On the last track we discussed methods of control. Four methods of control commonly used by BPD clients are manipulation, coercion, autocracy, and disengagement.
As you probably know, BPD often co-occurs with mood disorders. Have you found clients with borderline personality disorder seem to also suffer from depression? The first trouble I have in this finding, however, is the question of which is the primary disorder?
On this track... we will examine depression co-occurring with borderline personality disorder. We will examine primary depression; primary borderline personality disorder; and the combination of both primary depression and BPD. As you listen to this track, consider evaluating the BPD client you are currently treating to see if co-occurring depression is present.
#1 Primary Depression
The first aspect we will discuss is when depression is the primary disorder. Clients who have primary depression may exhibit symptoms of BPD. As you are aware, they may display transient paranoia, chronic feelings of emptiness, recurrent suicidal behavior, or an unstable self-image. This depressive state may lead to a client experiencing distorted perceptions based on depression. Also, the client may be unable to make up his or her mind about trivial matters.
In conjunction with these BPD symptoms, clients also display the tell-tale signs of depression. Some may sleep for long hours during the day. Many experience weight gain, listlessness, hopelessness, or the urge to cry at inappropriate times. Emily, age 34, was a client of mine who had originally been referred to me as a BPD client. Emily had reported impulsivity and periods of despair. However, she did not meet the criteria for borderline personality disorder. Instead, many of her other symptoms such as her overeating seemed to affect her daily life more than her BPD symptoms.
I asked Emily how she had been feeling lately and Emily stated, "Actually, not so good. I just went through a terrible divorce, so I feel like a wreck. I don’t feel like getting out of bed in the morning. But then I feel restless when I stay in bed. All I want to do is watch TV and eat junk food. This isn’t like me at all. I used to feel great about myself. Now, since there’s no one there to look good for, I’ve stopped trying." As you can clearly see, Emily seems to fit the diagnosis for depression not borderline personality disorder.
Think of your Emily. Could a cross-sectional presentation of depression mimicking some BPD symptoms lead to a possible misdiagnosis?
#2 Primary Borderline Personality Disorder
The second aspect of co-occurring depression and borderline personality disorder is when BPD is the primary disorder. When a client suffers from a primary borderline personality disorder, depression may be a result of the first condition. Many times, BPD can lead a client to become easily depressed and hopeless about a situation if they feel they cannot control it. Typically, I have found that clients whose BPD occurs primarily tend to have less intense depressive symptoms than those whose depression occurs primarily.
Tessa, age 31, was a BPD client of mine who had reported feelings of depression. Tessa stated, "When my sister was sick for a long while in the hospital, I was feeling almost as sick about losing her. I really needed her around, and it almost seemed like she was abandoning me on purpose. I kept expecting that call with the doctor on the other end saying, ‘We couldn’t do anything for her.’ Even though I knew the cancer was in remission, I had this overwhelming feeling that I would never see her again. This went on for about three months, and after a while, all I felt like doing was laying in bed and crying."
As you can see, as a result of her BPD, Tessa had developed depression. I explained to Tessa that these feelings of listlessness could be a symptom of her BPD. Her body had been so overwhelmed by worry that it was starting to shut down emotionally.
Technique: The Thinking Habit
To help Tessa overcome her feelings of depression, I introduced her to "The Thinking Habit" technique. This technique offers a BPD client experiencing symptoms of depression an alternative to negative thinking. As I found with Tessa, "The Thinking Habit" also puts the BPD client into a position where he or she must hold themselves accountable for the way he or she feels.
To explain "The Thinking Habit" to Tessa, I stated, "Let your thoughts flow. If any form of negativity enters your mind, let it pass by. Don’t even give it the time of day. Remain disinterested in the negative. Put your attention on positive thoughts like your sister’s recovery and your renewed relationship with her. How are you feeling?" Tessa stated that the way she felt depended on the way she was thinking.
Essentially, when Tessa’s thoughts were hopeful and positive, that was the way she felt. Conversely, Tessa stated, "When I start getting all pessimistic, I start feeling like shit all over again!" Think of your Tessa. Could she benefit from "The Thinking Habit"?
#3 Both Primary Depression and BPD
In addition to primary depression and primary borderline personality disorder, the third combination we will discuss is when both BPD and depression occur primarily. As you know, when this occurs, a differential diagnosis must be made. To do this, I examine the client’s medical history and the sequence of the symptoms, to perhaps discover if one may trigger the other. To obtain a differential diagnosis, I first ascertain a client’s mental health.
To do so, I use the following list of criteria as a secondary interview to discover co-occurrence of multiple problems. As I list these 12 criteria, consider your BPD client and his or her susceptibility to co-occurring disorders.
General appearance, manner, and attitude. Clients with borderline personality disorder may appear calm during the interview.
Consciousness, including orientation as to time, place, and person.
Apperception verses perception as modified by one’s own emotions, memories, and biases.
Affectivity and mood. Intense episodic dysphoria, irritability, or anxiety typify BPD.
Conation and motor aspects of behavior.
Associations and stream of thought.
Thought life and mental trend including delusions (false beliefs). I might suggest asking about dissociative symptoms or stress-related paranoia.
Perception, including auditory and visual hallucinations.
Memory, both recent and remote. Recall may be difficult for the BPD client.
Function of information. Intellectual function is generally intact in clients with BPD.
Judgment. The ability to consistently compare facts or ideas, to understand their relations and to draw realistic conclusions from them is not common among BPD clients.
Insight, the extent to which a client is aware that he or she is ill. BPD clients are often unwilling to accept an emotional explanation for what they believe to be a physical condition.
Using these criteria, I map out a line of questioning that can then be adapted for each client.
On this track... we discussed depression co-occurring with borderline personality disorder. We explored primary depression; primary BPD; and when both depression and BPD are primary.
On the next track we will discuss revisiting home. Three aspects regarding revisiting home as it relates to the BPD client are tension at home, dealing with residual effects, and maintaining control.
What are three aspects of a co-occurring borderline personality disorder and depression?
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