Eating Disorders: Handling Co-Occurring Borderline and Narcissistic Personality Disorders

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1 Eating Disorders: Handling Co-Occurring Borderline and Narcissistic Personality Disorders Dena Cabrera, PsyD, CEDS Executive Clinical Director Rosewood Centers for Eating Disorders

2 ASAM Disclosure of Relevant Financial Relationships Content of Activity: 2015 Cape Cod 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

3 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.

4 Agenda Eating Disorders Co-morbidity Assessment Treatment Finding Hope

5 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

6 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

7 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

8 Narcissus and Echo Narcissism: To Self-worship. Excessive selfabsorption is a protection against unconscious but powerful feelings of inadequacy. Pursuit to gain a sense of self.

9 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)

10 (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 highstatus people (or institutions) (4) requires excessive admiration (5) has a sense of entitlement, i.e.,

11 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 attitudes

12 Traits Common to BPD & NPD Pervasive shame Undefined Boundaries Control Issues Lack of Object Constancy Interpersonal Sensitivity Situational Competence

13 Biopsychosocial Theory of Emotions Attachment Identity Loss Trauma Wound Emotional Dysregulation Invalidating Environment

14 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.

15 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.

16 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.

17 Instead of: Reframe the Behavior Manipulating Gamey Lying Borderline

18 Reframe to: Reframe the Behavior Getting their needs met without being controlled

19 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.

20 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

21 In therapy get out of the becauses.

22 About Clients People are doing the best that they can. People want to improve DBT Assumptions People must learn new behaviors both in therapy and in the context of their dayto-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.

23 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.

24 Acceptance and Change Strategies Tools (DBT Apps) Behavior Chain Analysis (Handout) Diary Cards (Handout) Pros / Cons

25 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

26 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

27 Treatment Approach = Team Approach BIOLOGICAL SPIRITUAL PSYCHOLOGICAL SOCIAL

28 Distressed The Self-Injury Cycle Stage 2 - The breaking point the cutting begins *Intervention Stage 3 The self-injury itself. Tension Building Begins Stage 1 Stage 4 The self-injury stops Stage 6 Regret / Never Again Feeling Bad Stage 5 Relief/Recovery *Intervention Time

29 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

30 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

31 3. Restricting, tired, 3 Red Bulls 2. Boyfriend broke up with her Mom s critical; Dad s punishment BCA Self Injury Consequences: Mom comes to rescue go shopping Long term Consequences:

32 SOLUTION ANALYSIS 3. Hungry, caffeine, tired 2. Boyfriend, Mom s critical; Dad s punishment Be Honest Ask for Help Radical Acceptance Self-Soothing

33 SOLUTION ANALYSIS 4. Felt Shame Opposite to Emotion 4. Felt upset Wise Mind 4. I m worthless 4. Go to the bathroom Grateful List

34 SOLUTION ANALYSIS 4. I m worthless 4. Go to the bathroom Grateful List 4. Find a Friend 4. Pros/Cons 1. Self Injury Pray

35 SOLUTION ANALYSIS Consequences: 1. Self Injury (+)Relief (+) shopping Loss of trust, $, time, low self esteem (-) Shame, depression,

36 START Finish 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 Self-Harming Behavior What will you do differently next time? Call therapist for Coaching Radical acceptance Links can include: Actions Body Sensations Thoughts Feelings Event

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39 Skills Training Increase skill acquisition and strength 4 Modules 1.Mindfulness 2.Distress Tolerance 3.Emotion Regulation 4.Interpersonal Effectiveness (LInehan, 1993)

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41 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 Recognition Acceptance Investigation Non-identification Mindful Transformation: RAIN (Kornfield, 2008)

42 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.

43 Mindful Exercises and Meditation Can be difficult with ED patients trigger anxiety, self-critical states, confusion, hypoarousal, judging mind, comparing mind The Mindfulness App by MindApps $1.99

44 Teens Awareness Exercise 1. Find a favored object (ex. Rock, shell, blanket) 2. Have the teen hold the object for at least a few minutes 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.

45 Teach self-awareness of experience CDs for practicing Mindfulness Airy 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

46 My House We want you to compare your self to a house, outside and inside. First, draw or describe your life as if it where a house. Be specific. Note color size, style and condition of your house. What is around it? Does it stand alone or in a community? Now, think about the inside of your house. Describe what it looks like. Is it cozy an d inviting, or modern and cold? Are the rooms messy or organized? Keeping in mind the eating disorder and the effects it may have on your body, what type of repairs does your house need? How do you feel about your house? How would you change your house if you could change anything you wanted to? How did you feel about doing the assignment?

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48 Goals of Distress Tolerance Decreasing agony associated with emotional pain Crisis Survival Strategies Comforting Skills Guidelines for Accepting Reality

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50 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

51 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

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53 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

54 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 Psychiatric Intervention 54

55 FAMILY INVOLVEMENT THE THREE R S: Recognizing behaviors that are part of the illness Do not assume the worst. Don t be judgmental. Validate your child. Resisting being 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.

56 FAMILY INVOLVEMENT THE THREE R S: Reconstructing a meaningful relationship with their teen Choose the most effective response

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58 What s this about for me? HOPE PURPOSE VALUE MEANING We must embrace pain and burn it as fuel for our journey. Kenji Miyazawa

59 Dena Cabrera, PsyD., CEDS Executive Clinical Director Licensed Clinical Psychologist Rosewood Center for Eating Disorders Handouts: