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INDEX 1. Introduction


1. Cluster B (the "dramatic, emotional, erratic" cluster a. Antisocial Personality Disorder b. Histrionic Personality Disorder c. Narcissistic Personality Disorder d. Borderline Personality Disorder 2. Cluster A (the "odd, eccentric" cluster) a. Paranoid personality disorder b. Schizoid personality disorder c. Schizotypal personality disorder 3. Cluster C (the "anxious, fearful" cluster) a. Avoidant personality disorder b. Dependent personality disorder c. Obsessive-compulsive personality disorder 4. Personality disorder not otherwise specified

2. Codependence

4 5 6 7 11 11 12 13 14 14 15


Are you codependent Comparison: healthy vs codependent friendship Help! Can I Fix it? Helping a person who is codependent The 12 Traditions / The 12 Steps Recovery steps Self Affirmations that work

3. Narcissistic Personality Disorder Symptoms of Narcissistic Personality Disorder Relationships 20 Traits of malignant Narcissistic Personality Disorder

4. Borderline Personality Disorder Symptoms of Borderline Personality Disorder Frequently Asked Questions Guidelines for families, partners and friends Online Test Substance Abuse Treatment Self Injurious Behaviour Consequences of alcohol and drugs abuse Anxiety and panic attack symptoms Attention Deficit Hyperactivity Disorder and Borderline


28 32 37 38 41 53 70

75 76 86 95

101 110 116 118 122 127 129 132 133 134

1. INTRODUCTION Most of the personality disorders described in this publication are part of the Cluster B Personality Disorders. Disorders in this cluster are of a dramatic, emotional and / or erratic nature. This implies that people suffering from these disorders have problems with impulse control and emotional regulation Cluster B includes: 5. 6. 7. 8.

Antisocial Personality Disorder. Histrionic Personality Disorder. Narcissistic Personality Disorder. Borderline Personality Disorder.

1. Antisocial Personality Disorder The Antisocial Personality Disorder is characterized by a pervasive pattern of disregard for, and violation of, the rights of other people that often manifests as hostility and/or aggression. Deceit and manipulation are also central features. In many cases hostile-aggressive and deceitful behaviours may first appear during childhood or early adolescence and continue into adulthood. People with antisocial personality disorder have been described as lacking empathy (or the ability to “put yourself in someone else’s shoes” to understand their feelings), and they may often be deceitful or break the law. Antisocial personality disorder is also associated with impulsive behaviour, aggression (such as repeated physical assaults), disregard for their own or other’s safety, irresponsible behaviour, and lack of remorse. • • • •

These people may hurt or torment animals or people. They may engage in hostile acts such as bullying or intimidating others. They may have a reckless disregard for property such as setting fires. They often engage in deceit, theft, and other serious violations of standard rules of conduct.

When this is the case, Conduct Disorder (a juvenile form of Antisocial Personality Disorder) may be an appropriate diagnosis. Conduct Disorder is often considered the precursor to an Antisocial Personality Disorder. • •

In addition to reckless disregard for others, they often place themselves in dangerous or risky situations. They frequently act on impulsive urges without considering the consequences. This difficulty with impulse control results in loss of employment, accidents, legal difficulties, and incarceration.

Persons with Antisocial Personality Disorder typically do not experience genuine remorse for the harm they cause others. However, they can become quite adept at feigning remorse when it is in their best interest to do so (such as when standing before a judge). They take little to no responsibility for their actions. In fact, they will often blame their victims for "causing" their wrong actions, or deserving of their fate. The aggressive features of this personality disorder make it stand out among other personality disorders as individuals with this disorder take a unique toll on society. 2. Histrionic Personality Disorder Persons with Histrionic Personality Disorder are characterized by a pattern of excessive emotionality and attention seeking. Their lives are full of drama (socalled "drama queens"). They are uncomfortable in situations where they are not the centre of attention. The central features of histrionic personality disorder are intense expressions of emotion and excessive attention-seeking behaviour. People with histrionic personality disorder often seek out attention and are uncomfortable when others are receiving attention. They may often engage in seductive or sexually promiscuous behaviour, or use their physical appearance to draw attention to themselves. They also may demonstrate rapidly shifting emotions and express emotion in a very dramatic fashion.


• • •

People with this disorder are often quite flirtatious or seductive, and like to dress in a manner that draws attention to them. They can be flamboyant and theatrical, exhibiting an exaggerated degree of emotional expression. Yet simultaneously, their emotional expression is vague, shallow, and lacking in detail. This gives them the appearance of being disingenuous and insincere. Moreover, the drama and exaggerated emotional expression often embarrasses friends and acquaintances as they may embrace even casual acquaintances with excessive ardor, or may sob uncontrollably over some minor sentimentality. People with Histrionic Personality Disorder can appear flighty and fickle. Their behavioural style often gets in the way of truly intimate relationships, but it is also the case that they are uncomfortable being alone. They tend to feel depressed when they are not the centre of attention. When they are in relationships, they often imagine relationships to be more intimate in nature than they actually are. People with Histrionic Personality Disorder tend to be suggestible; that is, they are easily influenced by other people's suggestions and opinions.

3. Narcissistic Personality Disorder Narcissistic personality disorder is characterized by an inflated sense of selfimportance. People with narcissistic personality disorder often believe that they are “special,” require excessive attention, take advantage of others, lack empathy, and are described by others as arrogant. People with Narcissistic Personality Disorder have significant problems with their sense of self-worth stemming from a powerful sense of entitlement. This leads them to believe they deserve special treatment, and to assume they have special powers, are uniquely talented, or that they are especially brilliant or attractive. Their sense of entitlement can lead them to act in ways that fundamentally disregard and disrespect the worth of those around them. •

People with Narcissistic Personality Disorder are preoccupied with fantasies of unlimited success and power, so much so that they might end up getting lost in their daydreams while they fantasize about their superior intelligence or stunning beauty.

• • •

• •

These people can get so caught up in their fantasies that they don't put any effort into their daily life and don't direct their energies toward accomplishing their goals. They may believe that they are special and deserve special treatment, and may display an attitude that is arrogant and haughty. This can create a lot of conflict with other people who feel exploited and who dislike being treated in a condescending fashion. People with Narcissistic Personality Disorder often feel devastated when they realize that they have normal, average human limitations; that they are not as special as they think, or that others don't admire them as much as they would like. These realizations are often accompanied by feelings of intense anger or shame that they sometimes take out on other people. Their need to be powerful, and admired, coupled with a lack of empathy for others, makes for conflictual relationships that are often superficial and devoid of real intimacy and caring. Status is very important to people with Narcissistic Personality Disorder. Associating with famous and special people provides them a sense of importance. These individuals can quickly shift from over-idealizing others to devaluing them. However, the same is true of their self-judgments. They tend to vacillate between feeling like they have unlimited abilities, and then feeling deflated, worthless, and devastated when they encounter their normal, average human limitations. Despite their bravado, people with Narcissistic Personality Disorder require a lot of admiration from other people in order to bolster their own fragile self-esteem. They can be quite manipulative in extracting the necessary attention from those people around them.

4. Borderline Personality Disorder BPD is associated with specific problems in interpersonal relationships, self-image, emotions, behaviours, and thinking. People with BPD tend to have intense relationships characterized by a lot of conflict, arguments and break-ups. They also have difficulties related to the stability of their identity or sense of self. They report many "ups and downs" in how they feel about themselves. Individuals with


BPD may say that they feel as if they are on an emotional roller coaster, with very quick shifts in mood (for example, going from feeling OK to feeling extremely down or blue within a few minutes). BPD is associated with a tendency to engage in risky behaviours, such as going on shopping sprees, drinking excessive amounts of alcohol or abusing drugs, engaging in promiscuous sex, binge eating, or self-harming. Borderline Personality Disorder is one of the most widely studied personality disorders. People with Borderline Personality Disorder tend to experience intense and unstable emotions and moods that can shift fairly quickly. They generally have a hard time calming down once they have become upset. As a result, they frequently have angry outbursts and engage in impulsive behaviours such as substance abuse, risky sexual liaisons, self-injury, overspending, or binge eating. These behaviours often function to sooth them in the short-term, but harm them in the longer term. • •

• •

People with Borderline Personality Disorder tend to see the world in polarized, over-simplified, all-or-nothing terms. They apply their harsh either/or judgments to others and to themselves and their perceptions of themselves and others may quickly vacillate back and forth between "all good" and "all bad." This tendency leads to an unstable sense of self, so that persons with this disorder tend to have a hard time being consistent. They can frequently change careers, relationships, life goals, or residences. Quite often these radical changes occur without any warning or advance preparation.

Black-and-White Thinking and Emotion Deregulation in Borderline Personality Disorder People with Borderline Personality Disorder tend to view the world in terms of black-and-white, or all-or-nothing thinking. Their tendency to see the world in black-or-white (polarized) terms makes it easy for them to misinterpret the actions and motivations of others. These polarized thoughts about their relationships with others lead them to experience intense emotional reactions, which in turn interacts with their difficulties in regulating these intense emotions. The result is that they will characteristically experience great distress which they cannot easily control and may subsequently engage in self-destructive behaviours as they do their best to cope. The intensity of their emotions, coupled with their difficulty regulating these emotions, leads them to act impulsively.

To illustrate the way black-and-white thinking, emotional dys-regulation, and poor impulse regulation all merge and culminate to create interpersonal conflict and distress, let's use an example: Suppose the partner of a woman with Borderline Personality Disorder fails to remember their anniversary. Black-and-white thinking causes her to conclude, "He doesn't love me anymore" and all-or-nothing thinking leads her to (falsely) conclude, "If he does not love me, then he must hate me." Such thoughts would easily lead to some pretty intense emotions, such as feeling rejected, abandoned, sad, and angry. She has a hard time tolerating and dealing with these intense feelings and consequently becomes highly upset and overwhelmed. The intensity of her negative feelings seems unbearable. Next she has a powerful impulse to "do something" just so that these feelings will go away. She might angrily accuse her partner of having an affair and she might plead with her partner not to leave her. Meanwhile her partner is baffled by this extreme reaction, particularly since he is not having an affair, and he readily recalls all his other recent loving gestures. Her partner might also become angry at these wild accusations of infidelity and so the conflict escalates and things get more intense. Alone after the fight, the woman feels overwhelming self-loathing or numbness and goes on to intentionally injure herself (by cutting or burning herself) as a way to cope with her numbness. When her partner learns about this self-harm behaviour he can't understand it and concludes he is being manipulated. He expresses his strong concern for her well-being but also his anger. In turn, she feels misunderstood. Clearly, the Borderline Personality Disorder with its combination of distorted thought patterns, intense and under-regulated emotions, and poor impulse control is practically designed to wreak havoc on any interpersonal relationship. It is important to remember that everyone can exhibit some of these personality traits from time to time. To meet the diagnostic requirement of a personality disorder, these traits must be inflexible; i.e., they can be regularly observed without regard to time, place, or circumstance. Furthermore, these traits must cause functional impairment and/or subjective distress. Functional impairment means these traits interfere with a person's ability to functional well in society. The symptoms cause problems in interpersonal relationships; or at work, school, or home. Subjective distress means the person with a personality disorder may experience their symptoms as unwanted, harmful, painful, embarrassing, or otherwise cause them distress. The above list only briefly summarizes these individual Cluster B personality


disorders. Richer, more detailed descriptions of these disorders are found in the section describing the four core features of personality disorders.

Which Other Personality Disorders are defined in the DSM-5 ? The four defining features of personality disorders are: 1) 2) 3) 4)

Distorted thinking patterns, Problematic emotional responses, Over- or under-regulated impulse control, and Interpersonal difficulties.

These four core features are common to all personality disorders. Before a diagnosis is made, a person must demonstrate significant and enduring difficulties in at least two of those four areas: Furthermore, personality disorders are not usually diagnosed in children because of the requirement that personality disorders represent enduring problems across time. These four key features combine in various ways to form ten specific personality disorders identified in DSM-5 (APA, 2013). Each disorder lists asset of criteria reflecting observable characteristics associated with that disorder. In order to be diagnosed with a specific personality disorder, a person must meet the minimum number of criteria established for that disorder. Furthermore, to meet the diagnostic requirements for a psychiatric disorder, the symptoms must cause functional impairment and/or subjective distress. This means the symptoms are distressing to the person with the disorder and/or the symptoms make it difficult for them to function well in society. Furthermore, the ten different personality disorders can be grouped into three clusters based on descriptive similarities within each cluster. These clusters are: Cluster A (the "odd, eccentric" cluster) Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder P.M. : Cluster B (the "dramatic, emotional, erratic" cluster) Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Cluster C (the "anxious, fearful" cluster) Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder

Oftentimes, a person can be diagnosed with more than just one personality disorder. Research has shown that there is a tendency for personality disorders within the same cluster to co-occur (Skodol, 2005). Later, this issue of cooccurrence will be discussed in greater detail. The alternative model of personality disorder, proposed for further study in DSM-5 (APA, 2013), hopes to reduce this overlap by using a dimensional approach versus the present categorical one. These different models are discussed in another section. Now let's look at how all four core features merge to create specific patterns called personality disorders. Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Cluster A is called the odd, eccentric cluster. It includes Paranoid Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorders. The common features of the personality disorders in this cluster are social awkwardness and social withdrawal. These disorders are dominated by distorted thinking. The Paranoid Personality Disorder is characterized by a pervasive distrust and suspiciousness of other people. People with this disorder assume that others are out to harm them, take advantage of them, or humiliate them in some way. They put a lot of effort into protecting themselves and keeping their distance from others. They are known to preemptively attack others whom they feel threatened by. They tend to hold grudges, are litigious, and display pathological jealously. Distorted thinking is evident. Their perception of the environment includes reading malevolent intentions into genuinely harmless, innocuous comments or behaviour, and dwelling on past slights. For these reasons, they do not confide in others and do not allow themselves to develop close relationships. Their emotional life tends to be dominated by distrust and hostility. The Schizoid Personality Disorder is characterized by a pervasive pattern of social detachment and a restricted range of emotional expression. For these reasons, people with this disorder tend to be socially isolated. They don't seem to seek out or enjoy close relationships. They almost always chose


solitary activities, and seem to take little pleasure in life. These "loners" often prefer mechanical or abstract activities that involve little human interaction and appear indifferent to both criticism and praise. Emotionally, they seem aloof, detached, and cold. They may be oblivious to social nuance and social cues causing them to appear socially inept and superficial. Their restricted emotional range and failure to reciprocate gestures or facial expressions (such a smiles or nods of agreement) cause them to appear rather dull, bland, or inattentive. The Schizoid Personality Disorder appears to be rather rare. Persons with Schizotypal Personality Disorder are characterized by a pervasive pattern of social and interpersonal limitations. They experience acute discomfort in social settings and have a reduced capacity for close relationships. For these reasons they tend to be socially isolated, reserved, and distant. Unlike the Schizoid Personality Disorder, they also experience perceptual and cognitive distortions and/or eccentric behaviour. These perceptual abnormalities may include noticing flashes of light no one else can see, or seeing objects or shadows in the corner of their eyes and then realizing that nothing is there. People with Schizotypal Personality Disorder have odd beliefs, for instance, they may believe they can read other people's thoughts, or that that their own thoughts have been stolen from their heads. These odd or superstitious beliefs and fantasies are inconsistent with cultural norms. Schizotypal Personality Disorder tends to be found more frequently in families where someone has been diagnosed with Schizophrenia; a severe mental disorder with the defining feature of psychosis (the loss of reality testing). There is some indication that these two distinct disorders share genetic commonalities (Coccaro & Siever, 2005).

Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. These three personality disorders share a high level of anxiety. The Avoidant Personality Disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to negative evaluation. People with this disorder are intensely afraid that others will ridicule them, reject them, or criticize them. This leads them to avoid social situations and to avoid interactions with others. This further limits their ability to develop social skills. People with Avoidant Personality Disorders often have a very limited social world with a small circle of confidants. Their social life is otherwise rather limited.. Their way of thinking about and interpreting the world revolves around the thought that they are not good enough, and that others don't like them. They think of themselves as unappealing and socially inept. These types of thoughts create feelings of intense anxiety in social situations, along with a fear of being ridiculed, criticized, and rejected. The intensity of this fearful anxiety, and the discomfort it creates, compels them to avoid interpersonal situations. They might avoid parties or social events, and may have difficulty giving presentations at work or speaking up in meetings. Others might perceive them as distant or shy.


