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Linehan's bio-social theory on the causes of BPD


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(Scroll to the bottom of this entry for the super simple explanation.)

My interpretation of Marsha Linehan's theory* on common patterns during the childhoods of people who later develop Borderline Personality Disorder

According to Linehan's bio-social theory of BPD, BPD develops as a result from a combination of predisposing genetic factors and behaviors learned during childhood.  At this time, Borderline is considered an Axis II diagnosis, though the majority of people with BPD have a co morbid axis I diagnoses such as Major Depressive Disorder or Bipolar.  Borderline Personality Disorder develops in persons with a naturally high level of emotional reactivity (i.e. the type of person viewed by many as "overly sensitive" or kids that some would describe as prone to tantrums) who grew up in "emotionally invalidating" environments where they did not learn appropriate emotional regulation skills.

That is to say, BPD is not an inherent trait; it is a set of learned behaviors.  (This means, on the positive side, that these behaviors can be un-learned.)

As children, most borderlines were highly emotional.  InCognitive-Behavorial Treatment of Borderline Personality Disorder, Linehan states "Childhood temper tantrums and persistent rocking or head banging were more frequent among children later diagnosed as having BPD than among those later diagnosed as depressed or schizophrenic."

In addition to having a natural inclination towards high levels of emotional reactivity, most Borderlines experienced some form of major childhood trauma.  Between 67 and 75 percent of borderlines were victims of sexual abuse as children.  The prevalence of childhood sexual abuse in the Borderline community has lead to the misconception that all Borderlines were molested as children.  Many Borderlines experienced other forms of childhood trauma such as divorce, loss of a parent, or physical abuse.  However, not all Borderlines report major

traumas in their childhoods.

In my opinion, the most important childhood factor that leads to BPD is that Borderlines grew up in emotionally invalidating environments.  As children, Borderlines were either taught that the expression of negative emotions is inappropriate, or their emotions were inconsistently responded to.  Parents and family members disregarded or trivialize the child's emotional experience, leading them to believe that emotional expression is wrong, and should be suppressed.

In contrast, in many families children are taught to discuss their painful feelings openly, and taught coping skills for how to process and integrate trauma into their lives.

Not all emotionally invalidating families are "dysfunctional." Invalidating environments can be broken down into three types of families. 

Often the invalidation can arise from a family environment plagued by mental illness and/or substance abuse where family members do not consistently react to the Borderline child.  Another emotionally invalidating family environment is one in which absolute perfection is expected from every member of the family.  However, American culture by its nature is emotionally invalidating.  We have all been told to "grin and bear it" or that if we just "tried hard enough" or "let things roll off our shoulders" we would be happier people.  Emotional pain is commonly viewed in America as a weakness, a sign of laziness.  Therefore many families invalidate the emotions of their children merely by compiling with the American status quo.

Because of Borderlines' high level of emotional reactivity and their invalidating family environments, they never learned how to properly process and express emotions. As teenagers and adults, Borderlines act out in socially inappropriate and harmful ways because they do not know how to properly deal with negative emotions.  They know how to push them down, but they cannot process them, cannot appropriately ask for help, and cannot express emotional pain as others do.

This leads to a self-destructive pattern of behavior known as Borderline Personality Disorder...

To simplify this theory of the childhood development of Borderline Personality Disorder, one can look at it this way:

Emotionally Sensitive Child + Traumatic Childhood Event + A Family that does not properly nurture the child's emotional needs = an adult with Borderline Personality Disorder.

*Marsha Linehan is the Therapist who developed Dialectical Behavioral Therapy, a therapy clinically proven to have significant results in the treatment of BPD. She herself was a Borderline when she developed DBT, a therapy based on a combination of Cognitive Behavioral therapy and the Buddhist practice of Mindfulness.

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Excellent - thanks for sharing that. One p-doc dxed me with Borderline, and to be honest, I only related to Borderline as one who was manipulative (which as a survivor is a naural tendency to survivor,) and I never did allow myself to furher explore this, I just went on thinking I'm depressed and anxious, which I imagine are by-products of being Borderline. Anyway, I am taking through my hat here, but thanks for this info. I need to get into the literature.

