Post by Mel on Jan 15, 2006 23:12:21 GMT -5
Fairy Tale Princesses and Happier Endings
by Richard A. Moskovitz, M.D.
With the publication of Diana in Search of Herself: Portrait of a Troubled Princess by Sally Bedell Smith, Borderline Personality Disorder has suddenly become a household word, not only in America, but all over the world. This high profile biography, which claims that Princess Diana suffered from BPD, will have a powerful influence on how most of the public views BPD. While increasing awareness of BPD is sufficiently worthwhile to justify the book’s existence, I found its portrayal of the disorder too disheartening to bring many people out of the shadows and into treatment.
While the author states accurately that patients with BPD are often difficult and frustrating to treat, she goes on to imply that symptoms can at best be managed and not cured and that delving into the past is seldom of value in treatment. These generalizations do little justice to the potential resilience of borderline patients and the capacity of treatment to bring striking changes in the quality of life.
Over the past decade, a number of advances in the areas of both biological therapies and psychotherapy have occurred that have improved the outcomes of treatment for many people. Not the least of these developments has been the willingness of therapists to discuss the diagnosis of BPD openly with their patients. This has provided patients with a clearer framework for understanding their own experiences and behavior. It has also opened the door for patients and therapists to become more honest with one another and to avoid some of the power struggles that commonly undermine treatment.
I will provide here a brief overview of what I consider some of the most important recent advances in treatment. Treatment is evolving rapidly and some of the treatments discussed below have emerged since Lost in the Mirror was written and were not covered there.
The selective serotonin reuptake inhibitor (SSRI) antidepressants came into use with the availability of Prozac in the mid-80’s. These medications, which now include Prozac, Zoloft, Paxil, Luvox, and Celexa, have become powerful tools in the treatment of depression and various forms of anxiety. They have been helpful in limiting the depths of despair that many people with BPD experience as well as controlling panic attacks and other overwhelming feelings that often lead to self-destructive behaviors. For some people, these drugs significantly reduce the urge to self-mutilate or to engage in other mood-altering behaviors such as bingeing and purging. The new generation of antidepressants also includes Serzone, Effexor, Wellbutrin, and Remeron. While the mechanisms of action of each of these medications vary, each has had a role in the treatment of some borderline patients.
The mood-stabilizing drugs have also recently had a more prominent role in treating BPD. While until recently, lithium was the only drug commonly used to treat mood swings, a number of agents originally developed to treat seizures have been found to have powerful mood-stabilizing effects. Currently, Depakote is the anti-seizure medication most commonly used by psychiatrists to control mood swings. Data is accumulating on a growing list of related agents, including Tegretol, Neurontin, Lamictal, and Topamax, among others. They have been studied primarily in the treatment of patients with bipolar disorder (manic-depressive illness), but are also being used by some clinicians to treat the drastic mood changes that occur in BPD. These drugs may also enhance the effects of antidepressants when the response to treatment has been incomplete.
The major tranquilizers, or antipsychotic drugs, have long been used to treat some of the symptoms of BPD. They can be most helpful in treating dissociative symptoms and in controlling self-destructive impulses. The older drugs, such as Haldol. Navane, Stelazine, and Thorazine have unfortunately had severe and sometimes lasting side effects, including particularly muscle spasms and involuntary movements. A new generation of antipsychotics, which so far includes Risperdal, Zyprexa, and Seroquel, has drastically reduced the likelihood of these side effects. Since they can be used safely and comfortably, psychiatrists have been more willing to prescribe them for patients with BPD.
The minor tranquilizers, or benzodiazepines, have a very limited role in the treatment of BPD, primarily because of their potential for addiction. In some people, dissociative symptoms may increase under the influence of benzodiazepines. When prescribed, they should be closely monitored. An exception would be BuSpar, a unique, non-benzodiazepine anti-anxiety agent that is not addicting and, for the most part, non-sedating. BuSpar is often used in combination with an SSRI. When so combined, BuSpar may enhance the antidepressant and anti-anxiety effects of the SSRI’s. For some people, it may also counteract the sexual side effects that are perhaps the most vexing detrimental effects of the SSRI’s.