They likely come across as stiff and restricted. All this will likely interfere with their ability to make friends, or to move ahead professionally. The core feature of the Dependent Personality Disorder is a strong need to be taken care of by other people. This need to be taken care of, and the associated fear of losing the support of others, often leads people with Dependent Personality Disorder to behave in a "clingy" manner; to submit to the desires of other people. In order to avoid conflict, they may have great difficulty standing up for themselves. The intense fear of losing a relationship makes them vulnerable to manipulation and abuse. They find it difficult to express disagreement or make independent decisions, and are challenged to begin a task when nobody is available to assist them. Being alone is extremely hard for them. When someone with Dependent Personality Disorder finds that a relationship they depend on has ended, they will immediately seek another source of support. Persons with Obsessive-Compulsive Personality Disorder are preoccupied with rules, regulations, and orderliness. This preoccupation with perfectionism and control is at the expense of flexibility, openness, and efficiency. They are great makers of lists and schedules, and are often devoted to work to such an extent that they often neglect social relationships. They have perfectionist tendencies, and are so driven in their work to "get it right" that they become unable to complete projects or specific tasks because they get lost in the details, and fail to see the "forest for the trees." Persons with Obsessive-Compulsive Personality Disorder tend to be rigid and inflexible in their approach to things. It simply isn't an option for them to do a "sub-standard" job just to get something done. Often, they are unable to delegate tasks for fear that another person will not "get it right." Sometimes people with this disorder adopt a miserly style with both themselves and others. Money is regarded as something that must be rigidly controlled in order to ward off future catastrophe. People with this disorder are often experienced as rigid, controlling, and stubborn.

Note: It is important to remember that everyone can exhibit some of these personality traits from time to time. To meet the diagnostic requirement of a personality disorder, these traits must be inflexible; i.e., they can be repeatedly observed without regard to time, place, or circumstance. Furthermore, these traits must cause functional impairment and/or subjective distress. The above list only briefly summarizes these individual Cluster A personality disorders. Richer, more detailed descriptions of these disorders are found in the section describing the four core features of personality disorders. Personality disorder not otherwise specified Personality disorder not otherwise specified, also referred to as personality disorder NOS, is a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR). In current clinical practice, recognized mental health conditions and disorders are grouped by a general category — then by specific clinical diagnosis. Under “Mood Disorders” for example, we have Major Depression, Dysthymia, Bipolar Disorder (several types), Cyclothymia, and even Mood Disorder NOS. “Personality Disorders” is one of the general categories. This category is often given to individuals who have a long history of personality, behaviour, emotional, and relationship difficulties. This group is said to have a “personality disorder” — an enduring pattern of inner experience (mood, attitude, beliefs, values, etc.) and behaviour (aggressiveness, instability, etc.) that is significantly different from those in their family or culture. These dysfunctional patterns are inflexible and intrusive into almost every aspect of the individual’s life. These patterns create significant problems in personal and emotional functioning and are often so severe that they lead to distress or impairment in all areas of functioning. (Source: DSM-IV.) In my observation, Personality Disorders often have core personalities of selfpreoccupation, insensitivity to others, a refusal to accept personal responsibility (it’s always someone else’s fault), and a tremendous sense of entitlement. If a person has been diagnosed with a mood disorder, e.g. Bipolar l (Mixed) and a Personality Disorder NOS, than this is a way of saying that while that person requires treatment for Bipolar Disorder, the clinician suspects that he may have long-standing personality features that may complicate the treatment and/or recovery. The NOS diagnostic category is reserved for a clinically significant problem in personality functioning that does not fit into any of the other existing personality


disorder categories. It suggests that a full pattern of a specific personality disorder may not be present. This person may have a few symptoms of one type of personality disorder, but not enough to meet diagnostic criteria. Or perhaps he has some symptoms of one personality disorder and a few symptoms of another type. In either case, the provider has decided that while the symptoms are not a perfect match for any existing personality disorder category, they are important enough to warrant a diagnosis of PD-NOS. In treating such a patient, while this diagnosis sounds like a bunch of labels, it’s very important. The diagnosis means that the patient will need a combination of psychiatric treatment for the Bipolar Disorder and counselling/therapy to address the Personality Disorder features. Furthermore, treatment for Bipolar Disorder focuses on emotional and social stability — preventing both depressive and manic episodes. When treating individuals with personality disorder features, medication noncompliance is higher. Cluster B folks are more difficult to treat due to their emphasis on excitement and emotional drama. If the patient has Borderline Personality Disorder features, there is an additional risk for self-harm.

Sources: The Ten Personality Disorders: Cluster B by Authors: Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D., & Mark Dombeck, Ph.D. - EDITOR: MATTHEW S. GOODMAN, M.A., BCB American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition. American Psychiatric Association: 2000. DSM-5: The Ten Personality Disorders: SIMONE HOERMANN, PH.D., CORINNE E. ZUPANICK, PSY.D. & MARK DOMBECK, PH.D. DEC 6, 2013 Recently Diagnosed Personality Disorder NOS. What Does That Mean? Dr Joseph M Carver, PhD

CODEPENDENCE A compilation of Public Domain Publications about CODEPENCE. More compilations by Dean Amory are available at:

AUTHORS : Dr. Irene Matiatos Ph.D. Daniel Ploskin, MD Royane Real Melody Beattie Patty E. Fleener M.S.W. Wikipedia Encyclopedy


2. Codependence By Dr. Irene Matiatos Ph.D. Source: Some of the nicest people I know are codependent. They always smile, never refuse to do a favor. They are happy and bubbly all the time. They understand others and have the ability to make people feel good. People like them! So, what is wrong with this? Nothing, really, unless the giving is one-sided and so excessive that it hurts the giver. Then, the giver is showing the signs of codependence. Partners who go out of their way for each other are interdependent. Only relatively healthy people are capable of interdependent relationships, which involve give and take. It is not unhealthy to unilaterally give during a time when your partner is having difficulty. You know your partner will reciprocate should the tables turn. Interdependency also implies that you do not have to give until it hurts. By comparison, in a codependent relationship, one partner does almost all the giving, while the other does almost all the taking, almost all of the time. By giving, codependent people avoid the discomfort of entitlement. Giving allows them to feel useful and justifies their existence. Rather than simply approving of themselves, codependent people meet their need for self-esteem, by winning their partner's approval. Also, because they lack self-esteem, codependent people have great difficulty accepting from others. One must feel deserving and entitled in order to accept what is offered. Codependent behaviour is not easy. It requires a lot of work. It hurts. These individuals typically suffer with low self-esteem, depression, anxiety, and especially guilt, as well as other painful thoughts and feelings. They judge themselves using far stricter criteria than they use to measure the performance of others. While they are brutally critical of their own misbehaviour, they are very good at justifying and excusing the misbehaviour of others.


Codependent people misplace their anger. They get angry when they shouldn't, and don't get angry when they should. They have little contact with their inner world and thus very little idea about how they feel. Usually, they don't want to know because it gives rise to painful emotions. It is easier to stay on the surface and pretend things are peachy keen, rather than deal with the stuff going on inside. If they were to look inside, they would find their emotional starvation. They are busy taking care of others. Yet, they do not meet their own needs! They may put up with abusive relationships or relationships that are not fulfilling because any warm body beats (gasp) no warm body. Being alone is perceived as scary, empty, depressing, etc. After all, who will deliver their emotional supplies? Who will distract them so there is no time to deal with their inner life? Even an abusive relationship is better than no relationship. These loving, giving people find interesting ways of explaining their behaviour to themselves. Loyal to a fault, a codependent individual is likely to rationalize a loved one's disrespectful behaviour by making excuses for them. "He doesn't mean it." "It was not done with malice." "It is the best he can do." "She had such an awful childhood." Etc., etc., etc. The central concept is that the codependent individual "takes it" and understands," despite feeling hurt. Waiting for brownie points in heaven, or for a loved one to be magically healed through their persistent love and care taking, they accept disrespect from others. It does not occur to the codependent person that it is not OK to "take it" and "put up" no matter what! Much of this abuse acceptance occurs without the codependent individual feeling abused! More accurately, these individuals do not feel OK enough to expect respectful treatment at all times, and to notice when it is not forthcoming. Having grown up in a home where a parent or sibling demanded inordinate attention (due to addiction, illness, anger, or other problem), the codependent person is trained to care for others. Having grown up in a difficult environment, a negative emotional climate is experienced as normal and familiar. This is why there is often little recognition of disrespect. If their partner is angry or upset, the codependent individual will implicitly assume that they did something to cause the anger. It does not occur to them that it is their partner's responsibility to deal with their problem and to treat others respectfully. It does not occur to them that it is their responsibility to themselves to stop another

person's demeaning behaviour toward them. But, how can stop disrespect when misbehaviour is not perceived as disrespectful or abusive? Disrespect is normal. An unfortunate side effect of the codependent person's willingness to ignore, excuse, or otherwise allow the partner's abuse or disrespect, enables the misbehaviour directed at them to continue and intensify. Implicit or explicit permission to continue misbehaving is granted since the codependent partner "understands." Because codependent individuals are approval-driven, they cannot stand it when others are angry at or disappointed with them. As such, they unwittingly place themselves in a position to be taken advantage of. The more approval is needed, the less likely is the individual to realize the extent of their self-sacrifice in favor of tending to the needs of the other. This hurts ("Ouchhh!"), and creates or maintains depression and low selfesteem, in a vicious, downward spiral.

While abuse, disrespect, or unrequited sacrifice angers them, as it should, codependent people do not realize how angry they are and at whom they are angry! Targeting the appropriate person may jeopardize a source of approval and selfesteem. To avoid facing reality, they distort it. Codependent individuals are likely to somehow blame themselves and rationalize their "over-sensitivity." They justify the other person's behaviour by thinking they must deserve the treatment they are getting. This is preferable to facing the possibility that an individual who provides a measure of their self-esteem is hurting them. " a signal that something is wrong and needs attention". Anger is healthy. It is a signal that something is wrong and needs attention. However, if the source of anger is not articulated, how can it be fixed? Codependent people are expert at denying anger and turning it against the self into sadness and depression. Instead of asking themselves why are they are putting up with... (fill in the blank), they ask themselves how they could have behaved differently - to obtain a more favorable reaction from their partner! Unarticulated anger is often misdirected and expressed inappropriately. Anger may be experienced as resentment, expressed as an aggressive blow-up, or in passive-aggressive acting out. The cognitive and verbal skills to appropriately assert oneself are lacking.


Since codependent people are experts at controlling other people's thoughts, feelings, and behaviour, they feel hurt that others don't reciprocate and "know" what they need. "If they really loved me, they would know." Not so! Since codependents do not have the self-esteem to ask for what they secretly want, they are unlikely to get it. If they do make a request, it is often a roundabout hint. If their partner cannot decipher the request, they feel hurt and unloved. They believe they conveyed their desires, when, in fact, they have not! Because most codependent individuals are control-oriented, they are very responsible. They are great employees. Tasks are done thoroughly and on time. Even parts of the job that are not theirs get picked up if coworkers are neglectful or slow. They try to control outcomes, whether those outcomes are completed job tasks or reactions from other people. Anything for approval. However, some codependent individuals are very irresponsible, in select or diverse life areas. They don't know how to or don't feel the need to take care of some of their own basic needs, especially if there is another person to care for instead. Why spend the time trying to figure out what the self needs, when the self doesn't really matter anyway? It is far more preferable to be out avoiding one's own issues: out having fun, hunting for a partner, or self-medicating feelings. Codependent people are addiction prone. They may drink too much, shop too much, eat too much, etc. Dulling the senses is a great way to avoid knowing yourself and dealing with your feelings. Intimacy is avoided. Intimate behaviour requires familiarity and comfort with one's internal world. Since the codependent person regards ordinary human needs as shameful, embarrassing, dangerous, or otherwise uncomfortable, meeting basic needs are often dismissed. Any relationship that ignores the self is superficial. Unfortunately, superficial relationships are safe...but empty and unfulfilling. Control is central to the "MO" of the codependent person. They control their self-esteem by catering to others' needs. They control by their over-responsible performance, picking up where others leave off. They control by avoiding intimacy or by clouding the mind. They control by advising others on what to do. These individuals work very hard to control everything and everybody. Yet, they neglect the one person they do have control over: themselves.

Why Be Codependent? Why would anybody spend time and energy to control outcomes, while actively neglecting the inner self? How can they do this and not realize they are selling themselves short? The Why: they know no other way; The How: they received very good training early in life. Any dysfunction in the family predisposes a child to codependent behaviour. Children are biologically programmed to seek love and approval. They have to be cared for or they will die. When a parent or family member is dysfunctional, the child tends to focus on this person--rather than on enjoying a carefree and joyful kid existence. The child has to worry: if the caretaker does not care take, the child dies. For example, in an alcoholic home, little Sally has to worry about whether she can bring friends home because daddy may be in a bad mood and embarrass her. Such events are training her in codependent thinking, the art of anticipating the other person. If mom is physically ill, Teddy has to worry about exerting her. Who would care for him if anything happened to her? If daddy is angry and controlling, Timmy needs to worry about pleasing him to avoid punishment and humiliation - and to get his conditional love and approval. Children are naturally egocentric. That means that they see the world revolving around them. If mom and dad fight, children feel that it is somehow their fault. Julie may try to make her parents happy by getting straight As in school in an attempt to keep the parental marriage together. Another child may have an abusive, or simply overactive older sibling. Since the parents cannot be there at all times to police the situation, the younger sibling may learn to anticipate the sib's moods and to behave in ways that might increase the probability of "safety." Or, perhaps daddy is depressed. Jennifer may tiptoe around him wondering if he is unhappy because she is not good enough. And so on.


In sum, codependent thinking tends to develop any time a child is growing up in a home where life is not care free. Often, addiction can be traced in the family tree of these dysfunctional families, whether there is an active addict in residence, or not. Nevertheless, these kids have an adult they have to worry about! The codependent-in-training is taught to walk on eggshells. To ensure survival, the child learns to be extraordinarily sensitive in reading the moods and thoughts of others. The child learns very early to pay attention to and tiptoe around the dysfunctional family members - at the child's expense. These interactions take place silently, implicitly. The child learns to ignore the self's inner needs, instead pretending that all is OK. When I tell my clients that codependent adults were once children who had an adult to worry about, some sharply disagree. They tell me about the loving families they came from and insist that their family members were "wonderful," etc. As denial melts and self-awareness develops, they begin to recognize the failings in a caregiver that spawned their selflessness. Sometimes, both parents were codependent, modeling no other behaviours for the child to learn.

More About Codependence (Article by Daniel Ploskin, MD - August 21, 2007 – A.O.)

While not recognized as a diagnosable illness in the American Psychiatric Association’s Diagnostic and Statistical Manual of Psychiatric Disorders (a professional reference used to make diagnoses), codependence generally refers to the way past events from childhood “unknowingly affect some of our attitudes, behaviours and feelings in the present, often with destructive consequences,” according to the National Council on Codependence. Certain signs can help us identify a tendency toward codependence.

Self-worth comes from external sources Codependent people need external sources, things or other people to give them feelings of self-worth. Often, following destructive parental relationships, an abusive past and/or self-destructive partners, codependents learn to react to others, worry about others and depend on others to help them feel useful or alive. They put other people’s needs, wants and experiences above their own. In fact, codependence is a relationship with one’s self that is so painful a person no longer trusts his or her own experiences. It perpetuates a continual cycle of shame, blame and self-abuse. Codependent people might feel brutally abused by the mildest criticism or suicidal when a relationship ends. In his 1999 book, Codependence: The Dance of Wounded Souls, author Robert Burney says the battle cry of codependence is: “I’ll show you! I’ll get me!”

Examples of codependency Health professionals first identified codependence in the wives of alcoholic men. Through family treatment, they discovered that spouses and family members were codependent, or also had addictive tendencies. Co-addiction occurs when more than one person, usually a couple, has a relationship that is responsible for maintaining addictive behaviour in at least one of the persons. For example, co-addicted people might believe that, at some level, getting a partner or family member to become sober or drug-free might seem like the one goal which, if achieved, would bring them happiness. But on another level, they might realize they are behaving in a way that enables the addict with whom they live to maintain their addictions. For instance, they might never confront the addict about her behaviour. Or they might become her caretaker, spending limitless time worrying about her. They might assume it’s their responsibility to clean up after and apologize for their loved one’s behaviour. They might even help her continue to use alcohol or drugs by giving her money, food or even drugs and alcohol, for fear of what would happen to her if they did things differently. Many codependents come to believe


they are so unlovable and unworthy that to stay in a dysfunctional, destructive relationship is the best and safest way to live. Codependent people who believe they can’t survive without their partners do anything they can to stay in their relationships, however painful. The fear of losing their partners and being abandoned overpowers any other feelings they might have. The thought of trying to address any of their partner’s dysfunctional behaviours makes them feel unsafe. Excusing or denying a problem like addiction means they avoid rejection by their partners. Instead, as in the example above, coaddicted people often will try to adapt themselves and their lives to their partners’ dysfunction. They might have abandoned hope that something better is possible, instead settling for the job of maintaining the status quo. The thought of change might cause them great pain and sadness. Codependence works the same way, whether the addiction is drugs, alcohol or something else, such as sex, gambling, verbal or physical abuse, work or a hobby. If the addicts’ behaviour causes worry, forcing the partners to adjust to and deny the problem, they are at great risk of becoming codependent. Those who were abused as children face an even greater risk.