Sylvia

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Excellent - thanks for sharing that. One p-doc dxed me with Borderline, and to be honest, I only related to Borderline as one who was manipulative (which as a survivor is a naural tendency to survivor,) and I never did allow myself to furher explore this, I just went on thinking I'm depressed and anxious, which I imagine are by-products of being Borderline. Anyway, I am taking through my hat here, but thanks for this info. I need to get into the literature.

Sylvia

for obsessive reasons, i've read too much lit on bpd.  (too much time on my hands i guess)  i'll be posting another info post tomorrow, it just needs some fine tuning.  please feel free to ask me, or the mods of this board, if you have any questions.  i'm always avail via PM.  well, sometimes i go to class.  but i'm sick right now, so i have free time, so feel free to pick away at my little brain.

penny

and yeah... manipulator is what most non bpds seee borderline as.  the other stuff is internal and hard to see and define.  unless you're linehan and are both a borderline and a phd in psych... then you're amazing at describing it.

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Thanks PC

I will keep my eye out for your posts, I have to admit I hated that label. But, after much therapy and hard work, I feel ready to get a good objective definition, especially if it can serve me better as I continue to deal with some anger issues.

Have a good night - feel better.

Syl

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See I grew up without a significant loss (as a child anyway) in a fairly happy home, (two married parents and a brother, no divorce, substance abuse or mental illness) with no sexual molestation at all. I was a quiet, unassuming but pleasant kid, I wasn't prone to tantrums at all. My parents worked a lot but I remember school being a place where I was validated and praised, so I don't think I was ever told to grin and bear it or invalidated. However I did suffer extensive abuse and a death in my teens, so maybe that is where I fit the theory.

I am finding more and more that the best way to deal with my problems and my sense of self is not to look at BPD lit, but to look to my own experiences and who I wish to be. I do fit the DSMV in some respects and not in others. My therapist says that kids who know that acting out will go unnoticed often don't act out, so I am not surprised that I don't fit the mould, everyone has a unique personality and life experience, it is that we should be valuing, not some experts model. It can be helpful but it is just a theory.

After all, you can apply those traits to many people, or all of them to teenagers, a significant life problem would produce suicidal ideations or impulsive behaviour, we could all pick out and box up people who we felt were BPD if we wanted to, it's too crude a tool. I have found that thinking of myself as someone defined by that disorder has actually done me harm, giving me all kinds of hang ups about my self and getting what I percieved to be 'better.' Thinking about myself as a whole person who wants to improve herself and grow is far healthier inmho.

Edited by karuna
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I am finding more and more that the best way to deal with my problems and my sense of self is not to look at BPD lit, but to look to my own experiences and who I wish to be. I do fit the DSMV in some respects and not in others. My therapist says that kids who know that acting out will go unnoticed often don't act out, so I am not surprised that I don't fit the mould, everyone has a unique personality and life experience, it is that we should be valuing, not some experts model. It can be helpful but it is just a theory.

i agree that self-knowledge is more important than psychological theories. 

dx's and psychological models are just tools.  not every person fits into a category perfectly. 

i also think that in a LOT of ways dx's can be very damaging.  esp when the dx is something like borderline and is surrounded with so much stigma.  the goal of therapy and medication is to reach a place in life where you are stable and happy, not to get a label stuck on you.  because i was borderline (or am, depending upon whether or not you believe you can recover from it.  my doctors think you can, some people say you can't) i have had a lot of people treat me like utter shit.  people (and some doctors) saw only my diagnosis and not the person underneath the label.  this is, of course, a horrible way to treat people and i would love it if it never happened again.

despite this, i still find linehan's theories to be useful for several reasons.

the first reason is that her theories do happen to resonate deeply with my experience.  when i was first dx'd BPD i fit the dx perfectly.  i had every one of the required traits.  when i read linehan's text, i sobbed because i felt like she was inside my head. she also offered an alternate definition of borderline (that i will cover elsewhere) that i found to be more dynamic and useful than the DSM.  and, unlike other things i had read on borderline, her theories offered not just symptoms and plausible causes, but also a way to get better.

