for years but we just didn't say it out loud for politeness' sake.

"I was amazed at the amazement when it was revealed that Marsha Linehan herself had BPD. Well, duh. I thought it was glaringly obvious for years but we just didn't say it out loud for politeness' sake."

So true. And Heinz Kohut had a narcissistic personality and was himself the patient, Mr Z, that he wrote about. I think one of the things we all have to do is maintain a certain polite, respectful stance as we see elements of character structure in other clinicians as they discuss their work. We all have a character structure that inevitably affects what we see as well as our blind spots. But most of us would like to be the ones who make it explicit, rather than have colleagues announce it. Which is okay, because I think most of us understand that our more perceptive colleagues see who we are characterologically if we present our work in an honest and thorough manner.

I don't mind saying that I'm characterologically depressive with a healthy dose of compulsive defenses. The former is certainly not unusual for clinicians, if not the most common character structure in our profession, which makes us shocked when we naively first encounter the reality that empathy can piss off some patients. But since we've all got a personality structure, I think I'd choose this one even if given the option to choose another.

Anyone capable of rendering an armchair analysis of this intriguing physician.........

http://www.nytimes.com/2003/01/11/nyregion/case-against-a-psychiatrist-is-unfolding-gradually.html

I have an uncle with BPD. Observed his behavior on an intermittent basis from 1984 to 2003. Imagine my surprise in 1985 when I proved capable of drafting a two page "behavior contract" during a manic phase, which deterred him taking apart everything in his Florida condo. Many friends and relatives deserted him during these periods. Prior to this last resort contract experiment on my part I was unconvinced you could reason with a manic individual.

In light of the fact lithium seemed to serve very little purpose (don't recall the dose) I made the decision to take him to the ER in 2003 during the onset of a manic phase. He cycled like clockwork every 10 to 12 weeks and remained hyper for approximately 2 weeks. I always assumed there had be a more effective medication, despite learning big pharma was never motivated to develop a specific drug due the lack of a large patient base.

Hospital physician prescribed an antipsychotic which proved much more effective than lithium. I believe he is currently taking Abilify. He turned 86 in April. I cannot imagine someone his age, with recently installed pacemaker, enduring 2 weeks of non-stop activity without injuring himself.

Interesting link, Frank. I was unfamiliar with the Karpf case. Obviously he was a very troubled man, but could be a number of things going on.

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