One other drug that merits mention is ReVia (naltrexone). This drug, which blocks the effects of narcotics on the nervous system, was originally studied as a treatment for narcotics addiction. More recently, it has been found also to limit the craving for alcohol in some alcoholics. A less studied effect of ReVia is the reduction of self-mutilation in patients with a variety of diagnoses. While it is not clear how helpful this drug will turn out to be in preventing the self-mutilation that often accompanies BPD, it is worth watching. It may even be worth trying for some people who struggle both with chemical addictions and compulsive self-injury.
The selection, and in many cases the blending of the various medications discussed above requires a combination of science and art. The effects of the different classes of medications overlap considerably. The possibility of adverse drug interactions must also be taken into account. It is important also to be aware that many of the applications of the medications discussed above fall outside of the indications that have been approved for them by the FDA. When treating complex problems, experienced clinicians sometimes draw outside the lines of formally established treatments.
Two of the most innovative and promising psychotherapeutic approaches to BPD are Dialectical Behavior Therapy (DBT) and Eye Movement Desensitization and Reprocessing (EMDR). Since I have not been trained in DBT, my impressions must be taken as somewhat subjective. My impressions of EMDR, on the other hand, come from extensive first-hand experience.
Dialectical Behavior Therapy, developed by Marsha Linehan, Ph.D., addresses the tendency of people with BPD to see things in black and white extremes. It helps them find the middle ground between overvaluing themselves and their ideas, on the one hand, and condemning themselves, on the other. It simultaneously seeks to build self-esteem and to challenge the status quo, encouraging changes that will make life more fulfilling. When successful, DBT creates a stable context for experience and corrects the discontinuity of experience that is the central theme of Lost in the Mirror. DBT also focuses on developing problem-solving skills, interpersonal skills, an increased ability to regulate emotions, and the capacity to tolerate stress and pain.
DBT includes individual and group therapies as well as real world interventions, with therapists available by telephone to coach patients through solving problems as they develop. This broad availability between sessions makes DBT a team approach, best provided in a clinic setting where responses to calls can be divided among a number of therapists. The demands of such a labor-intensive treatment might quickly burn out a solo practitioner.
Eye Movement Desensitization and Reprocessing, developed by Francine Shapiro, Ph.D., was designed to address the symptoms that result from emotionally traumatic experiences. It combines the use of imagery with the physiological effects of rapid eye movements similar to the movements observed during the dreaming stage of sleep. The eye movements in EMDR are usually induced simply by having patients follow the therapist’s moving hand.
Intensely distressing events often seem frozen in time, recalled with particular vividness and unchanging detail long after the actual events have occurred. The memories may resemble a videotape that plays over and over without any alteration. The emotions accompanying the memories also remain vivid and identical from one replay to the next. These emotions are often accompanied by a state of arousal, or fight/fight response that occurs in the face of a threatening situation. It feels as if the original threat is still present.
When threatening events occur, they also tend to alter our view of ourselves, our relationships, and the nature of the world. They may impact our self-esteem, our security, and our willingness to risk trusting others. Such changes in beliefs may be as enduring as the memories themselves. If the memories are sufficiently painful, they may be kept from awareness for periods of time, their effects on our beliefs and on our interaction with others and the world becoming their only visible evidence.
While we do not know exactly how EMDR works, several effects are likely involved. The eye movements themselves appear to affect arousal, eventually ending the fight/flight response and producing relaxation. This is the "desensitization" part of the treatment, robbing the memory of its emotional intensity. The relaxation response varies considerably both in strength and pace from person to person. Moving the eyes also affects the pattern of activation in the brain, forcing the nervous system to turn on specific locations in sequence. This patterned activation may compete with the limited patterns associated with the "videotape" memory and bring new resources to bear upon how we process the memory. This enables the characteristics of the memory, emotions, and accompanying beliefs to change. One consequence of this reprocessing is to allow the events to assume their proper place and time in our personal histories, so that they no longer feel current.
EMDR can be a powerful and often rapid treatment for trauma. The experience can be intense, however, and may temporarily stir up symptoms. It should be undertaken only in the hands of a therapist experienced both in EMDR and in the treatment of people with BPD.
Effective treatment requires teamwork between patients and therapists. With a cooperative effort and open communication, symptoms can be relieved and fundamental changes can occur in the way people experience their world and themselves. While most borderline stories are not about fairy tale princesses, many can have happier endings.
August 1999
Permission by Richard A. Moskovitz, M.D.
Author of "Lost in the Mirror - An Inside Look at Borderline Personality Disorder (Uk) (Can)"
Dr. Moskovitz's website: www.braintracks.com/lost/
Chat Transcript with Dr. Richard Moskovitz, M.D.
by Richard A. Moskovitz, M.D.