DBT, and so by extension, linehan, saved my life. 

bare bones, what linehan is basically saying is that borderlines have developed destructive coping mechanisms in reaction to trauma and/or a lack of emotional guidance.  i think that by looking at borderline as a coping mechanism, you can take away a lot of the stigma associated with it. 

also, linehan really stresses the importance of validating a person's emotions.  and i think this is something that can help everyone.  to have another person recognize that you are in pain and that your pain is legitimate.  a lot of people feel guilt over their emotions, and this one small thing can really help someone in a moment of crisis. 

additionally, i think if you compare her bio-social model to some of the other theories for how bpd develops, well, at least hers is rational.

i have another linehan post coming, because i have a great deal of respect for her and because i think her work really can help a lot of people. 

but, you're right.  it's just a theory.  i happen to find it compelling because it tallies with my experiences and with those of many other borderlines i have met.  and, to be honest, i am somewhat of a linehan groupie because DBT really changed my life.

i hope that with my second post i will be able to show you that what linehan did with borderline was that she broke down the stigma and mystery of the label of borderline and showed therapists a way to find the human underneath the diagnosis, and help her  to become a healthier human being. 

After all, you can apply those traits to many people, or all of them to teenagers, a significant life problem would produce suicidal ideations or impulsive behaviour, we could all pick out and box up people who we felt were BPD if we wanted to, it's too crude a tool. I have found that thinking of myself as someone defined by that disorder has actually done me harm, giving me all kinds of hang ups about my self and getting what I percieved to be 'better.' Thinking about myself as a whole person who wants to improve herself and grow is far healthier inmho.

you're right.  the dsm is overly broad.  i think a lot of people are mis diagnosed with borderline.  suicidal girl with an eating disorder? borderline! cutter? borderline! 

still, i think there are people who are genuinley borderline.  who really do act in certain ways because they know no other way to survive, and they hurt themselves and those around them because of this.

"borderline" can be a tool or a hinderance on the road to mental health.  if borderline is properly applied as a dx and a patient receives good care from their doctor, then a borderline dx, while it sounds horrible, is a step towards being a healthier person.  if the dx is tossed on too many patients, and those patients are stigmatized and do not receive appropriate care, then borderline can be more than just a hinderance to getting healthier, it can actually make a patient feel worse about themselves.

i do not think that most of the theories in psychology are dangerous, but i think they can be used in dangerous manners.  just like how meds are great, but being put on the wrong med can really fuck up your brain.

best,

penny

Edited by Penny Century
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I agree with the basic premise of BPD in that it is an unhealthy set of coping behaviours and I am willing to give DBT a try, but I do have my reservations. You seem to have researched it well though and feel at peace with that dx so I can't fault that.

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Heya PennyCentury,

I'd heard that Linehan had good ideas but must admit I haven't read her.

Thank you for the analysis, and I look forward to hearing more.

I have a question for you.

I went to a presentation recently where the psychiatrist talking was concerned about the label, "borderline."

He had some thoughts on changing the label.

He tells his patients it's like a "self-identity disorder."

As a family doc, this makes sense a bit, b/c it's really hard for patients to hear "borderline" b/c it *sounds* so pejorative.

So I'm asking you, as someone diagnosed with borderline, and who has done a lot of reading around borderline, does it make *more* sense to re-frame the label "borderline" in more positive terms, or to re-name that symptom cluster as that presenter would do, or ___ ?

Thanks for any thoughts you may have.

--ncc--

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I also feel probably lots are misdiagnosed as borderline....however I believe I am a true borderline.  I don't fit 3 6 or 8 of the criteria.  When I read the DSM (which yes, can sometimes be off)  I feel like this is a label just for me.  The only thing I DONT do is cut and I feel like these days if you cut, you get labeled borderline.  To me, cutting is only a teeny aspect that probably doesn't even occur in most of us.  For me it is the changing identity, abandonment fears, stormy relationships, anger, suicidal behavior and threats, placing your self-worth in someone else, eating disorders......