Checklist for family members of people with Mental Health Disorders (Article by Patty E. Fleener M.S.W.) I wanted to touch on codependency. It seems like an old subject yet people are hurt by this "condition" so often and so many of us have these issues and are not aware. Why do I bring this up in a mental health website? Most person with a mental health disorder has a family member. If you are the family member, check yourself out for these behaviours quickly and if you can't relate then move on. Just because those of us who have mental health disorders may not be a family member of someone with a mental health disorder, doesn't mean we don't have a problem with codependency and it is very difficult to work on recovery when our focus is always on someone else. In fact, downright impossible. So many family members are focusing completely on the person who has the mental health disorder that they are not in touch with their own needs at all. This is not only unhealthy for the family member but for the person with the disorder as well.

You must learn to get your life back and as the author Melodie Beattie says "lovingly detaching." You are not on this earth to take care of your partner or your daughter or your cousin, etc. Let me repeat that. You are not on this earth to take care of your partner or your daughter or your cousin, etc. That may be a part of your life and a very important part of your life. But that is not the only reason you are on this earth and that is not the only thing that defines you. You must find out who you are and become that person once again. You must be that person you were before you knew "that person" and have that person in your life as well.

What does it feel like if you have been around someone strongly codependent?

I felt violated. My boundaries were crossed. I felt extremely angry and upset. I felt manipulated and power was taken away from me that belonged to me. I had always heard that 50% of chemically dependent people are codependent. My husband who attends AA says the joke there is that it is 100%. So I do not know what the exact figures are.


Are You Codependent? By Royane Real - Published: 5/6/2006

Do you feel like you give and give in your relationships but you get very little back? Are you always trying to save somebody or rescue somebody that doesn’t have their life together? You may be co-dependent. Take this quiz and find out.

In a relationship between two emotionally healthy adults, the roles of giving and receiving help are balanced. Both people offer help and receive help from each other in approximately equal amounts. However, there are some people who always take on the role of being the helper, no matter what relationship they are in. These people give, and give, and they always seem to get involved with people who have very serious emotional problems, such as addiction. And they exhaust themselves trying desperately to save the other person, even at tremendous cost to their own health.





These people have friendships that focus exclusively on trying to solve the problems of their friends. We sometimes call this quality "co-dependency", and we may obsessed with helping others "co-dependent".

A person who is co-dependent will tend to have relationships with people who have a lot of problems – emotional, social, familial and financial. The codependent person may spend much of their own time, money, and energy helping other people who have problems, while ignoring the problems in their own life.

Why would somebody be co-dependent? A person who is co-dependent often suffers from a deep sense of worthlessness and anxiety, and tries to derive a sense of self-worth by helping or rescuing others. A person who is co-dependent may not know how to relax and feel comfortable in a friendship where both people are equals and the relationship is based on enjoying each other’s company. Co-dependent people may even feel anxious if someone they have been helping gets their life in order and no longer wants their help. The co-dependent person may immediately look around for someone else they can "save". If you frequently take on the role of helping the people who are your friends, how can you tell if you are acting out of genuine kindness and concern, or whether your behaviour is in fact co-dependency?

When is it healthy to put the needs of other people first, and when is it unhealthy? There aren’t really any hard and fast lines between the two.

Here are some questions you can ask yourself to see whether your "helping" behaviour may actually be co-dependency: - Do you have a hard time saying no to others, even when you are very busy, financially broke, or completely exhausted? - Are you always sacrificing your own needs for everyone else? - Do you feel more worthy as a human being because you have taken on a helping role? - If you stopped helping your friends, would you feel guilty or worthless? - Would you know how to be in a friendship that doesn’t revolve around you being the "helper"? - If your friends eventually didn’t need your help, would you still be friends with them? Or would you look around for someone else to help? - Do you feel resentful when others are not grateful enough to you for your efforts at rescuing them or fixing their lives? - Do you sometimes feel like more of a social worker than a friend in your relationships? - Do you feel uncomfortable receiving help from other people? Is the role of helping others a much more natural role for you to play in your relationships? - Does it seem as if many of your friends have particularly chaotic lives, with one crisis after another? - Did you grow up in a family that had a lot of emotional chaos or addiction


problems? - Are many of your friends addicts, or do they have serious emotional and social problems? - As you were growing up, did you think it was up to you to keep the family functioning? - As an adult, is it important for you to be thought of as the "dependable one"? - Do you feel responsible for other people--their feelings, thoughts, actions, choices, wants, needs, well-being and destiny? - Do you feel compelled to help people solve their problems or by trying to take care of their feelings? - Do you find it easier to feel and express anger about injustices done to others than about injustices done to you? - Do you feel safest and most comfortable when you are giving to others? - Do you feel insecure and guilty when someone gives to you? - Do you feel empty, bored and worthless if you don't have someone else to take care of, a problem to solve, or a crisis to deal with? - Are you often unable to stop talking, thinking and worrying about other people and their problems? - Do you lose interest in your own life when you are in love? - Do you stay in relationships that don't work and tolerate abuse in order to keep people loving you? - Do you leave bad relationships only to form new ones that don't work, either? If you answered "yes" to a lot of these questions, you may indeed have a problem with co-dependency. This does not mean that you are a flawed person. It means that you are spending a lot of energy on other people and very little on yourself. If it seems that a lot of your friendships are based on co-dependent rescuing behaviours, rather than on mutual liking and respect between equals, you may wish to step back and rethink your role in relationships. If you suspect that your helping behaviour is a form of co-dependency, a good therapist or counselor can help you gain perspective on your actions and learn a more balanced way of relating to others.

Let's review some basic codependency behaviours. What do Codependents try to do? Control others or situations. Do they really think they can control others? Yes. Can anyone ever control others? No Do they cross our boundaries? Yes Do they mind their own business? No Do they manipulate? Yes Do they know what is best for you? Yes What do they say when we get angry with them for crossing our boundaries? I was only trying to help. What are some reasons they do this? To avoid their own issues. To get their mind off of themselves. What does Al-Anon tell them to do? Butt out! Mind their own business. Get the focus off of them and back on their selves. What do they do when they can't control you? Get angry.

Characteristics of Codependency 1. My good feelings about who I am stem from being liked by you 2. My good feelings about who I am stem from receiving approval from you 3. Your struggle affects my serenity. My mental attention focuses on solving your problems/relieving your pain 4. My mental attention is focused on you 5. My mental attention is focused on protecting you 6. My mental attention is focused on manipulating you to do it my way 7. My self-esteem is bolstered by solving your problems 8. My self-esteem is bolstered by relieving your pain 9. My own hobbies/interests are put to one side. My time is spent sharing your hobbies/interests 10. Your clothing and personal appearance are dictated by my desires and I feel you are a reflection of me 11. Your behaviour is dictated by my desires and I feel you are a reflection of me 12. I am not aware of how I feel. I am aware of how you feel. 13. I am not aware of what I want - I ask what you want. I am not aware - I assume 14. The dreams I have for my future are linked to you 15. My fear of rejection determines what I say or do 16. My fear of your anger determines what I say or do 17. I use giving as a way of feeling safe in our relationship 18. My social circle diminishes as I involve myself with you 19. I put my values aside in order to connect with you 20. I value your opinion and way of doing things more than my own 21. The quality of my life is in relation to the quality of yours Melody Beattie, author of Codependent No More developed this check list:

********************************************************* Website Links for Codependents: *********************************************************


What does a healthy friendship look like compared to a codependent friendship? I'm just at the beginning stages of discovering what that's like. From what I know so far I can say that you should not have such high expectations of your friends. You should value the differences you see in them. Also, you should not depend on them. You can depend on them to a certain extent, but with a healthy relationship it's not life or death if you are not with them. Obviously love is a part of a friendship, but now I'm learning to love others by faith unconditionally. We all fail but you have to leave room for failure in a friendship because

we're all human so disappointment and mistakes are bound to happen. I've also discovered that relationships are not all about me. It's about how loving and serving the other person. Also a good friendship is really about how we can build each other up. I have learned a lot about forgiveness too. I had to forgive people in my past for what they did to me. Now I have to forgive myself for what I did to Anna. Holding onto my past hurts facilitated a lot of my actions. I know that a healthy friendship brings freedom. I'm so much more relaxed now. I have lots of friends but I don’t feel as if I really need any friends or one best friend.

How can someone recognize this pattern in their own life? I think there always has to be a more dominant person in a codependent relationship. You could be the dominant one. I was the dominant one. The dominant one takes the initiative. The dominant one has all the expectations of the other person and can feel like the other person doesn't measure up. Often as the dominant one I felt sad or lonely. When I hung out with other people I would think of her. My heart would not be fully engaged with other friends. People considered us to be so close so the thought of even breaking away from each other was horrifying. I invested a lot in her. I shared my emotions with her. I never got close to anyone as I did with her.

That's another pattern of codependency - only letting that one person get close and not letting others get close to you. Even if someone were to show me, I still didn't see at all how I was codependent on Anna. It is very much a process of discovering on my own the kind of lifestyle I was living. I am a stubborn person too. I didn't quite want to give her friendship up, as unhealthy as it was. I knew I had a problem, but I didn't want to break from this friendship because I was scared of the unknown. All I knew was what I was comfortable with and I didn't want to separate myself from that comfort. I wanted to change my life but it took months and months before I could take the necessary steps, which made me realize just how unhealthy my relationship had been.

What are some key questions that would help someone realize if they are in a codependent relationship? • • • • •

How much time am I spending with this friend? That determines a lot right there. Am I neglecting other friends? Do I think this relationship is healthy? What do others in my life who care about me think about this relationship? Are there questions about the past that I need to answer for myself? Have I forgiven people in my past that have hurt me, and moved on?

What addictive behaviour were you struggling with? A codependent friendship.

How did it start? Six years ago I met a person I thought would be my best friend for life. I was going through a huge transition in my life coming home from college and having to start over in building friendships. Although I graduated, all my friends were still in college and my old friends from high school had all changed. It was hard for me to identify and connect again with my old friends. I connected with a few of my old friends from high school, and through one of them I met Anna. At the beginning of our friendship Anna and I connected really well and we had a lot of fun. We spent a lot of time together right from the beginning. She too had just come home from college and didn't know anyone.


We started hanging out 2-3 times a week, but I started calling her more and more. By the second year of our friendship we hung out every night and were communicating thoroughly every day. We became inseparable to the point that people thought we were sisters. Neither of us had been in an unhealthy friendship before and because we shared a deeper dimension of life in our friendship (faith and spirituality), we never thought our attachment to each other was unhealthy. But, over time, I started becoming more manipulative over her and placed higher and higher expectations on her. I figured that if she knew me best she should know how to treat me perfectly. She was the one that I thought had to give me what I needed and I would get upset if I didn't get it. I demanded a lot from her and she complied most of the time with what I needed.

What kinds of needs did you want her to meet? I was really looking for Anna to meet my emotional needs.

Why did you feel "addicted" to this relationship? Because I felt I needed. It seemed to be a safe place to go for refuge. To me, she seemed like a safe haven. I tried to find my satisfaction and fulfilment in Anna. But, she could hardly meet a tenth of what I expected or thought I needed from her.

When did you start to see a problem with your relationship? Anna's relatives and close friends would say that we hung out too much. But both of us were too entrenched in our friendship to think anything was really wrong. We were both needy and we both fulfilled needs in each other. But, at the same time, we weren't satisfied because there was a void there that we could feel and sense, especially spiritually. We began to realize that we were becoming too dependent on each other. At first there was no way I'd drop her friendship, because she still meant the world to me. But after spending more time reading books on friendship and codependence, we were both seeing just how unhealthy the relationship had become.

Describe what your relationship looked like in its most dependent stage... Often Anna would get angry easily because I was manipulative and possessive. I was outgoing and dominant, and she, being opposite, was a good follower. Our difference in personality made it easy for our friendship to get out of balance. Throughout this time I was blinded to my other friends. I didn't see how my other friends were really important to me. I also neglected to value my own family. I cared more about Anna coming over on a family day more than I cared about seeing my family. I wanted to be with her all the time. I would shower her with cards and gifts. She would do the same for me. When I was hanging out with Anna I would try to control who she hung out with and control how deep her friendship with others would get. I would ask her what she was doing during the week and made sure she spent the most time with me. I continually re-affirmed in my mind that I was number one in her life. Throughout all of this, I didn't realize how manipulative I had become. Looking back I can see how much of what I did had an ulterior motive. I wanted what was best for her, but I was the one who determined that. I figured what was best for her was to build our friendship. I tended to see myself as a needed person in her life. If I wasn't in her life I thought she would be weakened and not grow to her potential. It was selfish because I thought I was everything to her. But often, our friendship was disappointing. When we spent time together, I would expect it to look a certain way and would be angry, sad, or disappointed when it didn't go the way I expected. I would analyze our time together and question if our time together was quality or deep enough. This wore me out and made me anxious. It felt like the end of the world when we couldn't hang out together. Overall, my self esteem sucked.


How would you feel if she wanted to leave you? We constantly confirmed with each other that we would never be separated. Any time I would panic she would always affirm that "I'll always be your friend, I'll always be there for you." But, you can't make promises like that to a friend because you don't know where you'll be or how you'll change. We made these promises to each other to give each other a sense of stability.

What steps did you have to take to get back out of this codependent relationship? Through mentorship and reading books I learned that our friendship was unhealthy. About 5 months ago she took an important step and asked to take time away from our friendship. Since then, we haven't communicated or talked. It was the best thing we've ever done.

Did you notice a pattern of control in your past relationships? Yes, it started immediately after high school. High school was a crucial time in my life and I never felt accepted. I felt rejected basically for who I was and felt very alone. I tried really hard, and was afraid I wouldn't have any friends. I wanted to ensure that I had friends so I was always trying to be in control. In college I became dependent on friends. But, this dependency didn't reach its peak until I met Anna because at that point I really wanted a best friend. Anna was so compliant to go along with all my suggestions. There were so many things I didn't believe about myself. I loved others but I loved wrongly. My love was misdirected. .

Help! Can I Fix it? Good news! You certainly can! You can get control over your life! You can stop trying to control the lives of others and take charge of yourself!

While children are truly not responsible for their actions, adults are. To experience a more satisfying life, it becomes incumbent upon the adult to take control of the unavoidable childhood or presentday scars they experienced. Parents don't set out to hurt their children; neither do abusive partners! We get hurt and we in turn hurt others because we are imperfect. We may never achieve perfection, but we can improve. It is important to remember that we are in part a product of our environment. If we mis-behave, we have learned to do so. The good news is that what was learned can be unlearned or modified. The best news is that, in my experience, codependency issues are in most cases not particularly difficult problems to deal with. I find a blend of cognitive behaviour therapy with an emphasis on cognitive and verbal skills training combined with a 12-Step approach very effective. Many selfhelp resources are available from books to support groups, as well as professional guidance. "Codependence" is cocktail party talk. Walk into your local book store's self-help or psychology section and look around. Melodie Beattie and Pia Mellody are two of my favorite authors in the field. Also, check out some of Albert Ellis' cognitivebehavioural work that helps in stamping out irrational codependent thinking. Self-help groups such as ALANON and CODA are 12-Step programs that have their own formula help change codependent behaviour. So, go to therapy. Read, get to a meeting. Get yourself evaluated for medication if you are depressed. Do whatever you need to do. As an adult, you have options. You can take control of your life! You are the only one who can take control of your life.


Helping a Person Who Is Codependent If someone in your life is codependent -a spouse, parent, child or friend- your support may be an important part of recovery. Here are some ways you can help.

Spouse Begin a dialogue about childhood and messages your spouses might have received from his parents that could have caused shame. You might want to share your own experiences of shame and how they affected you. If you are recovering from an addiction, it might be useful to discuss how most spouses are affected by their partner’s addiction and what might be helpful to him (Al-Anon Meetings, Codependence Anonymous Meetings). Attending therapy with a spouse or buying a book on codependence and reading it together are other ways to begin to help.

Friend You might want to get a friend to open up to you by sharing your own insights with him. You can offer to go to a Codependents Anonymous Meeting with him or buy him a book to read about codependence. You also could offer him a place to stay (if he is living with an addict and could benefit from time apart) or a referral to a mental health professional. Sometimes making the first phone call for help can be the first step toward empowering the person to get well.

Child Helping a child, unless it’s an adult child, might not be appropriate since codependency as dysfunctional behaviour is hard to distinguish from normal dependency when a child is still young. If you are the parent of an adult son or daughter who is now in a codependent relationship, you could help by telling your child how much you love her and that getting well is possible. Remind your child of the strengths and positive qualities that sustained her through other difficult times. Offer a place to stay or to go to a 12-Step meeting with her.

