The 50% with Axis II:
Handling Co-Occurring
Borderline and Narcissistic
Personality Disorders
Dena Cabrera, PsyD, CEDS Clinical Director
Rosewood Centers for Eating Disorders
ASAM Disclosure of Relevant Financial Relationships Content of Activity: 2015 West
Coast Symposium on Addictive Disorders
Name Commercial Interests Relevant Financial Relationships: What Was Received Relevant Financial Relationships: For What Role
No Relevant Financial Relationships with Any Commercial Interests X
Glossary of Terms
Commercial Interest - The ACCME defines a “commercial interest” as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.
Financial relationships -Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. Relevant financial relationships - ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.
Conflict of Interest - Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.
Agenda
• Eating Disorders • Co-morbidity • Assessment • Treatment • Finding HopeHelp by Shel Silverstein
Borderline Concept
Neurotic Psychotic
Characterized by:
Unstable sense of self (identity diffusion) Use of Primitive, immature defense mechanisms Denial
Projection Acting out Defective reality testing
Borderline Personality Disorder
DSM-IV-TR criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:• Frantic efforts to avoid real or imagined
abandonment.
• A pattern of unstable and intense
interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• Identity disturbance: markedly and
persistently unstable self-image or sense of self
DSM-IV-TR criteria cont’d
• Impulsivity in at least two areas that are
potentially self damaging
• Recurrent suicidal behavior, gestures, or
threats, or self-mutilating behavior
• Affective instability due to a marked reactivity
of mood
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty
controlling anger
• Transient, stress related paranoid ideation or
severe dissociative symptoms
Narcissus and Echo
• Narcissism: To Self-worship. Excessive
self-absorption is a protection against unconscious but powerful feelings of inadequacy.
• Pursuit to gain a sense of self.
Narcisstic Personality D/O
DSM IV-TR Criteria
• Pervasive pattern of grandiosity (in fantasy or
behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
• (1) has a grandiose sense of self-importance
(e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• (2) is preoccupied with fantasies of unlimited
success, power, brilliance, beauty, or ideal love
• (3) believes that he or she is "special" and
unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• (4) requires excessive admiration
• (5) has a sense of entitlement, i.e.,
• unreasonable expectations of especially
favorable treatment or automatic compliance with his or her expectations
• (6) is interpersonally exploitative, i.e., takes
advantage of others to achieve his or her own ends
• (7) lacks empathy: is unwilling to recognize or
identify with the feelings and needs of others
• (8) is often envious of others or believes that
others are envious of him or her
• (9) shows arrogant, haughty behaviors or
Traits Common to BPD & NPD
• Pervasive shame
• Undefined Boundaries
• Control Issues
• Lack of Object Constancy
• Interpersonal Sensitivity • Situational Competence
Emotional Dysregulation
• Attachment • Identity • Loss • Trauma • Wound Invalidating EnvironmentBiopsychosocial Theory of Emotions
Invalidating Environment
Consequences:• 1. Inability to label feelings
• 2. An inability to trust one’s own emotions as
valid interpretations of events
• 3. An inability to tolerate distress, regulate
emotional arousal and / or reactions.
• 4. Invalidation of one’s own experience.
EXAMPLES
• Invalidation
–“You shouldn’t feel that way, don’t let it bother you; you should feel happy you have a job.”
–“So he didn’t ask you to the dance. So What, -after all, he hardly knows you.”
• Validation – think Mirror not mind reader
–“It sounds like you are really upset, he didn’t ask you to the dance.”
Validation
• Validation enhances communication
–Gives voice to the unspoken
• Soothes Emotions
• Slows negative reactivity
• Builds trust and closeness
• Establishes you as a safe and respectful
therapist/parent/loved one
• Learning to self-validate helps validate others
Fruzzetti, Alan, E. (2006). The high-conflict couple: A DBT guide to finding peace, intimacy, & validation.