With the publication of Diana in Search of Herself: Portrait of a Troubled Princess by Sally Bedell Smith, Borderline Personality Disorder has suddenly become a household word, not only in America, but all over the world. This high profile biography, which claims that Princess Diana suffered from BPD, will have a powerful influence on how most of the public views BPD. While increasing awareness of BPD is sufficiently worthwhile to justify the book’s existence, I found its portrayal of the disorder too disheartening to bring many people out of the shadows and into treatment.
While the author states accurately that patients with BPD are often difficult and frustrating to treat, she goes on to imply that symptoms can at best be managed and not cured and that delving into the past is seldom of value in treatment. These generalizations do little justice to the potential resilience of borderline patients and the capacity of treatment to bring striking changes in the quality of life.
Over the past decade, a number of advances in the areas of both biological therapies and psychotherapy have occurred that have improved the outcomes of treatment for many people. Not the least of these developments has been the willingness of therapists to discuss the diagnosis of BPD openly with their patients. This has provided patients with a clearer framework for understanding their own experiences and behavior. It has also opened the door for patients and therapists to become more honest with one another and to avoid some of the power struggles that commonly undermine treatment.
I will provide here a brief overview of what I consider some of the most important recent advances in treatment. Treatment is evolving rapidly and some of the treatments discussed below have emerged since Lost in the Mirror was written and were not covered there.
The selective serotonin reuptake inhibitor (SSRI) antidepressants came into use with the availability of Prozac in the mid-80’s. These medications, which now include Prozac, Zoloft, Paxil, Luvox, and Celexa, have become powerful tools in the treatment of depression and various forms of anxiety. They have been helpful in limiting the depths of despair that many people with BPD experience as well as controlling panic attacks and other overwhelming feelings that often lead to self-destructive behaviors. For some people, these drugs significantly reduce the urge to self-mutilate or to engage in other mood-altering behaviors such as bingeing and purging. The new generation of antidepressants also includes Serzone, Effexor, Wellbutrin, and Remeron. While the mechanisms of action of each of these medications vary, each has had a role in the treatment of some borderline patients.
The mood-stabilizing drugs have also recently had a more prominent role in treating BPD. While until recently, lithium was the only drug commonly used to treat mood swings, a number of agents originally developed to treat seizures have been found to have powerful mood-stabilizing effects. Currently, Depakote is the anti-seizure medication most commonly used by psychiatrists to control mood swings. Data is accumulating on a growing list of related agents, including Tegretol, Neurontin, Lamictal, and Topamax, among others. They have been studied primarily in the treatment of patients with bipolar disorder (manic-depressive illness), but are also being used by some clinicians to treat the drastic mood changes that occur in BPD. These drugs may also enhance the effects of antidepressants when the response to treatment has been incomplete.
The major tranquilizers, or antipsychotic drugs, have long been used to treat some of the symptoms of BPD. They can be most helpful in treating dissociative symptoms and in controlling self-destructive impulses. The older drugs, such as Haldol. Navane, Stelazine, and Thorazine have unfortunately had severe and sometimes lasting side effects, including particularly muscle spasms and involuntary movements. A new generation of antipsychotics, which so far includes Risperdal, Zyprexa, and Seroquel, has drastically reduced the likelihood of these side effects. Since they can be used safely and comfortably, psychiatrists have been more willing to prescribe them for patients with BPD.
The minor tranquilizers, or benzodiazepines, have a very limited role in the treatment of BPD, primarily because of their potential for addiction. In some people, dissociative symptoms may increase under the influence of benzodiazepines. When prescribed, they should be closely monitored. An exception would be BuSpar, a unique, non-benzodiazepine anti-anxiety agent that is not addicting and, for the most part, non-sedating. BuSpar is often used in combination with an SSRI. When so combined, BuSpar may enhance the antidepressant and anti-anxiety effects of the SSRI’s. For some people, it may also counteract the sexual side effects that are perhaps the most vexing detrimental effects of the SSRI’s.
One other drug that merits mention is ReVia (naltrexone). This drug, which blocks the effects of narcotics on the nervous system, was originally studied as a treatment for narcotics addiction. More recently, it has been found also to limit the craving for alcohol in some alcoholics. A less studied effect of ReVia is the reduction of self-mutilation in patients with a variety of diagnoses. While it is not clear how helpful this drug will turn out to be in preventing the self-mutilation that often accompanies BPD, it is worth watching. It may even be worth trying for some people who struggle both with chemical addictions and compulsive self-injury.