Parent Helping a parent often is like helping adult children. Parents may resist taking advice from their children. But if, together, you can go to a 12-step meeting, go to therapy or read a book on codependence, you may begin to stir up a desire for recovery.

Co-worker Helping a coworker might include sharing information over lunch or inviting her over for coffee after work. If you are aware of a codependence problem with a coworker, chances are she already has entrusted you with some intimate information. However, work might not be the best place to discuss a topic as personal as codependence. Often, you can help just by offering to listen outside work or to be an escort to a 12-step meeting.

Treatment Options for Codependence If you think you have a problem with codependence, treatment is available and can help you feel better. Healing takes time and hard work, but talking with other codependents and seeing a therapist are two of the best ways to start your recovery.

Therapy Treatment may consist of individual therapy, group therapy and, eventually, couples and family therapy. A clinical social worker, psychologist or psychiatrist with experience treating codependents and families of addicts can help you identify and discuss the feelings, thoughts and behaviours that you and others find troubling.

Twelve-step groups Many advocates of the codependency theory view codependency as a type of addiction. Therefore, they maintain that codependents can overcome their symptoms with a 12-step process similar to that used by Alcoholics Anonymous. Twelve-step recovery programs bring codependents together as a group to talk about their struggles and share hope and experiences. The 12-step recovery process involves spirituality and is nondenominational. Codependents Anonymous meetings can provide participants with a great source of emotional and practical support. Program recovery involves admitting your life has become unmanageable because of your codependence. It requires expressing your feelings, doing what you can to get better and letting go of things you can’t control. Familiar 12-step affirmations include “One Day at a Time,” “Easy Does It,” “Let Go and Let God (a higher power).”


If you are interested in going to a meeting, contact your local mental health center and ask where you can find a Codependents Anonymous meeting in your area.

Medication If you are confronting codependence issues as well as mental illness such as a depression or anxiety disorder [Link to articles on Depression and Anxiety Disorder], you might want to see your primary care doctor or a psychiatrist. He can determine whether medication such as an antidepressant might help you. Often those who take medication and attend therapy and 12-step sessions find this combination to be the fastest and easiest way to get well.

Healing shame The key to healing a “wounded self� is to change the distorted, negative perspectives and reactions to our human emotions that result from having grown up in a dysfunctional, emotionally repressive and spiritually hostile environment. Most therapists agree that part of this healing process must involve grief. Grieving for the pain that caused the codependence and for the difficulties you suffered is a difficult but rewarding process. Learning to love yourself requires acknowledging your shame, disowning it, grieving the emotional damage you have sustained and healing the emotional wounds.

The Twelve Traditions The Twelve Steps are accompanied by The Twelve Traditions of group governance as developed by Alcoholics Anonymous through its early formation. Most 12-step fellowships also adopted these principles as their structural governance. In AA, the empathetic desire to save other drunks resulted in a radical emphasis on service to other sufferers only. Thus “the only requirement for AA membership is the desire to stop drinking”. Similar membership guidelines were adopted by other fellowships, with particular emphasis on freedom from alcohol because of the formative history of these traditions (note that alcohol is considered a drug in most substance-related twelve-step groups).

The Twelve Traditions of Alcoholics Anonymous: − Our common welfare should come first; personal recovery depends upon A.A. unity. − For our group purpose there is but one ultimate authority — a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern. − The only requirement for A.A. membership is a desire to stop drinking. − Each group should be autonomous except in matters affecting other groups or A.A. as a whole. − Each group has but one primary purpose to carry its message to the alcoholic who still suffers. − An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose. − Every A.A. group ought to be fully self-supporting, declining outside contributions. − Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers. − A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve. − Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy. − Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films. − Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.


Meeting Process One of the most widely-recognized characteristics of twelve-step groups is the requirement that members focus on the admission that they "have a problem". In this spirit, many members open their address to the group along the lines of, "Hi, I'm Pam and I'm an alcoholic" — a catchphrase now widely identified with support groups. Attendees at group meetings share their experiences, challenges, successes and failures, and provide peer support for each other. Many people who have joined these groups report they found success that previously eluded them, while others — including some ex-members — criticize their efficacy or universal applicability. This varied success rate, along with the fact that twelvestep programs have been associated with the belief in a higher power -- a belief often associated with religion -- has caused some controversy.

Twelve Step process Twelve Step programs symbolically represent human structure in three dimensions: physical, mental, and spiritual. The disorders and diseases the groups deal with are understood to manifest themselves in each dimension. For addicts the physical dimension is best described by the "allergy-like bodily reaction" resulting in the inability to stop using substances after the initial use. For groups not related to substance abuse the physical manifestation could be much more varied including, but not limited too: agoraphobia, apathy, distractibility, forgetfulness, hyperactivity, hypomania, insomnia, irritability, lack of motivation, laziness, mania, panic attacks, poor impulse control, procrastination, self-injury, suicide attempts, and stress. The illness of the spiritual dimension, in all Twelve Step groups, is considered to be self-centeredness. This model is not intended to be a scientific explanation. It is only a model that members of Twelve Step organizations have found useful. In time, the process is intended to replace self-centeredness with a growing moral consciousness and a willingness for self-sacrifice and unselfish constructive action. In Twelve Step groups, this is known as a spiritual awakening or religious experience. This should not be confused with abreaction, which generally only results in temporary change. In Twelve Step groups, "spiritual awakening" is believed to develop, most frequently, slowly over a period of time.

Sponsorship In twelve-step programs, a sponsor is a more experienced person in recovery who guides the less-experienced aspirant ("sponsee") through the process of the steps as a program of personal recovery. One of the first suggestions newcomers to 12-step meetings are offered is to secure a relationship with a sponsor. A vast array of publications from various fellowhips emphasize that sponsorship is a "one on one" relationship of shared experiences focused on working the 12 steps Many forms of sponsorship exist. Sponsors and sponsees participate in activities that lead to spiritual growth as defined by the twelve-step process. These may include practices such as literature discussion and study, meditation, and writing. Part of the final of the twelve steps is often interpreted to imply becoming a sponsor to newcomers in recovery. "Sponsorship, with its continuing interest in


another alcoholic, often develops when the second person is willing to be helped, admits having a drinking problem, and decides to seek a way out of the trap." "Sponsors share their experience, strength, and hope with their sponsees... A sponsor’s role is not that of a legal adviser, a banker, a parent, a marriage counselor, or a social worker. Nor is a sponsor a therapist offering some sort of professional advice. A sponsor is simply another addict in recovery who is willing to share his or her journey through the Twelve Steps." – from NA's Sponsorship: Revised Sponsees typically do their Fifth Step with their sponsor. The Fifth Step, as well as the Ninth Step, have been compared to confession and penitence. Many, such as Michel Foucault, noted such practices "produces intrinsic modifications in the person" and exonerates, redeems, purifies them; it unburdens them of their wrongs, liberates them and promises their salvation. The personal nature of the behavioural issues that lead to seeking help in 12-step fellowships results in a strong relationship between sponsee and sponsor. As the relationship is based on spiritual principles, it is unique and not generally characterized as "friendship." Fundamentally, the sponsor has the single purpose of helping the sponsee recover from the behavioural problem that brought the sufferer into 12-step work[18], which reflexively helps the sponsor recover.

Acceptance of a Higher Power A primary tenet of 12-step recovery requires a member to surrender willful selfreliance (a characteristic of afflicted persons) and adopt a practice of reliance upon a "Higher Power" of the member's own understanding. Proponents of twelve-step programs allege that agnostics and even atheists can be helped by the program, as a member’s concept of a Higher Power may focus on the 12-step group itself. With time, any other entity, thing(s) or object(s) that aid a member in accepting their powerlessness over their problem, are claimed to become the Higher Power that will help them to recover. It is colloquially stated that any Power perceived as being greater than oneself will do, provided the power is not any other, single individual, or one's own unaided will.

Literature studied in most 12-step groups is limited to their own publications, as these groups claim no outside affiliation. The members of 12-step groups make the distinction that the groups are spiritual, and not religious. Some members of 12step groups are also members of a wide variety of religious bodies. Nearly every meeting begins with the Serenity Prayer, a prayer addressed to "God." Some critics also question the idea of giving up on self-reliance, which, they argue, results in a form of idealized despair. Others acknowledge a debt to the twelve-steps movement but do not have a culture of belief in God.

Court-mandated Twelve-step attendance The success of twelve-step programs in aiding the recovery of chemicallydependent persons is an argument of significance in jurisdictions of some criminal justice systems. The criminal justice system of the United States has ordered attendance at 12-step meetings to convicted criminals as well as inmates as a condition of parole, condition of shortened sentence, or as an element of a sentence. Four courts have ruled that Alcoholics Anonymous groups are religious organizations. The New York Court of Appeals ruled in Griffin v. Coughlin, 88 N.Y.2d 674 (1996) that doing so compromises the Establishment Clause of the United States Constitution on the grounds that A.A. practices and doctrine are (in the words of the district court judge who wrote the decision) "unequivocally religious". The Supreme Court of the United States denied US Legal Certiorari and allowed the New York court's decision to stand. Such a denial "imports no expression of opinion upon the merits of the case, as the bar has been told many times." Missouri v. Jenkins, 515 U.S. 70 (1995). Denial of certiorari means that no binding precedent is created, and that the lower court decision is authoritative only within its area of jurisdiction -- in this case the State of New York. However, the decision does create a persuasive precedent for other jurisdictions.


These are some versions of the Twelve Steps from different sources. The 12 Steps of Alcoholics Anonymous

The 12 Steps of Co-Dependents Anonymous

1. We admitted we were powerless over alcohol --- that our lives had become unmanageable.

1. We admitted we were powerless over others --- that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and 3. Made a decision to turn our will our lives over to the care of God as we and our lives over to the care of God understood God. as we understood Him. 4. Made a searching and fearless 4. Made a searching and fearless moral inventory of ourselves. moral inventory of ourselves. 5. Admitted to God, to ourselves, and 5. Admitted to God, to ourselves, to another human being the exact and to another human being the nature of our wrongs. exact nature of our wrongs. 6. Were entirely ready to have God 6. Were ready to have God remove remove all these defects of character. all these defects of character. 7. Humbly asked God to remove our shortcomings. 7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make 8. Made a list of all persons we had amends to them all. harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do 9. Made direct amends to them so would injure them or others. wherever possible, except when to 10. Continued to take personal do so would injure them or others. inventory and when we were wrong 10. Continued to take personal promptly admitted it. inventory and when we were wrong 11. Sought through prayer and promptly admitted it. meditation to improve our conscious 11. Sought through prayer and contact with God, praying only for meditation to improve our conscious knowledge of God's will for us and the contact with God as we understood power to carry that out. Him, praying only for His will for us 12. Having had a Spiritual awakening and the power to carry that our. as the result of these steps, we tried to carry this message to other co12. Having had a Spiritual dependents, and to practice these awakening as the result of these steps, we tried to carry this message principles in all our affairs. to other alcoholics, and to practice these principles in all our affairs.

The 12 Steps to Recovery for Codependents From: Choicemaking by Sharon Wegscheider Cruse

16 Steps for Discovery and Empowerment From: Many Roads, One Journey; Moving Beyond the 12 Steps by Charlotte Kasl Ph.D.

1. We acknowledge and accept that we are powerless in controlling the lives of 1. We affirm we have the power to others, and that trying to control others take charge of our lives and stop being makes our lives unmanageable. dependent on substances or other people for our self-esteem and security. 2. We have come to believe that a power greater than ourselves can 2. We come to believe that God /the restore enough order and hope in our Goddess /Universe /Great Spirit /Higher lives to move us to a growth Power awakens the healing wisdom framework. within us when we open ourselves to that power. 3. We make a decision to turn our lives over to this power to the best of 3. We make a decision to become our our ability, and honestly accept that authentic Selves and trust in the healing taking responsibility for ourselves is the power of Truth. only way growth is possible. 4. We examine our beliefs, addictions, 4. We make an inventory of ourselves, and dependent behaviour in the context looking for our mental, emotional, of living in a hierarchical, patriarchal spiritual, physical, volitional, and social culture. assets and liabilities. We look at what we have, how we use it, and how we 5. We share with another person and can acquire what we need. the Universe all those things inside of us for which we feel shame and guilt. 5. Using this inventory as a guide, we admit to ourselves, to God as we 6. We affirm and enjoy our strengths, understood him, and to other caring talents, and creativity, striving not to persons, the exact nature of what is hide these qualities to protect other's within that is causing ourselves pain. egos. 6. We give to God as we know him all former pain, hurt, and mistakes, resentments and bitterness, anger, and guilt. We trust that we can let go of the hurt that we cause and receive.

7. We become willing to let go of shame, guilt, and any behaviour that keeps us from loving ourSelves and others.

7. We can ask for help, support, and guidance and be willing to take responsibility for ourselves and to others.

8. We make a list of people we have harmed and people who have harmed us, and take steps to clear out negative energy by making amends and sharing our grievances in a respectful way.

8. We begin a program of living responsibly for ourselves, for our own feelings, mistakes, and successes. We become responsible for our part in relationship to others.

9. We express love and gratitude to others, and increasingly appreciate, the wonder of life and the blessings we do have. 10. We continue to trust our reality and


daily affirm that we see what we see, 9. We make a list of persons to whom we know what we know, and we feel we want to make amends and what we feel. commence to do so, except where doing so would cause further pain for others. 11. We promptly acknowledge our mistakes and make amends when 10. We continue to work our program, appropriate, but we do not say we are each day checking out our progress and sorry for things we have not done and asking for feedback from others in our we do not cover up, analyze, or take attempt to recover and grow. We do responsibility for the shortcomings of this through support groups. others. 11. We seek through our own power and a Higher Power, awareness of our inner selves. We do this through reading, listening, meditation, sharing, and other ways of centering and getting in touch with our inner selves. 12. Having experienced the power of growing toward wholeness, we find our bodies, minds, and spirits awakened to a new sense of physical and emotional relief which leaves us open to a new awareness of Spirituality. We seek to explore our meaning in life by honest sharing with others, remember that BECOMING WHO WE ARE is a lifetime task which must be done one day at a time.

12. We seek out situations, jobs, and people that affirm our intelligence, perceptions, and self-worth and avoid situations or people who are hurtful, harmful, or demeaning to us. 13. We take steps to heal our physical bodies, organize our lives, reduce stress, and have fun. 14. We seek to find our inward calling, and develop the will and wisdom to follow it. 15. We accept the ups and downs of life as natural events that can be used as lessons for growth. 16. We grow in awareness that we are interrelated with all living things, and we contribute to restoring peace and balance on the planet.

12 Steps for Kids From: Kids' Power: Healing Games for Children of Alcoholics, by Jerry Moe 1. I am powerless over alcohol, drugs, and other people's behaviour and my life got real messed up because of it.

The Twelve Steps of NonRecovery Evidently originally called the Twelve Steps to Insanity From the March 1990 Issue of the ACA Communicator, published by the Omaha - Council Bluffs Area Intergroup.

2. I need help. I can't do it alone anymore.

1. We admitted we were powerless over nothing, that we would manage our lives perfectly and those of anyone 3. I've made a decision to reach out for else who would allow us to. a Power greater than me to help out. 2. Came to believe there was no power greater than ourselves and the 4. I wrote down all of the things that rest of the world was insane. bother me about myself and others, and 3. Made a decision to have our loved the things that I like too. ones and friends turn their will and their lives over to our care, even though they 5. I shared these with someone I trust couldn't understand us. because I don't have to keep them a 4 Made a searching moral and immosecret anymore. ral inventory of everyone we knew. 5. Admitted to the whole world the 6. My Higher Power helps me with exact nature of everyone else's wrongs. this, too. 6. Were entirely ready to make others straighten up and do right. 7. The more I trust myself and my 7. Demanded others to either shape up Higher Power, the more I learn to trust or ship out. others. 8 Made a list of all persons who had harmed us and became willing to go to 8. I made a list of the people I hurt any length to get even with them all. and the ways I hurt myself. I can now 9. Got direct revenge on such people forgive myself and others. whenever possible, except when to do so would cost us our lives, or at the 9. I talked to these people even if I very least a jail sentence. was scared to because I knew that it 10. Continued to take inventory of would help me feel better about myself. others, and when they were wrong promptly and repeatedly told them 10. I keep on discovering more things about it. about myself each day and if I hurt 11. Sought through complaining and someone, I apologize. nagging to improve our relations with others as we couldn't understand them, 11. When I am patient and pray, I get asking only that they knuckle under and closer to my Higher Power, and that do it our way. helps me know myself better. 12. Having had a complete physical, emotional and spiritual breakdown as a 12. By using these steps, I've become result of these steps, we tried to blame a new person. I don't have to feel it on others and to get sympathy and alone anymore, and I can help others. pity in all of our affairs.