Reframe the Behavior
Instead of: “Manipulating”
“Gamey” “Lying” “Borderline”
Reframe the Behavior
• Reframe to:
Getting their needs met without being controlled
Transference and Countertransference
• Transference: an unconscious process of
transferring ideas and feelings from their original sources (directed at the self, the mother, the father, etc.) toward another person
• Countertransference: the therapists’
transference onto patients.
Countertransference
• What role is the patient placing me in?
• What part, if any, of the motivation for my
intervention is based on my
countertransference rather than the patient’s needs at the moment?”
• Boundaries
• Supervision and/or Consultation
In therapy get out of the
becauses….
DBT Assumptions
About Clients
• People are doing the best that they can.
• People want to improve
• People must learn new behaviors both in therapy and in the context of their day-to-day life.
• People cannot fail in DBT
• People may not have caused all of their problems, but they have to solve them anyway.
• People need to do better, try harder and be more motivated to change.
• The lives of people who are suicidal are unbearable as they are currently being lived.
DBT Assumptions
About Treatment
• The most caring thing a therapist or treatment provider can do is help people change in ways that bring them closer to their own ultimate goals.
• Clarity, precision and compassion are of the utmost importance.
• The treatment relationship is a real relationship between equals.
• Principles of behavior are universal, affecting clinicians no less than clients.
• Treatment providers need support
• Treatment providers can fail.
• What do you think of these assumptions? Are any of them contradictions? Can these assumptions still be true, despite contradiction? Do these assumptions fit with your experience of therapy.
•Behavior Chain Analysis
(Handout)•Diary Cards
(Handout)•Pros / Cons
Acceptance and Change Strategies –
Tools (DBT Apps)
Guidelines for a BCA
1. Describe the specific problem 2. Precipitating event
3. Vulnerability factors
4. Chain of events – feelings, thoughts, behaviors
5. Consequence 6. Solutions 7. Repair
Processes that get us Stuck
• Cognitive Fusion
–Means you become inseparable from your thoughts
–Thoughts dominate behavior
–Leads to inflexibility, stiffness, limited functioning
–“If I think, it is real!”
• Experiential Avoidance
–Avoiding, getting rid of, supressing, escaping from unwanted thoughts or feelings
–Facilitates repetitive behavior – reinforces escape
Treatment Approach
= Team Approach
BIOLOGICAL PSYCHOLOGICAL SOCIAL SPIRITUALThe Self-Injury Cycle
Time
Stage 6 Regret / Never Again
Distressed
Overall Treatment Plan
GOAL:Teach life-management skills
Structure the environment to motivate, reinforce, and individualize appropriate skills
Identify, break up learned behavioral sequences that precede dysfunctional behaviors
Remove reinforcers for negative behaviors Generalization from therapy to life situations Provide support for team
Guidelines for a BCA
1. Describe the specific problem 2. Precipitating event
3. Vulnerability factors
4. Chain of events – feelings, thoughts, behaviors 5. Consequence 6. Solutions 7. Repair Mom comes to rescue – go shopping
BCA
1. Consequences: . 4. 4. 4. 4. 4. 4. 4. 4. 4. 4. 3. 2. Self Injury Restricting, tired,3 Red Bulls Boyfriend broke up with her Mom’s critical; Dad’s punishment
Long term Consequences:
2.Boyfriend, Mom’s critical; Dad’s punishment 3. Hungry, caffeine, tired
SOLUTION ANALYSIS
•Be Honest •Ask for Help •Radical Acceptance •Self-Soothing 4. 4. 4. 4. Felt Shame I’m worthless Felt upset Go to the bathroom •Opposite to Emotion •“Wise Mind” •Grateful ListSOLUTION ANALYSIS
4. 4. I’m worthless Go to the bathroom •Grateful List 4. 4. •Find a Friend •Pros/Cons 1. Self Injury •PraySOLUTION ANALYSIS
1. Self Injury Consequences: (+)Relief (+) shopping (-) Shame, depression, Loss of trust, $,time, low self esteem
Self-Harming Behavior
__________ Links can include:Actions
Body Sensations Thoughts Feelings Event What will you do differently next time? Call therapist for Coaching Radical acceptance I was vulnerable because of… Unbalanced eating Physical illness Unbalanced Sleeping Drug or Alcohol Use Misusing Prescriptions Stressful Environmental Events (good and bad) Old Behaviors or Memories
START
Finish
Increase skill acquisition and
strength
4 Modules
1.Mindfulness 2.Distress Tolerance 3.Emotion Regulation 4.Interpersonal Effectiveness (LInehan, 1993)Skills Training
Mindfulness
“The art of listening is neither careless drifting on the one hand nor fearful clinging on the other. It consists in
being sensitive to each moment, in regarding it as utterly new and unique, in having the mind open and
wholly receptive.”