The selection, and in many cases the blending of the various medications discussed above requires a combination of science and art. The effects of the different classes of medications overlap considerably. The possibility of adverse drug interactions must also be taken into account. It is important also to be aware that many of the applications of the medications discussed above fall outside of the indications that have been approved for them by the FDA. When treating complex problems, experienced clinicians sometimes draw outside the lines of formally established treatments.
Two of the most innovative and promising psychotherapeutic approaches to BPD are Dialectical Behavior Therapy (DBT) and Eye Movement Desensitization and Reprocessing (EMDR). Since I have not been trained in DBT, my impressions must be taken as somewhat subjective. My impressions of EMDR, on the other hand, come from extensive first-hand experience.
Dialectical Behavior Therapy, developed by Marsha Linehan, Ph.D., addresses the tendency of people with BPD to see things in black and white extremes. It helps them find the middle ground between overvaluing themselves and their ideas, on the one hand, and condemning themselves, on the other. It simultaneously seeks to build self-esteem and to challenge the status quo, encouraging changes that will make life more fulfilling. When successful, DBT creates a stable context for experience and corrects the discontinuity of experience that is the central theme of Lost in the Mirror. DBT also focuses on developing problem-solving skills, interpersonal skills, an increased ability to regulate emotions, and the capacity to tolerate stress and pain.
DBT includes individual and group therapies as well as real world interventions, with therapists available by telephone to coach patients through solving problems as they develop. This broad availability between sessions makes DBT a team approach, best provided in a clinic setting where responses to calls can be divided among a number of therapists. The demands of such a labor-intensive treatment might quickly burn out a solo practitioner.
Eye Movement Desensitization and Reprocessing, developed by Francine Shapiro, Ph.D., was designed to address the symptoms that result from emotionally traumatic experiences. It combines the use of imagery with the physiological effects of rapid eye movements similar to the movements observed during the dreaming stage of sleep. The eye movements in EMDR are usually induced simply by having patients follow the therapist’s moving hand.
Intensely distressing events often seem frozen in time, recalled with particular vividness and unchanging detail long after the actual events have occurred. The memories may resemble a videotape that plays over and over without any alteration. The emotions accompanying the memories also remain vivid and identical from one replay to the next. These emotions are often accompanied by a state of arousal, or fight/fight response that occurs in the face of a threatening situation. It feels as if the original threat is still present.
When threatening events occur, they also tend to alter our view of ourselves, our relationships, and the nature of the world. They may impact our self-esteem, our security, and our willingness to risk trusting others. Such changes in beliefs may be as enduring as the memories themselves. If the memories are sufficiently painful, they may be kept from awareness for periods of time, their effects on our beliefs and on our interaction with others and the world becoming their only visible evidence.
While we do not know exactly how EMDR works, several effects are likely involved. The eye movements themselves appear to affect arousal, eventually ending the fight/flight response and producing relaxation. This is the "desensitization" part of the treatment, robbing the memory of its emotional intensity. The relaxation response varies considerably both in strength and pace from person to person. Moving the eyes also affects the pattern of activation in the brain, forcing the nervous system to turn on specific locations in sequence. This patterned activation may compete with the limited patterns associated with the "videotape" memory and bring new resources to bear upon how we process the memory. This enables the characteristics of the memory, emotions, and accompanying beliefs to change. One consequence of this reprocessing is to allow the events to assume their proper place and time in our personal histories, so that they no longer feel current.
EMDR can be a powerful and often rapid treatment for trauma. The experience can be intense, however, and may temporarily stir up symptoms. It should be undertaken only in the hands of a therapist experienced both in EMDR and in the treatment of people with BPD.
Effective treatment requires teamwork between patients and therapists. With a cooperative effort and open communication, symptoms can be relieved and fundamental changes can occur in the way people experience their world and themselves. While most borderline stories are not about fairy tale princesses, many can have happier endings.
August 1999
Permission by Richard A. Moskovitz, M.D.
Author of "Lost in the Mirror - An Inside Look at Borderline Personality Disorder (Uk) (Can)"
Dr. Moskovitz's website: www.braintracks.com/lost/
Chat Transcript with Dr. Richard Moskovitz, M.D.