Twelve-step program From Wikipedia, the free encyclopedia A Twelve-step program is a set of guiding principles for recovery from addictive, compulsive, or other behavioural problems, originally developed by the fellowship of Alcoholics Anonymous ("A.A.") to guide recovery from alcoholism. The twelve steps were first published in the text Alcoholics Anonymous ("The Big Book"). This method has been adapted as the foundation of other twelve-step programs such as Narcotics Anonymous, Overeaters Anonymous, Marijuana Anonymous, Crystal Meth Anonymous, Co-Dependents Anonymous and Emotions Anonymous. Mandated court involvement with 12-step fellowships is a controversial practice of some governments; as stated in the Twelve Traditions, Twelve-step fellowships have no opinion as a group on issues other than personal recovery. As summarized by the American Psychological Association, working the Twelve Steps involves the following. • • • • • •

admitting that one cannot control one's addiction or compulsion; recognizing a spiritual higher power that can give strength; examining past errors with the help of a sponsor (experienced member); making amends for these errors; learning to live a new life with a new code of behaviour; helping others that suffer from the same addictions or compulsions.

Overview of Twelve-Step Programs The way of life outlined in the 12-steps has been adapted widely. The effects of A.A. recovery within the family unit providing improved quality of life resulted in fellowships like Al-Anon; substance-dependent people who did not relate to the specifics of alcohol dependency started meeting together as Narcotics Anonymous[3]; similar groups were formed for sufferers of cocaine addiction, crystal meth addiction and many other behavioural problems. Behavioural issues such as compulsion and/or addiction with sex, food, and gambling were found to be solved for some people with the daily application of the 12-steps in such fellowships as Sexual Compulsives Anonymous, Overeaters Anonymous and Emotions Anonymous. Other groups addressing problems with

certain types of behaviours include Clutterers Anonymous, Debtors Anonymous and Gamblers Anonymous. Over 50 fellowships composed of millions of recovery members, all based in the same principles, are found around the world. "After a while I began to wonder why I was not [happy] ... I decided to strive for my own spiritual growth. I used the same principles [Bill] did to learn how to change my attitudes. ... We began to learn that ...the partner of the alcoholic also needed to live by a spiritual program." – "Lois's Story" in the Al-Anon "Big Book", a typical story of a sufferer finding fulfillment through application of the 12 steps

The Twelve Steps These are the original Twelve Steps as defined by Alcoholics Anonymous: 1. We admitted we were powerless over alcohol—that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10.Continued to take personal inventory and when we were wrong promptly admitted it. 11.Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His Will for us and the power to carry that out. 12.Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs. Other twelve-step groups have adapted these steps of Alcoholics Anonymous as guiding principles for problems other than alcoholism; in some cases the steps have been altered to emphasize particular principles important to those fellowships.


History The first such program was Alcoholics Anonymous (A.A.), which was begun in 1935 by Bill Wilson and Dr. Bob Smith, known to A.A. members as "Bill W." and "Dr. Bob", in Akron, Ohio. They established the tradition within the "anonymous" Twelve-step programs of using only first names. The Twelve Steps were originally written by Wilson and represented Wilson's incorporation of the teachings of Rev. Sam Shoemaker about the Oxford Group's life-changing program. As Alcoholics Anonymous was growing in the 1930s and 1940s and definite guiding principles began to emerge as the 12 traditions, a singleness of purpose emerged as tradition five: "Each group has but one primary purpose to carry its message to the alcoholic who still suffers." [9] Consequently, drug addicts who do not suffer from the specifics of alcoholism involved in Alcoholics Anonymous hoping for recovery technically are not welcome in 'closed' meetings for alcoholics only[10]. The reason for such emphasis on alcoholism as the problem is to overcome denial and distraction[11]. Thus the principles of Alcoholics Anonymous have been used to form many numbers of other fellowships for those recovering from various pathologies, each of which in term emphasizes recovery from the specific malady which brought the sufferer into the fellowship.

Key Recovery Concepts There are five key recovery concepts that, through her research, Mary Ellen found to be essential to effective recovery work. They are: Hope - People who experience mental health difficulties get well, stay well and go on to meet their life dreams and goals. Personal Responsibility - It's up to you, with the assistance of others, to take action and do what needs to be done to keep yourself well. Education - Learning all you can about what you are experiencing so you can make good decisions about all aspects of you life. Self Advocacy -Effectively reaching out to others so that you can get what it is that you need, want and deserve to support your wellness and recovery. Support - While working toward your wellness is up to you, receiving support from others, and giving support to others will help you feel better and enhance the quality of your life.

Recovery Steps Relief of symptoms is only the first step in treating depression or bipolar disorder. Wellness, or recovery, is a return to a life that you care about. Recovery happens when your illness stops getting in the way of your life.

What is Recovery? SAMSHA (the Substance Abuse and Mental Health Services Administration / Center for Mental Health Services) defines recovery as: Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

Next Steps in Recovery Depression and bipolar disorder are mood disorders, real physical illnesses that affect a person’s moods, thoughts, body, energy and emotions. Both illnesses, especially bipolar disorder, tend to follow a cyclical course, meaning they have ups and downs. Treatment for these illnesses can also have ups and downs. As much as we may want it to, wellness often does not happen overnight. It is normal to wish you could feel better faster or to worry that you will never feel better. However, know that you can feel better, and that ultimately you are in charge of your recovery. There are many things you can do to help yourself. Relief of symptoms is only the first step in treating depression or bipolar disorder. Wellness, or recovery, is a return to a life that you care about. Recovery happens when your illness stops getting in the way of your life. You decide what recovery means to you.


You have the right to recover according to your needs and goals. Talk to your health care provider (HCP) about what you need from treatment to reach your recovery. Your HCP can provide the treatment(s) and/or medication(s) that work best for you. Along the way, you have a right to ask questions about the treatments you are getting and choose the treatments you want. It can also be helpful to work with a therapist, family member, friend and peer supporters to help define your recovery. Your definition of a meaning life may change at different times in life. At times, depression and bipolar disorder might make it seem difficult to set a goal for yourself. Sometimes it might feel almost impossible to think about the things that you hope for or care about. But goal setting is an important part of wellness, no matter where you are on your path to recovery. Work on what you can when you can.

Setting Goals Identifying life goals is the heart of the recovery process. When we see a future for ourselves, we begin to become motivated to do all we can to reach that future. Goals can be big or small, depending on where you are in your recovery journey.

Ask yourself: •

What motivates me?

What interests me?

What would I do more if I could?

What do I want?

What do I care about, or what did I care about before my illness?

Where do I want my life to go?

What brings me joy?

What are my dreams and hopes?

It can help to start small and work up to larger goals. You might want to begin by setting one small goal for yourself at the beginning of each day. As you move forward with your recovery, look at the different areas of your life and think about your short and long term goals.

Short term goals might include: Be out of bed by xx:00 am. Finish one household chore. Call a DBSA support group.

Long term goals might include: Get training or experience for a job. Change a living situation, e.g., find an apartment Build a relationship with a friend or family member. Remember break your goals down into small steps at first. Looking at a goal such as 'move to a new city' can be difficult to visualize and plan all at once. Ask yourself what you need to do first. What can you do now that will help you eventually reach this goal? Not only will this help move you closer to your goal, but it will also help give you a positive feeling of accomplishment.

What are some things I can do that might help me feel better? Know the difference between your symptoms and your true self. Your HCPs can help you separate your true identity from your symptoms by helping you see how your illness affects your behaviour. Be open about behaviours you want to change and set goals for making those changes. Educate your family and involve them in treatment when possible. They can help you spot symptoms, track behaviours and gain perspective. They can also give encouraging feedback and help you make a plan to cope with any future crises. Work on healthy lifestyle choices. Recovery is also about a healthy lifestyle, which includes regular sleep, healthy eating, and the avoidance of alcohol, drugs, and risky behaviour. Find the treatment that works for you. Talk to your HCP about your medications' effects on you, especially the side effects that bother you. Remember to chart these effects so that you can discuss them fully with your HCP. You might need to take a lower dosage, a higher dosage, or a different medication. You might need to switch your medication time from morning to evening or take medication on a full stomach. There are many options for you and your HCP to try. Side effects can be reduced or eliminated. It is very important to talk to your HCP first before you make any changes to your medication or schedule. Talk with your HCP first if you feel like changing your dosage or stopping your medication. Explain what you want to change and why you think it will help you.


Treatments for Depression and Bipolar Disorder Treatments that work can help you: Reach your goals. Build on the strengths you have and the things you can do. Plan your health care based on your needs. Live your life without the interference of symptoms. Treatments can include some or all of these elements: therapy, medications, peer support, and overall lifestyle changes.

Medications for Depression and Bipolar Disorder Your HCP might prescribe one or more medications to treat your symptoms. These may include: ■ Mood stabilizers: These medications help balance your highs and lows. Some mood stabilizer medications are called anticonvulsants, because they are also used to treat epilepsy. ■ Antidepressants: These medications help lift the symptoms of depression. There are several different classes (types) of antidepressants. ■ Antipsychotics: These medications are primarily used to treat symptoms of mania. Even if you are not hallucinating or having delusions, these medications can help slow racing thoughts to a manageable speed.

Talk Therapy There are many types of talk therapy that can help you address issues in your life and learn new ways to cope with your illness. Goal setting is an important part of talk therapy. Talk therapy can also help you to: Understand your illness Overcome fears or insecurities Cope with stress Make sense of past traumatic experiences Separate your true personality from the mood swings caused by your illness Identify triggers that may worsen your symptoms Improve relationships with family and friends Establish a stable, dependable routine Develop a plan for coping with crises Understand why things bother you and what you can do about them End destructive habits such as drinking, using drugs, overspending or risky sex Address symptoms like changes in eating or sleeping habits, anger, anxiety, irritability or unpleasant feelings

Peer Support Support from people who understand is another important part of recovery. There are many ways to get this support. DBSA offers a variety of ways to interact with your peers, such as support groups, discussion forums, and an interactive chat room. Find a support group DBSA's discussion board Interactive chat room

Lifestyle A healthy lifestyle is always important. Even if symptoms of depression or bipolar disorder make things like physical activity, healthy eating or regular sleep difficult, you can improve your moods by improving your health. Take advantage of the good days you have. On these days, do something healthy for yourself. It might be as simple as taking a short walk, eating a fresh vegetable or fruit, or writing in a journal. A talk about lifestyle changes should be a part of your goal setting with your HCPs. You have the power to change. You are the most important part of your wellness plan. Your treatment plan will be unique to you. It will follow some basic principles and paths, but you and your HCPs can adapt it to fit you. A healthy lifestyle and support from people who have been there can help you work with your HCP and find a way to real and lasting wellness.

Family and Friends' Guide to Recovery From Depression and Bipolar Disorder When a friend or family member has an episode of depression or bipolar disorder (manic depression), you might be unsure about what you can do to help. You might wonder how you should treat the person. You may be hesitant to talk about the person’s illness, or feel guilty, angry, or confused. All of these things are normal. There are ways you can help friends or family members throughout their recovery while empowering them to make their own choices.


The Five Stages of Recovery It can be helpful to view recovery as a process with five stages. People go through these stages at different speeds. Recovery from an illness like depression or bipolar disorder, like the illness itself, has ups and downs. Friends and family who are supportive and dependable can make a big difference in a person’s ability to cope within each of these stages.

1. Handling the Impact of the Illness Being overwhelmed and confused by the illness. An episode of mania or depression, especially one that causes major problems with relationships, money, employment or other areas of life, can be devastating for everyone involved. A person who needs to be hospitalized may leave the hospital feeling confused, ashamed, overwhelmed, and unsure about what to do next.

What friends and family can do: Offer emotional support and understanding. Help with health care and other responsibilities. Offer to help them talk with or find health care providers. Keep brief notes of symptoms, treatment, progress, side effects and setbacks in a journal or personal calendar. Be patient and accepting. Your loved one’s illness is not your fault or theirs. It is a real illness that can be successfully treated. Resist the urge to try to fix everything all at once. Be supportive, but know that your loved one is ultimately responsible for his or her own treatment and lifestyle choices.

2. Feeling Like Life is Limited Believing life will never be the same. At this stage, people take a hard look at the ways their illness has affected their lives. They may not believe their lives can ever change or improve. It is important that friends, families, and health care providers instill hope and rebuild a positive self-image.


What friends and family can do: •

Believe in the person’s ability to get well.

Tell them they have the ability to get well with time and patience. Instill hope by focusing on their strengths.

Work to separate the symptoms of the illness from the person’s true personality. Help the person rebuild a positive self-image.

Recognize when your loved one is having symptoms and realize that communication may be more difficult during these times. Know that symptoms such as social withdrawal come from the illness and are probably not a reaction to you. Do your best not to rush, pressure, hover or nag.

A mood disorder affects a person’s attitude and beliefs. Hopelessness, lack of interest, anger, anxiety, and impatience can all be symptoms of the illness. Treatment helps people recognize and work to correct these types of distorted thoughts and feelings. Your support and acceptance are essential during this stage.

3. Realizing and Believing Change is Possible Questioning the disabling power of the illness and believing life can be different.

Hope is a powerful motivator in recovery. Plans, goals, and belief in a better future can motivate people to work on day-to-day wellness. At this stage people begin to believe that life can be better and change is possible. What friends and family can do: Empower your loved on to participate in wellness by taking small steps toward a healthier lifestyle. This may include: • Sticking with the same sleep and wake times Consistently getting good nutrition Doing some sort of physical activity or exercise Avoiding alcohol and substances Finding a DBSA support group Keeping health care appointments and staying with treatment Offer reassurance that the future can and will be different and better. Remind them they have the power to change. Help them identify things they want to change and things they want to accomplish. •

• • • • • • •

Symptoms of depression and bipolar disorder may cause a hopeless, “what’s the point?” attitude. This is also a symptom of the illness. With treatment, people can and will improve. To help loved ones move forward in recovery, help them

identify negative things they are dissatisfied with and want to change, or positive things they would like to do. Help them work toward achieving these things.

4. Commitment to Change Exploring possibilities and challenging the disabling power of the illness. Depression and bipolar disorder are powerful illnesses, but they do not have to keep people from living fulfilling lives. At this stage, people experience a change in attitude. They become more aware of the possibilities in their lives and the choices that are open to them. They work to avoid feeling held back or defined by their illness. They actively work on the strategies they have identified to keep themselves well. It is helpful to focus on their strengths and the skills, resources and support they need.

What friends and family can do: Help people identify: • • • • • • • •

Things they enjoy or feel passionate about Ways they can bring those things into their lives Things they are dissatisfied with and want to change Ways they can change those things Skills, strengths and ideas that can help them reach their goals. Resources that can help build additional skills Help them figure out what keeps them well. Encourage and support their efforts.


The key is to take small steps. Many small steps will add up to big positive changes. Find small ways for them to get involved in things they care about. These can be activities they enjoy, or things they want to change, in their own lives or in the world.

5. Actions for Change Moving beyond the disabling power of the illness.

At this stage, people turn words into actions by taking steps toward their goals. For some people, this may mean seeking full-time, parttime or volunteer work, for others it may mean changing a living situation or working in mental health advocacy. What friends and family can do: Help your friends or family members to use the strengths and skills they have. Keep their expectations reachable and realistic without holding them back. Help them find additional resources and supports to help them reach their goals step-by-step. Continue to support them as they set new goals and focus on life beyond their illness. Help them identify and overcome negative or defeatist thinking. Encourage them to take it easy on themselves and enjoy the journey. People with depression or bipolar disorder have the power to create the lives they want for themselves. When they look beyond their illness, the possibilities are limitless.

What you can say that helps: You are not alone in this. I’m here for you. I understand you have a real illness and that’s what causes these thoughts and feelings. You many not believe it now, but the way you’re feeling will change. I may not be able to understand exactly how you feel but I care about you and want to help. When you want to give up, tell yourself you will hold of for just one more day, hour, minute - whatever you can manage. You are important to me. Your life is important to me. Tell me what I can do now to help you. I am here for you. We will get through this together.

Avoid saying: It’s all in your head. We all go through times like this. You’ll be fine. Stop worrying. Look on the bright side. You have so much to live for why do you want to die? I can’t do anything about your situation. Just snap out of it. Stop acting crazy. What’s wrong with you? Shouldn’t you be better by now?


What to find out: Contact information (including emergency numbers) for your loved one’s doctor, therapist, and psychiatrist, your local hospital, and trusted friends and family members who can help in a crisis Whether you have permission to discuss your love one’s treatment with his or her doctors, and if not, what you need to do to get that permission. The treatments and medications your loved one is receiving, any special dosage instructions and any needed changes in diet or activity. The most likely warning signs of a worsening manic or depressive episode (words and behaviours) and what you can do to help. What kind of day-to-day help you can offer, such as doing housework or grocery shopping. When talking with your love one’s health care providers, be patient, polite and assertive. Ask for clarification of things you do not understand. Write things down that you need to remember.