I don't know.  Seems like what is seen as typical "girl" behavior is often misdiagnosed as this, but really those of us true BPD's know that this is not just a trend or a phase....this is my life......WE don't think we deserve anything......

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I also feel probably lots are misdiagnosed as borderline....however I believe I am a true borderline.  I don't fit 3 6 or 8 of the criteria.  When I read the DSM (which yes, can sometimes be off)  I feel like this is a label just for me.  The only thing I DONT do is cut and I feel like these days if you cut, you get labeled borderline.  To me, cutting is only a teeny aspect that probably doesn't even occur in most of us.  For me it is the changing identity, abandonment fears, stormy relationships, anger, suicidal behavior and threats, placing your self-worth in someone else, eating disorders......

you totally hit the nail on the head with this.  so many ppl are mis diagnosed b/c they're moody girls who cut... but they're NOT bpd.  you're 100% right, the deep charateristics of BPD are the unstable sense of self, abandonment fears, stormy relationships, etc... and these are things that a lot of people really do act out.  a lot of people are pushing to move BPD into BPII as they have a LOT of overlap... but nothing in the DMSIV of BPII deals with the unstable sense of self or abandonment fears and how these shape emotional responses to events.

I don't know.  Seems like what is seen as typical "girl" behavior is often misdiagnosed as this, but really those of us true BPD's know that this is not just a trend or a phase....this is my life......WE don't think we deserve anything......

i agree that mis dxing hurts all parties.  so many people are mis diagnosed that those who really suffer from it become confused because the overdiagnosis takes away from what is unique about being BPD, and it also causes problems because there are not enough docs (imho) qualified to treat BPD out there, and BPDers need all the help they can get... 

i should stop my ranting now ;)

penny

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.  a lot of people are pushing to move BPD into BPII as they have a LOT of overlap... but nothing in the DMSIV of BPII deals with the unstable sense of self or abandonment fears and how these shape emotional responses to events.

Conversely the concept of a 'personality disorder' that has a high number of remitters is a paradox and is outside of the DSM construct of a personality disorder. In the end this may be nothing more than a game of semantics. BPII and BPD respond to the same medications and therapies.

well, i mean there are studies showing that DBT helps borderline more than medication alone. 

i think they are different things because i am in remission due to DBT and i am not medicated as bipolar.  granted, i can not take ssris, but i am not diagnosed bipolar, nor am i now diagnosed borderline.

anyway, there's a pretty good breakdown of the argument that they are the same here that is interesting 

He states that the only difference he sees is "However, I think there is indeed one symptom that differentiates the two (to the extent there's any point in doing so; more on that in a moment)....  People with profound fear of abandonment, and a feeling of chronic emptiness, have a different struggle in life from those who don't have these problems."

but, he characterizes both BP and BPD as having unstable self, and i wonder if he understands what unstable self for borderline means.  to look in the mirror and not know who you are.  to dissociate.  to actually feel that you have no idea who you are.  i no longer have an unstable sense of self, because of therapy.  i do not know what an unstable sense of self feels like to someone with bipolar, perhaps they are the same...  but i think this is also a distinguishing characteristic.

it's a fun semantic debate... but i don't know if it really helps, other than possibly by removing the stigma of BPD. 

penny

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He states that the only difference he sees is "However, I think there is indeed one symptom that differentiates the two (to the extent there's any point in doing so; more on that in a moment)....