—Alan Watts
Mindful Transformation: “RAIN” (Kornfield, 2008)
Recognition
Acceptance
Investigation
Mindfulness
• Three principles of Attention – living life more
experientially
–One thing at a time
–Adopting a nonjudgmental attitude
–Describing from experience rather than through constructs or predefined categories – “mindful reflection” on emotions.
Mindful Exercises and Meditation
• Can be difficult with ED patients – trigger
anxiety, self-critical states, confusion, hypo-arousal, judging mind, comparing mind
• The Mindfulness App by MindApps $1.99
Teens Awareness Exercise
1. Find a favored object (ex. Rock, shell, blanket) 2. Have the teen hold the object for at least a fewminutes
3. While the teen is holding the object, encourage him to touch it, smell it, squeeze it, look at it, and use as many senses as she can.
4. When your child has finished experiencing the object, help him find words to describe it. You can ask if he has discovered something he didn’t notice before, whether it is smooth, rough, etc.
Teach self-awareness of experience
CDs for practicing MindfulnessAiry Melody’s Rainbows and Sunshine (AGES 6 -11) relaxation CD
Indigo Dreams for Children and Teens
Mindfulness for Teens: Meditation Practices to Reduce Stress
Still Quiet Place: Mindfulness for Teens
Goals of Distress Tolerance
• Decreasing agony associated with emotional
pain
• Crisis Survival Strategies
• Comforting Skills
Emotion Regulation
Goals of Emotion Regulation Module
• Understanding your emotions
• Being able to watch and label them
• Allowing exposure to emotions – learning
from them to improve adaptive responsiveness
• Reduce emotional vulnerability
Goals of Emotional Regulation
• Increase positive emotional experiences
• Increasing Mindfulness
• Develop these coping skills so your emotions
are an important but not controlling factor in your life
Goals for Interpersonal Effectiveness
• The skills required to ask for what you want
to say or no to a request.
• The skills required to repair or enhance a
relationship.
• The skills for setting a limit while holding on
to your self-respect
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DBT Family Skills
• DBT Family Involvement
–Family CONNECTIONS Course
•A 12-wk manualized education program for relatives of persons with BPD.
• Setting Limits / Boundaries
• Therapy / Support
FAMILY INVOLVEMENT THE THREE R’S:
Recognizingbehaviors that are part of the illness
• Do not assume the worst.
• Don’t be judgmental.
• Validate your child.
Resistingbeing drawn into the vortex of dysregulation and irrationality
• Be responsive, not reactive.
• You can lose the battle and still win the war.
• It takes two to engage in power struggles.
• Balance your responses.
Reconstructinga meaningful relationship with their teen
–Choose the most effective response
FAMILY INVOLVEMENT
THE THREE R’S:
What’s this about for me?
HOPE PURPOSE VALUE MEANING
“We must embrace pain and burn it as fuel for our journey.”
Kenji Miyazawa
Dena Cabrera, PsyD., CEDS Clinical Director of Adolescent Licensed Clinical Psychologist
Rosewood Center for Eating Disorders 36075 S. Rincon Road
Wickenburg, AZ 85390 928-684-9594
[email protected] http://www.rosewoodranch.com