Helping and getting help As a friend or family member you can provide the best support when you’re taking care of yourself. It helps to talk to people who know how it feels to be in your situation. Talk with understanding friends or relatives, look for therapy of your own, or find a support group. DBSA support groups are run by families and friends affected by depression or bipolar disorder. They are safe, confidential, free meetings where people can learn more about these illnesses and how to live with them. One father of a daughter with bipolar disorder says, “DBSA support groups help take a lot of stress out of your life. As a family member, you have to be as prepared as possible, and accept that things will still happen that you aren’t totally prepared for. DO all the research you can. Build a long list of dependable resources and support people, so when a situation arises, you know where to turn and how to take the next step. This really helped my family when we needed it.”

WHAT TO DO WHEN SOMEONE IS IN CRISIS Sometimes depression and bipolar disorder have symptoms that can best be helped by inpatient psychiatric treatment. Try to find out what treatment is available to your loved one, and what steps you can take during a crisis before the crisis occurs, if possible.

People may need to go to the hospital if they:

• • • • • • •

Threaten or try to take their lives or hurt themselves or others See or hear things (hallucinations) Believe things that aren’t true (delusions) Need special treatments such as electroconvulsive therapy Have problems with alcohol or substances Have not eaten or slept for several days Are unable to care for themselves or their families, e.g., getting out of bed, bathing, dressing Have tried treatment with therapy, medication and support and still have a lot of trouble with symptoms Need to make a significant switch in treatment or medication under the close supervision of their

doctor Have any symptom of mania or depression that significantly interferes with life

Voluntary hospitalization takes place when a person willingly signs forms agreeing to be treated in the hospital. A person who signs in voluntarily may also ask to leave. This request should be made in writing. The hospital must release people who make requests within a period of time (two to seven days, depending on state laws), unless they are a danger to themselves or others. Most psychiatric hospital stays are from five to ten days. There are also longer residential rehabilitation programs for alcohol or substance abuse, eating disorders or other issues that require long-term treatment. Involuntary hospitalization is a last resort when someone’s symptoms have become so severe that they will not listen to others or accept help. You may need to involve your loved one’s doctor, the police or lawyers. It is better to talk with your loved one before a crisis and determine the best treatment options together. Work with your loved one in advance to write down ways to cope and what to do


if symptoms become severe. Having a plan can ease the stress on you and your loved one, and ensure that the appropriate care is given.

How can I convince my loved one to check in voluntarily? Explain that the person is not going to an institution, asylum or prison. Hospitalization is treatment, not punishment. Reassure your loved one that the hospital is a safe place where a person can begin to get well. No one outside the family needs to be told about the hospitalization. Tell your loved one that getting help does not mean someone has failed. A mood disorder is an illness that needs treatment, like diabetes or heart disease. Hospitalization is nothing to be ashamed of. Call the hospital and find out more about admission, treatment and policies. Help your loved one pack comfortable clothing and safe items that are reminders of home. Offer the person a chance to make choices (such as what to take to the hospital, or who to go with), if this is desired.

How should I talk to a person in crisis? Stay calm. Talk slowly and use reassuring tones. Realize you may have trouble communicating with your loved one. Ask simple questions. Repeat them if necessary, using the same words each time. Don’t take your loved one’s actions or hurtful words personally. Say, “I’m here. I care. I want to help. How can I help you?” Don’t say, “Snap out of it,” “Get over it,” or “Stop acting crazy.” Don’t handle the crisis alone. Call family, friends, neighbors, people from your place of worship or people from a local support group to help you. Don’t threaten to call 911 unless you intend to. When you call 911, police and/or an ambulance are likely to come to your house. This may make your loved one more upset, so use 911 only when you or someone else is in immediate danger.

Crisis Planning: Some people find it helpful to write down mania prevention and suicide prevention plans, and give copies to trusted friends and relatives. These plans should include: A list of symptoms that might be signs the person is becoming manic or suicidal. Things you or others can do to help when you see these symptoms. A list of helpful phone numbers, including health care providers, family members, friends and a suicide crisis line such as 1-800-273-TALK. A promise from your friend or family member that he or she will call you, other trusted friends or relatives, one of his or her doctors, a crisis line or a hospital when manic or depressive symptoms become severe. Encouraging words such as “My life is valuable and worthwhile, even if it doesn’t feel that way right now.” “Reality checks” such as, “I should not make major life decisions when my thoughts are racing and I’m feeling ‘on top of the world’. I need to stop and take time to discuss these things with others

before going through with them.� How can an advance directive or a medical power of attorney help? An advance directive and a medical power of attorney are written documents that give others authority to act on a person’s behalf when that person is ill. Your loved one can specify what decisions should be made and when. It is best to consult a qualified attorney to help with an advance directive or a medical power of attorney. These documents work differently in different states.


Helping Others Throughout Their Lives What can I do when my child is ill? Patience and understanding are especially important when a child is ill. Children with bipolar disorder often have different symptoms than adults do, and are more likely to switch quickly from manic symptoms to depressive symptoms. Make sure you have a doctor who understands mood disorders in children, and is able to spend time discussing your child’s treatment. Communicate to your child that there is hope you and the doctors are working on a solution that will help him or her feel better. Explain your child’s disorder to siblings on a level they can understand. Suggest ways they can help. Seek family counseling if necessary. It is also helpful to network with other parents whose children have a mood disorder. With the assistance of your child’s mental health care provider, help your child learn relaxation techniques and use them at home. Teach positive coping strategies to help him or her feel more prepared for stressful situations. Encourage your child to self-express through art, music, writing, play, or any other special gifts he or she has. Provide routine and structure in the home, and freedom within limits. Above all, remember that mood disorders are not caused by bad parenting, and do not blame yourself for your child’s illness. Children with mood disorders do better in a low-stress, quiet home environment, and with a family communication style that is calm, low-volume, non-critical, and focused on problem-solving rather than punishment or blaming. Stress reduction at school through use of an Individual Educational Plan (IEP) is also very important. Request an evaluation from your child’s school counselor or psychologist to get the process started. If your child with a mood disorder is an adult, it is important to treat him or her like an adult, even when he or she is not acting like one. As much as you may want to, you may not be able to force your adult child to keep doctor’s appointments or take medications. As with any other family member, keep encouraging treatment and offering your support, but establish boundaries for yourself too, such as not lending money if your adult child seems to be having manic or hypo manic symptoms.

What can I do when an older relative is ill? Mood disorders are not a normal part of aging. You may face more challenges if an elderly relative is ill and lives far away from you or in an assisted living facility. Stay informed about the treatment your loved one is receiving. Develop a relationship with his or her doctors and the staff at the facility. Your relative may need special help remembering to take medications. Make sure all of his or her doctors communicate if he or she is being treated for multiple illnesses. This is extremely important, since some medications for mood disorders can interact with medications for other illnesses and cause problems. It may be helpful for you to spend additional time with your elderly relative, or, if that is difficult, meet with other relatives to see if you can take turns visiting or caring for your loved one.


Self Help Affirmations That Work Memory Storage: It used to be thought that information is planted in long term memory through repetition. Today, we know that information transfers to long term memory through association between new data and the already stored information.

Affirmations that Don’t Work: Ever promised yourself, “I’m going to do better, I’m going to do better, I’m not going to eat so much junk food, I’m going to eat healthier” to find you ate even more? Most try such affirmations hoping the repetition, earnestness, positive words and thoughts will transform a habitual negative behaviour. Wrong! Truth is, for the most part, just the opposite transpires. You often end up doing more of what you don’t want and less of what you do want. Affirmations done in this way just may be a part of the problem, not a part of the solution.

On a conscious brain and body awareness level, you made a promise that the unconscious brain and body did not hear, understand or agree to. Often times, the more the incongruent affirmation is repeated, the further into despair and failure you can sink. Sometimes the only result is increased guilt, hopelessness, powerlessness and self doubt that further sabotage your positive intention to change. Detrimental early experiences, generational coding, and environmental learning drive the unconscious reactions and are not readily resolved with traditional affirmations, medicine, or treatments. Learning new habits requires unlearning existing ones. For several reasons, it is easier to learn something new than to unlearn something old. First, many factors influence how information is stored in the memory. The hippocampus part of the brain records a lifetime of experiences and thoughts. One thought connects to another. Information is retrieved by searching through the network of interconnections to the place where it is stored. The more frequently a path of retrieval is followed, the stronger the path becomes. It took years to create the negative part in the first place, so how many repetitions would it take to create a new one in it’s place? You could just try harder, but the latest scientific research found it takes at least a 1000 repetitions before a habit begins to change on the unconscious level. Most people are not motivated to commit to such a long term process of repetitions, no matter how much they desire the outcome.

Second, the unconscious does not hear or process negative words. Traditionally, affirmations state what you don’t want, plus what you do want. For example, you may say, “I’m not going to eat ice cream every day, because I don’t want to get fat so I’ll choose more fruits and vegetables.” Your unconscious hears, “I’m going to eat ice cream, I’m going to get fat, I’m going to choose more fruits and vegetables.” These messages are usually enhanced mentally with pictures of ice cream and being fat instead of eating healthy vegetables and a healthy body.

Affirmations That Work! Most spend far more time thinking what they don’t want than what they desire. Each time you think about a problem in a particular habitual way, the mental circuits or pathways get activated and strengthen with each recall. Through time, mental ruts form that makes it difficult to reorganize infor-mation, or see it from a different perspective, much less choose a different behaviour. Reversal Conflict Tapping Technique uses a combination of energy modalities including Touch for health, Eye Movement Desensitization, and the Acupuncture Meridian System. The goal is to 1) confuse and weaken negative habits and neural pathways, and 2) replace and strengthen new, positive patterns of connections between the nerve cells, so increasing the odds are that you will call up the new memory. Real change without the struggle can be realized when the unconscious and conscious brain and body are congruent. Given the right tools, all parts are willing, ready and able to change.

Reversal Conflict Tapping Technique: Goal: Confuse and delete old habits and install a new ones. 1. Pinpoint your underlying negative emotion or state: fear, stressed, anxious, depressed, failure, angry, overwhelmed, guilty, sad, jealous, stuck, frustrated, hopeless, powerless 2. The key to choice and change is to make peace with your conflicting parts that sabotage your intentions and affirmations. This requires self acceptance and love for yourself just the way you are presently, even before things change, even if things never change. Say: “In spite of this inner conflict, _______ (ie, fear, anxiety,depression, apathy, anger, failure, conflict, etc.) “ I deeply and profoundly love, accept, and respect myself.” 3. Stimulate both brain hemispheres. Since your brain has 100 billion neurons, each being a “learning center” capable of storing new information, activate this potential by tapping. Do: Tap lightly in a semi-circle on the area one inch above and around the ear.


4. Circular eye movements integrate both brain hemispheres to assist in deleting the mental ruts and replacing them with new information. Do: With your head still and facing straight, move your eyes in a large circle, then begin looking down on the floor, move them to the right as if you are outlining a large circle with your eye. Follow the imaginary circle up and down the opposite side, and back to the floor where you started. Repeat the circles for 5-6 times in one direction, then change directions for 5-6 eye circles. * Combine A, B, C to delete the old and enhance the new. 5. Exercise your mind to strengthen your desired outcome. Expedite change through the visual field of your brain. Take advantage of your brain’s inability to know the difference between the past, the present, and the future. Play the new, more positive movie as if it already is … in the present. Do: Put a picture of the affirmation you desire on the movie screen of your mind. See it clearly, with color, up close, and life size, the way you dream it to be. Play that movie often.

How long will it take before the person feels better? Some people are able to stabilize quickly after starting treatment; others take longer and need to try several treatments, medications or medication combinations before they feel better. Talk therapy can be helpful for managing symptoms during this time. If your friend or family member is facing treatment challenges, the person needs your support and patience more than ever. Education can help you both find out all the options that are available and decide whether a second opinion is needed. Help your loved one to take medication as prescribed, and don’t assume the person isn’t following the treatment plan just because he or she isn’t feeling 100% better.

There is hope: As a friend or family member of someone who is coping with bipolar disorder or depression, your support is an important part of working toward wellness. Don’t give up hope. Treatment for mood disorders does work, and the majority of people with mood disorders can return to stable and productive lives. Keep working with your loved one and his or her health care providers to find treatments that work, and keep reminding your loved one that you are there for support.

Check for more publications like this, about: coaching, family therapy, borderline personality disorder, crisis counseling, empowerment, mental imagery, mind reading, communication, influencing, manipulation, interpersonal relationships etc...


3. Narcissistic personality disorder

Personality disorders are conditions in which people have traits that cause them to feel and behave in socially distressing ways, limiting their ability to function in relationships and in other areas of their life, such as work or school. Narcissistic personality disorder is one of several types of personality disorders. It is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they're superior to others and have little regard for other people's feelings. But behind this mask of ultra-confidence lies a fragile selfesteem, vulnerable to the slightest criticism.


Narcissistic personality disorder Symptoms Narcissistic personality disorder is characterized by dramatic, emotional behaviour, which is in the same category as antisocial and borderline personality disorders.

Narcissistic personality disorder symptoms may include: • • • • • • • • • • • • • • • •

Believing that you're better than others Fantasizing about power, success and attractiveness Exaggerating your achievements or talents Expecting constant praise and admiration Believing that you're special and acting accordingly Failing to recognize other people's emotions and feelings Expecting others to go along with your ideas and plans Taking advantage of others Expressing disdain for those you feel are inferior Being jealous of others Believing that others are jealous of you Trouble keeping healthy relationships Setting unrealistic goals Being easily hurt and rejected Having a fragile self-esteem Appearing as tough-minded or unemotional

Although some features of narcissistic personality disorder may seem like having confidence or strong self-esteem, it's not the same. Narcissistic personality disorder crosses the border of healthy confidence and self-esteem into thinking so highly of yourself that you put yourself on a pedestal. In contrast, people who have healthy confidence and self-esteem don't value themselves more than they value others.

When you have narcissistic personality disorder, you may come across as conceited, boastful or pretentious. You often monopolize conversations. You may belittle or look down on people you perceive as inferior. You may have a sense of entitlement. And when you don't receive the special treatment to which you feel entitled, you may become very impatient or angry. You may insist on having "the best" of everything — the best car, athletic club, medical care or social circles, for instance. But underneath all this behaviour often lies a fragile self-esteem. You have trouble handling anything that may be perceived as criticism. You may have a sense of secret shame and humiliation. And in order to make yourself feel better, you may react with rage or contempt and efforts to belittle the other person to make yourself appear better.


Tests and diagnosis Narcissistic personality disorder is diagnosed based on signs and symptoms, as well as a thorough psychological evaluation that may include filling out questionnaires. Although there's no laboratory test to diagnose narcissistic personality disorder, you may also have a physical exam to make sure you don't have a physical problem causing your symptoms. Some features of narcissistic personality disorder are similar to those of other personality disorders. It's possible to be diagnosed with more than one personality disorder at the same time. To be diagnosed with narcissistic personality disorder, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for narcissistic personality disorder to be diagnosed include: • • • • • • • • •

Having an exaggerated sense of self-importance Being preoccupied with fantasies about success, power or beauty Believing that you are special and can associate only with equally special people Requiring constant admiration Having a sense of entitlement Taking advantage of others Having an inability to recognize needs and feelings of others Being envious of others Behaving in an arrogant or haughty manner

When to see a doctor

When you have narcissistic personality disorder, you may not want to think that anything could be wrong — doing so wouldn't fit with your self-image of power and perfection. But by definition, a narcissistic personality disorder causes problems in many areas of your life, such as relationships, work, school or your financial affairs. You may be generally unhappy and confused by a mix of seemingly contradictory emotions. Others may not enjoy being around you, and you may find your relationships unfulfilling. If you notice any of these problems in your life, consider reaching out to a trusted doctor or mental health provider. Getting the right treatment can help make your life more rewarding and enjoyable.

Causes It's not known what causes narcissistic personality disorder. As with other mental disorders, the cause is likely complex. The cause may be linked to a dysfunctional childhood, such as excessive pampering, extremely high expectations, abuse or neglect. It's also possible that genetics or psychobiology — the connection between the brain and behaviour and thinking — plays a role in the development of narcissistic personality disorder. 79

Prevention Because the cause of narcissistic personality disorder is unknown, there's no known way to prevent the condition with any certainty. Getting treatment as soon as possible for childhood mental health problems may help. Family therapy may help families learn healthy ways to communicate or to cope with conflicts or emotional distress. Parents with personality disorders may benefit from parenting classes and guidance from therapists or social workers.

Risk factors Narcissistic personality disorder is rare. It affects more men than women. Narcissistic personality disorder often begins in early adulthood. Although some adolescents may seem to have traits of narcissism, this may simply be typical of the age and doesn't mean they'll go on to develop narcissistic personality disorder. Although the cause of narcissistic personality disorder isn't known, some researchers think that extreme parenting behaviours, such as neglect or excessive indulgent praise, may be partially responsible.