Edited by Sylvia
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Yes but until recently BPD was not addressed  the same way as BD. Now that the pharmacological interventions are more analogous to the treatment of BD you are seeing greater efficacy. Insofar as DBT is concerned, psychotherapy is just as important in BD. It goes without saying that good therapy is invaluable but the old philosophy of DBT is the only real hope for BPD is most likely based on comparisons using medications that are generally effective (SSRIs).

the old philosophy of DBT is the only hope?  did i say that?  i don't think it's the only hope.  it worked for me.  it's been studied.  but i don't think anyone ever said it was the only hope?

do you mean based on using meds that are ineffective (SSRIs) or effective?  (just wondering if it's a typo or if you think the studies weren't done with SSRIs)

penny

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  • 1 month later...

NCC,

SO sorry for my late reply (and never posting the other stuff i've been meaning to post.  life got... in the way)

I went to a presentation recently where the psychiatrist talking was concerned about the label, "borderline."

He had some thoughts on changing the label.

He tells his patients it's like a "self-identity disorder."

As a family doc, this makes sense a bit, b/c it's really hard for patients to hear "borderline" b/c it *sounds* so pejorative.

So I'm asking you, as someone diagnosed with borderline, and who has done a lot of reading around borderline, does it make *more* sense to re-frame the label "borderline" in more positive terms, or to re-name that symptom cluster as that presenter would do, or ___ ?

Thanks for any thoughts you may have.

--ncc--

if changing the label actually got rid of the stigma, i'm all for changing it.  the original name came from way back and refered to patients who were on the "borderline" between neurosis and psychosis, and that has nothing to do with the current diagnostic criteria.  i've heard moves to change it to self-identity disorder or affect regulation disorder.  they both make sense.  self-identity moreso to me because i think that is one of the parts of BPD that really sets it apart from other dx's... the lonley, empty, "who am i?" feeling.

when i was dx'd bpd, i looked up the dsm iv and cried because i had finally found an "answer" and i knew, FINALLY what was wrong with me.  and, i was lucky enough to get access to DBT, and now am no longer BPD.

it was not untill i had finished treatment that i learned that borderline is basically a slur in the mental health community.  (even amongst those with mental illness it's an insult, which saddens me.)  i think because i didn't know it was "bad" and i was able to get treatment, i never had to suffer the feeling that i was at the bottom of the barrel of the psychiatric patient world. 

if changing the name would mean that patients would no longer be treated poorly, that the diagnosis would stop being a near-insult, then i'm all for the name change.

would changing the name do that?

i don't know.

penny

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Heya Penny,

He seemed to think so, but I dunno.

I hope so.

I know *too many* docs who give up on the "borderlines" and the "antisocials" b/c of those labels.

Maybe changing the labels would help?

I honestly don't think it would make things worse, but I'm cautious.

--ncc--

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To simplify this theory of the childhood development of Borderline Personality Disorder, one can look at it this way:

Emotionally Sensitive Child + Traumatic Childhood Event + A Family that does not properly nurture the child's emotional needs = an adult with Borderline Personality Disorder.

Is it a thought distortion on my part that I think this describes just about everybody?

Obviously Karuna is an example, until we hit the trauma of teen years.

Having had horrific childhood rearing, I guess I'm just drawn to similar people and I assume everyone was raised like I was. Not everyone, but the majority. You know what I mean?

I also tend to be highly suspiscious of folks who say, "my childhood was dandy, parents stayed together, nurtured us, etc."

I guess I have to read more. I only have "Stop Walking on Eggshells" as a reference. But I still don't feel like I've landed in the right dx bucket. Yes, I have MDD, but it's so f'ing complicated by PTSD, ADD, I'm not looking for another dx, I don't even know what I'm trying to say here other than by the simple definition, in my mind, we ALL are borderline or whatever you call it.

Yet, I know there are people out there who truly did have nurturing childhoods and still ended up mentally ill or drug and alcohol addicted, as I did. Olga for one. But I tend to think they (the collective they) are lying.

Does this make any sense?

S9

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Heya S9,

Yes.

Makes sense.

Recipe for a borderline, that's what it is.  Been saying that for years.

Probly we all have some elements.But.

Also doesn't help if you're a bipolar kid.  So maybe they *are* on a spectrum.

Can't say more.

Just.Can't.

But.  Makes sense.

--ncc--

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