Risk factors for narcissistic personality disorder may include: • • • • • •

Parental disdain for fears and needs expressed during childhood Lack of affection and praise during childhood Neglect and emotional abuse in childhood Excessive praise and overindulgence Unpredictable or unreliable care giving from parents Learning manipulative behaviours from parents

Children who learn from their parents that vulnerability is unacceptable may lose their ability to empathize with others' needs. They may also mask their emotional needs with grandiose, egotistical behaviour that's calculated to make them seem emotionally "bulletproof."

Complications Complications of narcissistic personality disorder can include: • • • • • •

Substance abuse Alcohol abuse Depression Suicidal thoughts or behaviour Relationship difficulties Problems at work or school

Preparing for your appointment People with narcissistic personality disorder are most likely to seek treatment when they develop symptoms of depression — often because of perceived criticisms or rejections. If you recognize that aspects of your personality are common to narcissistic personality disorder or you're feeling overwhelmed by sadness, talk with your doctor. Whatever your diagnosis, your symptoms signal a need for medical care. When you call to make an appointment, your doctor may immediately refer you to a mental health provider, such as a psychiatrist. Use the information below to prepare for your first appointment and learn what to expect from the mental health provider.

What you can do •

• •

Write down any symptoms you're experiencing and for how long. It will help the mental health provider to know what kinds of events are likely to make you feel angry or defeated. Write down key personal information, including traumatic events in your past and any current, major stressors. Make a list of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications or supplements you're taking. Take a family member or friend along, if possible. Someone who has known you for a long time may be able to ask questions or share information with the mental health provider that you don't mention. Write down questions to ask your mental health provider in advance so that you can make the most of your appointment.


For narcissistic personality disorder, some basic questions to ask your mental health provider include: • • • • •

• • • •

What exactly is narcissistic personality disorder? Could I have different mental health conditions? What is the goal of treatment in my case? What treatments are most likely to be effective for me? How much do you expect my quality of life may improve with treatment? How frequently will I need therapy sessions and for how long? Would family or group therapy be helpful in my case? Are there medications that can help? I have these other health conditions. How can I best manage them together? Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your mental health provider, don't hesitate to ask any additional questions that may come up during your appointment.

What to expect from your mental health provider The mental health provider is likely to ask you a number of questions to gain an understanding of your symptoms and how they're affecting your life. The mental health provider may ask: • • • • • • • •

What are your symptoms? When do these symptoms occur, and how long do they last? How do you feel — and act — when others seem to criticize or reject you? Do you have any close personal relationships? If not, how do you explain that lack? What are your accomplishments? What do you plan to accomplish in the future? How do you feel when someone needs your help? How do you feel when someone expresses difficult feelings, such as fear or sadness, to you?

• • • • • •

How would you describe your childhood, including your relationship with your parents? How would you say your symptoms are affecting your life, including school, work and personal relationships? Have any of your close relatives been diagnosed with a mental health problem, including a personality disorder? Have you been treated for any other mental health problems? If yes, what treatments were most effective? Do you use alcohol or illegal drugs? How often? Are you currently being treated for any other medical conditions?

Treatments and drugs Narcissistic personality disorder treatment is centered around psychotherapy. There are no medications specifically used to treat narcissistic personality disorder. However, if you have symptoms of depression, anxiety or other conditions, medications such as antidepressants or anti-anxiety medications may be helpful. Types of therapy that may be helpful for narcissistic personality disorder include: •

Cognitive behavioural therapy. In general, cognitive behavioural therapy helps you identify unhealthy, negative beliefs and behaviours and replace them with healthy, positive ones. 83


Family therapy. Family therapy typically brings the whole family together in therapy sessions. You and your family explore conflicts, communication and problem solving to help cope with relationship problems.


Group therapy. Group therapy, in which you meet with a group of people with similar conditions, may be helpful by teaching you to relate better with others. This may be a good way to learn about truly listening to others, learning about their feelings and offering support.

Because personality traits can be difficult to change, therapy may take several years. The short-term goal of psychotherapy for narcissistic personality disorder is to address such issues as substance abuse, depression, low self-esteem or shame. The long-term goal is to reshape your personality, at least to some degree, so that you can change patterns of thinking that distort your self-image and create a realistic selfimage. Psychotherapy can also help you learn to relate better with others so that your relationships are more intimate, enjoyable and rewarding. It can help you understand the causes of your emotions and what drives you to compete, to distrust others, and perhaps to despise yourself and others.

Lifestyle and home remedies Whether you decide to seek treatment on your own or are encouraged by loved ones or a concerned employer, you may feel defensive about treatment or think it's unnecessary. The nature of narcissistic personality disorder can also leave you feeling that the therapy or the therapist is not worth your time and attention, and you may be tempted to quit. Try to keep an open mind, though, and to focus on the rewards of treatment.

Also, it's important to: Stick to your treatment plan. Attend scheduled therapy sessions and take any medications as directed. Remember that it can be hard work and that you may have occasional setbacks. • Learn about it. Educate yourself about narcissistic personality disorder so that you can better understand symptoms, risk factors and treatments. • Get treatment for substance abuse or other mental health problems. Your addictions, depression, anxiety and stress can feed off each other, leading to a cycle of emotional pain and unhealthy behaviour. Learn relaxation and stress management. Try such stress-reduction techniques as meditation, yoga or tai chi. These can be soothing and calming. Stay focused on your goal. Recovery from narcissistic personality disorder can take time. Keep motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and become happier with your life. •

• •


Narcissistic Relationships Narcissistic Relationships bring with them huge risks to the partner of the narcissist because their behaviour is a manifestation of an excessive ego and self absorption at the cost of everyone around them. Over the years, if this behaviour doesn't change, it generally results in a codependent, emotionally draining and abusive relationship. Narcissistic Relationships will require lots of energy and work, because narcissists are in constant need for outside support and approval. Once these needs are fulfilled they feel powerful, but many times this need will be very hard to be satisfied and the self image and the peace of the partner may be dramatically impacted. Narcissistic Relationships test the mental limits of their partners patience, and individuals in a relationship with a narcissist feel something is not 'quite right', feel a lack of emotional connection and most eventually realize it's wise to seek answers to the unsettling experience of their day to day contact with a narcissist. However, it's important for you to know that you do not have to be the victim of narcissism forever. You don't have to lose your confidence, self image, hope and passion for life because you are in a relationship with a narcissist. You can learn the skills to move beyond the downside effects of your narcissistic relationship and move on to a more normal relationship.

The first step is to recognise the signs. Narcissists have a grandiose sense of self-importance, like they have a special mission on this earth and they often have a 'I am the emperor' type of personality, and they expect all others should behave as humble servants of their wishes. They always exaggerate their achievements and talents making everything in their power to gain everybody's attention and recognition. Most of the times they are arrogant and self absorbed to fulfill what they see as their special destiny.

Narcissists will indulge in fantasies of tremendous power, success or beauty, being addicted to the attention and admiration that others manifest. You will find much snobbery between them which they do not deny it but rather be proud of it. They see themselves as unique masterpieces. Complicated rather than complex personalities, they will find it difficult to empathize with other people. They can't actually go out of the margins of their own personality, not understanding how people don't think the same as they do. That's why many times you may have the feeling of talking to a blank wall because no matter how deep you explain your point of view, most likely a narcissist will not understand. They often can't maintain long relationships, because they lack empathy and most times people around them give up on explaining themselves over and over again. Narcissists tend to transform their partners in beggars - you will beg for understanding and some unconditional attention but most of the time you will celebrate only leftovers from the feast in which the narcissist has indulged. Narcissists expect and demand that the ones nearest and dearest to them, love, admire, tolerate, and cater to their needs. They expect others to be at their immediate disposal.

Here are the seven most common signs of narcissism. 1. He or she displays a lack of empathy. As you spend more time investing in a narcissist, you may notice that he / she seems unable to put him / herself in someone else's place emotionally. This often leads to callous and self serving behaviours. Sometimes dangerous behaviours. 2. A narcissistic personality will often show a willingness to exploit other people. You may well see they have few qualms about stepping on other people if it benefits him / her. 3. Idealized thinking is a prevalent theme. A narcissistic might put others, including you, on a pedestal, only to completely discard or describe you as worthless further down the track. He or she often fantasizes about the perfect love, beauty, or power, and feels he / she has a right to it.


4. Having a grandiose sense of self worth is a very common pattern. Your narcissist might exaggerate his or her accomplishments and expect to associate with other 'high level' people. This most often leads to feelings of superiority, a haughty attitude and / or excessive expectations. 5. A narcissistic personality often will exhibit an excessive sense of entitlement. He or she may feel as if preferential treatment ought to come her / his way as of right. 6. A narcissist will most often will crave admiration and praise to the point that it becomes almost like a drug. This drug has been termed 'narcissistic supply' and the narcissist most often goes to excessive lengths to obtain it. 7. He or she often may be very jealous of the accomplishments of others, They may even become angry at the successes of others who then take the focus away from her or him.

Narcissistic Relationships - You Must Protect Yourself! This is your first priority if you have a narcissistic partner. If you're in a narcissistic relationship it's essential that you protect yourself, from many areas that you will be under attack. Some of these types of abuse are: Emotional Abuse: The verbally abusive and controlling narcissist - the one who uses emotional abuse as his weapon of choice. He tells his victim who she can see, think and do. Or in the case of Janet, whose husband makes her recite every day, "I'm only worth 29 cents - the price of a bullet," and in doing so he erodes her self-worth to nothing to keep her under his control. Who else could possible want such a worthless woman? With that belief formed, she will never leave him for good, although she makes many brief attempts to do so. The brainwashing that continues daily is emotionally exhausting, draining, and vastly unhealthy.

Verbal Abuse: Verbal abuse is hurtful and usually attacks the nature and abilities of the partner. Over time, the partner may begin to believe that there is something wrong with her / her abilities. She may come to feel that she is the problem, rather than her partner. Verbal abuse is often insidious. The partner's self-esteem gradually diminishes, usually without her realizing it's happening. She may consciously or unconsciously try to change her behaviour so as not to upset the abuser. Sexual Abuse: Normally a narcissist stays within the law, but may break the rules of morality of a society. Narcissist are careful about it because, even if they do not feel guilty, they want to avoid the shame of discovery. The sexual relationship with the narcissist is peculiar. Narcissists are exhibitionists and sex is just one further means of being admired to her or him. True intimacy doesn't and you will frequently feel used. The narcissist will demand that you subdue yourself to their wishes.

Physical Abuse: Narcissistic individuals do not tend to be physically abusive although there are some out there that are. Their worst weapon is their mouth. With their mouth they spit verbal negations and dispense emotional abuse. Their vocal cords are their method of attempting to control others.

Narcissistic Relationships Can Be Improved. (But it will take detailed knowledge and considerable effort.) Since narcissists cannot be changed, you need to reevaluate your needs and long term goals for the relationship - it may be interesting for a while to be around such type of people but in the long run it gets exhausting and anger and resentment will overshadow any feelings of love and tenderness. Don't give in to their never-ending demands, keep your independence from this type


of person - if in any way you depend on them, they will blackmail you to make you give in to their desires. Don't let yourself be infuriated by their lack of empathy or understanding - they are not capable of it. Showing them their incapacity will do nothing - they will blame you for everything that it doesn't work. Narcissists will be attached to those that satisfy their needs but will never treat them as partners but as followers. They have the need to lead and be in control constantly they do not need equals but disciples or pleasers. The worst thing that can happen is when one narcissist meets someone with low self-esteem - it will be the perfect victim and toy for them. Finally, you need to decide when enough is enough. A relationship with a narcissist can take you places where you do not want to be, can make you behave in ways you do not recognize yourself . It can undermine your self esteem and will rob you of the attention you need to give to yourself trying to meet all their needs.

Arm Yourself Now With Detailed Information. Detailed knowledge can help you so you never are involved, ever again, in a continuing toxic relationship. I hope the brief information above has helped you and that it prompts you to go on now to get the detailed information that will insure that your relationship moves quickly in a more positive direction. I wish you every success and lasting happiness.

Experts Recommend: All the experienced experts in preventing narcissistic abuse make two vital recommendations: 1) If at all possible, walk away (leave) your narcissistic abuser. 2) If that's not possible due to constraints of your employment, wider family, children or love, you must, repeat must, take advantage of the support and resources available to learn how to deal with a narcissist, and in doing so discover how to protect yourself from ongoing emotional, mental and sometimes physical harm. Please take action TODAY to protect yourself!

How to Cope with a Narcissist?

Give up on your “relationship” with the narcissist and maintain a “no contact” policy. If you choose to stay with him either give him a taste of his own medicine by reflecting his misbehaviour – or provide him with narcissistic supply (attention and adulation).


No one should feel responsible for the narcissist's predicament. To him, others hardly exist – so enmeshed he is in himself and in the resulting misery of this very selfpreoccupation. Others are objects on which he projects his wrath, rage, suppressed and mutating aggression and, finally, ill disguised violence. How should his closest, nearest and dearest cope with his eccentric vagaries? The short answer is by abandoning him. Alternatively, you can try by threatening to abandon him. The threat to abandon need not be explicit or conditional ("If you don't do something or if you do it – I will ditch you"). In some cases it may be sufficient to confront the narcissist, to completely ignore him, to insist on respect for one's boundaries and wishes, or to shout back at him. The narcissist takes these signs of personal autonomy to be harbinger of impending separation and reacts with anxiety. The narcissist might be tamed by the very same weapons that he uses to subjugate others. The spectre of being abandoned looms large over everything else. In the narcissist's mind, every discordant note presages solitude and the resulting confrontation with his self. The narcissist is a person who is irreparably traumatized by the behaviour of the most important people in his life: his parents, role models, or peers. By being capricious, arbitrary, and sadistically judgmental, they moulded him into an adult, who fervently and obsessively tries to recreate the trauma in order to, this time around, resolve it (repetition complex). Thus, on the one hand, the narcissist feels that his freedom depends upon reenacting these early experiences. On the other hand, he is terrified by this prospect. Realizing that he is doomed to go through the same traumas over and over again, the narcissist distances himself by using his aggression to alienate, to humiliate and in general, to be emotionally absent.

This behaviour brings about the very consequence that the narcissist so fears abandonment. But, this way, at least, the narcissist is able to tell himself (and others) that HE was the one who fostered the separation, that it was fully his choice and that he was not surprised. The truth is that, governed by his internal demons, the narcissist has no real choice. The dismal future of his relationships is preordained. The narcissist is a binary person: the carrot is the stick in his case. If he gets too close to someone emotionally, he fears ultimate and inevitable abandonment. He, thus, distances himself, acts cruelly and brings about the very abandonment that he feared in the first place. In this paradox lies the key to coping with the narcissist. If, for instance, he is having a rage attack – rage back. This will provoke in him fears of being abandoned and the resulting calm will be so total that it might seem eerie. Narcissists are known for these sudden tectonic shifts in mood and in behaviour. Mirror the narcissist’s actions and repeat his words. If he threatens – threaten back and credibly try to use the same language and content. If he leaves the house – leave it as well, disappear on him. If he is suspicious – act suspicious. Be critical, denigrating, humiliating, go down to his level – because that's the only way to penetrate his thick defences. Faced with his mirror image – the narcissist always recoils.


Source: This article appears in my book, "Malignant Self-love: Narcissism Revisited"

We must not forget that the narcissist behaves the way he does in order to engender and encourage abandonment. When mirrored, the narcissist dreads imminent and impending desertion, which is the inevitable result of his actions and words. This prospect so terrifies him – that it induces in him an incredible alteration of conduct. He instantly succumbs and obsequiously tries to make amends, moving from one (cold and bitter, cynical and misanthropic, cruel and sadistic) pole to another (warm, even loving, fuzzy, engulfing, emotional, maudlin, and saccharine). The other coping strategy is to give up on him. Dump him and go about reconstructing your own life. Very few people deserve the kind of investment that is an absolute prerequisite to life with a narcissist. To cope with a narcissist is a full time, energy and emotion-draining job, which reduces people around him to insecure nervous wrecks. Who deserves such a sacrifice? No one, to my mind, not even the most brilliant, charming, breathtaking, suave narcissist. The glamour and trickery wear thin and underneath them a monster lurks which irreversibly and adversely influences the lives of those around it for the worse. Narcissists are incorrigibly and notoriously difficult to change. Thus, trying to "modify" them is doomed to failure. You should either accept them as they are or avoid them altogether. If one accepts the narcissist as he is – one should cater to his needs. His needs are part of what he is. Would you have ignored a physical handicap? Would you not have assisted a quadriplegic? The narcissist is an emotional cripple. He needs constant adulation. He cannot help it. So, if one chooses to accept him – it is a package deal, all his needs included.

TWENTY TRAITS OF MALIGNANT NARCISSISTIC PERSONALITY DISORDER 1. THE PATHOLOGICAL LIAR is skilfully deceptive and very convincing. Avoids accountability by diverting topics, dodging questions, and making up new lies, bluffs or threats when questioned. His memory is self serving as he denies past statements. Constant chaos and diverting from reality is their chosen environment. Defence Strategy: Verify his words. Do not reveal anything about yourself - he'll use it against you. Head for the door when things don't add up. Don't ask him questions you'll only be inviting more lies. 2. THE CONTRACT BREAKER agrees to anything then turns around and does the opposite. Marriage, Legal, Custody agreements, normal social/personal protocol are meaningless. This con artist will accuse you of being the contract breaker. Enjoys orchestrating legal action and playing the role of the 'poor me' victim. Defence Strategy: Expect him to disregard any agreement. Have Plan B in place. Protect yourself financially and emotionally. 3. THE HIGH ROLLER Successfully plows and backstabs his way to the top. His family a disposable prop in his success facade. Is charismatic, eloquent and intelligent in his field, but often fakes abilities and credentials. Needs to have iron-fisted control, relying on his manipulation skills. Will ruthlessly support, exploit or target others in pursuit of his ever-changing agenda. Mercilessly abuses the power of his position. Uses treachery or terrorism to rule or govern. Potential problem or failure situations are delegated to others. A vindictive bully in the office with no social or personal conscience. Often suspicious and paranoid. Others may support him to further their own Mephistophelian objectives, but this wheeler-dealer leaves them holding the bag. Disappears quickly when consequences loom. Defence Strategy: Keep your references and resume up to date. Don't get involved in anything illegal. Document thoroughly to protect yourself. Thwarting them may backlash with a cascade of retaliation. Be on the lookout and spot them running for office and vote them out. Educate yourself about corporate bullies 4. THE SEXUAL NARCISSIST is often hypersexual (male or female). Pornography, masturbation, incest are reported by his targets. Anything, anyone, young, old, male/female, are there for his gratification. This predator takes what is available. Can have a preference for 'sado-maso' sexuality. Often easily bored, he demands increasingly deviant stimulation. However, another behaviour exists, the one who withholds sex or emotional support. Defence Strategy: Expect this type to try to degrade you. Get away from him. Expect him to tell lies about your sexuality to evade exposure of his own. 5. THE BLAME-GAME NARCISSIST never accepts responsibility. Blames others for his failures and circumstances. A master at projection.


Defence Strategy: Learn about projection. Don't take the bait when he blames you. He made the mess, let him clean it up. 6. THE VIOLENT NARCISSIST is a wife-Beater, Murderer, Serial Killer, Stalker, Terrorist. Has a 'chip-on-his-shoulder' attitude. He lashes out and destroys or uses others (particularly women and children) as scapegoats for his aggression or revenge. He has poor impulse control. Fearless and guiltless, he shows bad judgement. He anticipates betrayal, humiliation or punishment, imagines rejection and will reject first to 'get it over with'. He will harass and push to make you pay attention to him and get a reaction. He will try to make you look out of control. Can become dangerous and unpredictable. Has no remorse or regard for the rights of others. Defence Strategy: Don't antagonize or tip your hand you're leaving. Ask for help from the police and shelters. 7. THE CONTROLLER/MANIPULATOR pits people against each other. Keeps his allies and targets separated. Is verbally skilful at twisting words and actions. Is charismatic and usually gets his way. Often undermines our support network and discourages us from seeing our family and friends. Money is often his objective. Other people's money is even better. He is ruthless, demanding and cruel. This control-freak bully wants you pregnant, isolated and financially dependent on him. Appears pitiful, confused and in need of help. We rush in to help him with our finances, assets, and talents. We may be used as his proxy interacting with others on his behalf as he sets us up to take the fall or enjoys the performance he is directing. Defence Strategy: Know the 'nature of the beast'. Facing his failure and consequences will be his best lesson. Be suspicious of his motives, and avoid involvement. Don't bail him out. 8. THE SUBSTANCE ABUSER Alcohol, drugs, you name it, this N does it. We see his over-indulgence in food, exercise or sex and his need for instant gratification. Will want you to do likewise. Defence Strategy: Don't sink to his level. Say No. 9. OUR "SOUL MATE" is cunning and knows who to select and who to avoid. He will come on strong, sweep us off our feet. He seems to have the same values, interests, goals, philosophies, tastes, habits. He admires our intellect, ambition, honesty and sincerity. He wants to marry us quickly. He fakes integrity, appears helpful, comforting, generous in his 'idealization' of us phase. It never lasts. Eventually Jekyll turns into Hyde. His discarded victims suffer emotional and financial devastation. He will very much enjoy the double-dipping attention he gets by cheating. We end the relationship and salvage what we can, or we are discarded quickly as he attaches to

a "new perfect soul mate". He is an opportunistic parasite. Our "Knight in Shining Armour" has become our nightmare. Our healing is lengthy. Defence Strategy: Seek therapy. Learn about this disorder. Know the red flags of their behaviour, and "If he seems too good to be true..." Hide the hurt you feel. Never let him see it. Be watchful for the internet predator. 10. THE QUIET NARCISSIST is socially withdrawn, often dirty, unkempt. Odd thinking is observed. Used as a disguise to appear pitiful to obtain whatever he can. 11. THE SADIST is now the fully-unmasked malignant narcissist. His objective is watching us dangle as he inflicts emotional, financial, physical and verbal cruelty. His enjoyment is all too obvious. He'll be back for more. His pleasure is in getting away with taking other people's assets. His target: women, children, the elderly, anyone vulnerable. Defence Strategy: Accept the Jekyll/Hyde reality. Make a "No Contact' rule. Avoid him altogether. End any avenue of vulnerability. Don't allow thoughts of his past 'good guy' image to lessen the reality of his disorder. 12. THE RAGER flies off the handle for little or no provocation. Has a severely disproportionate overreaction. Childish tantrums. His rage can be intimidating. He wants control, attention and compliance. In our hurt and confusion we struggle to make things right. Any reaction is his payoff. He seeks both good or bad attention. Even our fear, crying, yelling, screaming, name calling, hatred are his objectives. If he can get attention by cruelty he will do so. Defence Strategy: Manage your responses. Be fully independent. Don't take the bait of his verbal abuse. Expect emotional hurt. Violence is possible. 13. THE BRAINWASHER is very charismatic. He is able to manipulate others to obtain status, control, compliance, money, attention. Often found in religion and politics. He masterfully targets the naive, vulnerable, uneducated or mentally weak. Defence Strategy. Learn about brainwashing techniques. Listen to your gut instinct. Avoid them. 14. THE RISK-TAKING THRILL-SEEKER never learns from his past follies and bad judgment. Poor impulse control is a hallmark. Defence Strategy: Don't get involved. Use your own good judgement. Say No. 15. THE PARANOID NARCISSIST is suspicious of everything usually for no reason. Terrified of exposure and may be dangerous if threatened. Suddenly ends relationships if he anticipates exposure or abandonment. 97

Defence Strategy: Give him no reason to be suspicious of you. Let some things slide. Protect yourself if you anticipate violence. 16. THE IMAGE MAKER will flaunt his 'toys', his children, his wife, his credentials and accomplishments. Admiration, attention, even glances from others, our envy or our fear are his objective. He is never satisfied. We see his arrogance and haughty strut as he demands centre stage. He will alter his mask at will to appear pitiful, inept, solicitous, concerned, or haughty and superior. Appears the the perfect father, husband, friend - to those outside his home. Defence Strategy: Ignore his childlike behaviours. Know his payoff is getting attention, deceiving or abusing others. Provide him with 'supply' to avert problems. 17. THE EMOTIONAL VACUUM is the cruellest blow of all. We learn his lack of empathy. He has deceived us by his cunning ability to mimic human emotions. We are left numbed by the realization. It is incomprehensible and painful. We now remember times we saw his cold vacant eyes and when he showed odd reactions. Those closest to him become objectified and expendable. Defence Strategy: Face the reality. They can deceive trained professionals. 18. THE SAINTLY NARCISSIST proclaims high moral standing. Accuses others of immorality. "Hang 'em high" he says about the murderer on the 6:00 news. This hypocrite lies, cheats, schemes, corrupts, abuses, deceives, controls, manipulates and torments while portraying himself of high morals. Defence Strategy: Learn the red flags of behaviour. Be suspicious of people claiming high morals. Can be spotted at a church near you. 19. THE CALLING-CARD NARCISSIST forewarns his targets. Early in the relationship he may 'slip up' revealing his nature saying "You need to protect yourself around me" or "Watch out, you never know what I'm up to." We laugh along with him and misinterpret his words. Years later, coping with the devastation left behind, his victims recall the chilling warning. Defence Strategy: Know the red flags and be suspicious of the intentions of others. 20. THE PENITENT NARCISSIST says "I've behaved horribly, I'll change, I love you, I'll go for therapy." Appears to 'come clean' admitting past abuse and asking forgiveness. Claims we are at fault and need to change too. The sincerity of his words and actions appear convincing. We learn his words are verbal hooks. He knows our vulnerabilities and what buttons to push. We question our judgement about his disorder. We can disregard "Fool me once..." We hope for change and minimize past abuse. With a successful retargeting attempt, this N will enjoy his second reign of terror even more if we allow him back in our lives. Defence Strategy: Expect this. Self-impose a "No Contact" rule. Focus on the reality of his disorder. Journal past abusive behaviour to remind yourself. Join our support group.


Check for more publications like this, about: coaching, family therapy, borderline personality disorder, crisis counseling, empowerment, mental imagery, mind reading, communication, influencing, manipulation, interpersonal relationships etc...


4. Borderline Personality Disorder




Borderline Personality Disorder Treatment by John M. Grohol, Psy.D. - June 22, 2007 Table of Contents • • • • •

Introduction Psychotherapy Hospitalization Medications Self-Help

Introduction Borderline personality disorder is a disturbance of certain brain functions that causes four types of behavioural disturbances: 1. 2. 3. 4.

poorly regulated and excessive emotional responses; harmful impulsive actions; distorted perceptions and impaired reasoning; and markedly disturbed relationships.

The symptoms of borderline personaliy disorder were first described in the medical literature over 3000 years ago. The disorder has gained increasing visibility over the past three decades. The full spectrum of symptoms of bordelrine personality disorder typically first appears in the teenage years and early twenties. Although some children with significant behavioural disturbances may develop readily diagnosable borderline disorder as they get older, it is very difficult to make the diagnosis in children. After its onset, the disorder becomes chronic. Remissions, relapses, and overall significant improvement with treatment is the most common course of the illness. Borderline disorder appears to be caused by the interaction of biological, usually genetic, and environmental risk factors, such as poor parental nurturing, and early and sustained emotional, physical or sexual abuse. Physical disorders, such as migraine headaches, and other mental disorders, such as depression, anxiety, panic and substance abuse disorders, occur much more often in people with borderline disorder than they do in the general population.

Borderline Personality Disorder is experienced in individuals in many different ways. Often, people with this disorder will find it more difficult to distinguish between reality from their own misperceptions of the world and their surrounding environment. While this may seem like a type of delusion disorder to some, it is actually related to their emotions overwhelming regular cognitive functioning. People with this disorder often see others in “black-and-white” terms. Depending upon the circumstances and situation, for instance, a therapist can be seen as being very helpful and caring toward the client. But if some sort of difficulty arises in the therapy, or in the patient’s life, the person might then begin characterizing the therapist as “bad” and not caring about the client at all. Clinicians should always be aware of this “all-or-nothing” liability most often found in individuals with this disorder and be careful not to validate it. Therapists and doctors should learn to be like a rock when dealing with a person who has this disorder. That is, the doctor should offer his or her stability to contrast the client’s liability of emotion and thinking. Many professionals are turned-off by working with people with this disorder, because it draws on many negative feelings from the clinician. These occur because of the client’s constant demands on a clinician, the constant suicidal gestures, thoughts, and behaviours, and the possibility of self-mutiliating behaviour. These are sometimes very difficult items for a therapist to understand and work with. Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings. Controversy surrounds overmedicating people with this disorder.

Psychotherapy Like with all personality disorders, psychotherapy is the treatment of choice in helping people overcome this problem. While medications can usually help some symptoms of the disorder, they cannot help the patient learn new coping skills, emotion regulation, or any of the other important changes in a person’s life. An initially important aspect of psychotherapy is usually contracting with the person to ensure that they do not commit suicide. Suicidality should be carefully assessed and monitored throughout the entire course of treatment. If suicidal feelings are severe, medication and hospitalization should be seriously considered. The most successful and effective psychotherapeutic approach to date has been Marsha Linehan’s Dialectical Behaviour Therapy. Research conducted on this treatment have shown it to be more effective than most other psychotherapeutic and medical approaches to helping a person to better cope with this disorder. It seeks to teach the client how to learn to better take control of their lives, their emotions, and themselves through self-knowledge, emotion regulation, and cognitive restructuring. It is a comprehensive approach that is most often conducted within a group setting. Because the skill set learned is new


and complex, it is not an appropriate therapy for those who may have difficulty learning new concepts. Like all personality disorders, borderline personality disorder is intrinsically difficult to treat. Personality disorders, by definition, are long-standing ways of coping with the world, social and personal relationships, handling stress and emotions, etc. that often do not work, especially when a person is under increased stress or performance demands in their lives. Treatment, therefore, is also likely to be somewhat lengthy in duration, typically lasting at least a year for most. Other psychological treatments which have been used, to lesser effectiveness, to treat this disorder include those which focus on social learning theory and conflict resolution. These types of solutionfocused therapies, though, often neglect the core problem of people who suffer from this disorder — difficulty in expressing appropriate emotions (and emotional attachments) to significant people in their lives due to faulty cognitions. Providing a structured therapeutic setting is important no matter which therapy type is undertaken. Because people with this disorder often try and “test the limits” of the therapist or professional when in treatment, proper and well-defined boundaries of your relationship with the client need to be carefully explained at the onset of therapy. Clinicians need to be especially aware of their own feelings toward the patient, when the client may display behaviour which is deemed “inappropriate.” Individuals with borderline personality disorder are often unfairly discriminated against within the broad range of mental health professionals because they are seen as “troublemakers.” While they may indeed need more care than many other patients, their behaviour is caused by their disorder. Phillip W. Long, M.D. also notes that: “The therapeutic alliance should form within the patient’s real experiences with the therapist and with the treatment. The therapist must be able to tolerate repeated episodes of primitive rage, distrust, and fear. Uncovering is to be avoided in favor of bolstering of ego defences, in order to eventually allow the patient to be less anxious about potential fragmentation and loss. The goals of therapy should be in terms of life gains toward independent functioning, and not complete restructuring of the personality.”

Hospitalization Hospitalization is often a concern with people who suffer from borderline personality disorder because they so often visit hospital emergency rooms and are sometimes seen on inpatient units because of severe depression. People with this disorder often present in crisis at their local community mental health center, to their therapist, or at the hospital emergency room. While an emergency room is an immediate source of crisis intervention for the patient, it is a costly treatment and regular visits to the E.R. should be discouraged. Instead, patients should be encouraged to find additional social support within their community (including self-help support groups), contact a crisis hotline, or contact their therapist or treating physician directly. Emergency room personnel should be careful not to treat the person with borderline personality disorder in blind conjunction with another set of therapists or doctors who are treating the patient for the same problem at another facility. Every attempt should be made to contact the client’s attending physician or primary therapist as soon as possible, even before the administration of medication which may be contraindicated by the primary treatment provider. Crisis management of the immediate problem is usually the key component to effective treatment of this disorder when it presents in a hospital emergency room, with discharge to the patient’s usual care provider. Inpatient treatment often takes the form of medication in conjunction with psychotherapy sessions in groups or individually. This is an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning. It is, however, relatively rare to be hospitalized in the U.S. for this disorder. Long-term care of the person suffering from borderline personality disorder within a hospital setting is nearly never appropriate. The typical inpatient stay for someone with borderline personality disorder in the U.S. is about 3 to 4 weeks, depending upon the person’s insurance. Since this treatment is so expensive, it is getting more difficult to obtain. Results of such treatment are also mixed. While it is an excellent way of helping stabilize the client, it is usually too short a time to attain significant changes within the individual’s personality makeup. Good inpatient care facilities for this disorder should be highly structured environments which seek to expand the individual’s independence. Phillip W. Long, M.D., adds that the goals of such a treatment modality, “include decreasing acting out, clearly identifying and working with inappropriate behaviours and feelings, accepting with the patient the magnitude of the therapeutic task, fostering more effective interpersonal relationships, and working with both real and transference relationships within the hospital.”


Partial hospitalization or a day treatment program is often all that’s needed for people who suffer from borderline personality disorder. This allows the individual to gain support and structure from a safe environment for a short time, or during the day, and returning home in the evening. In times of increased stress or difficulty coping with specific situations, this type of treatment is more appropriate and more healthy for most people than full inpatient hospitalization.

Medications Phillip W. Long, M.D. has noted: Medications play three very important roles in the treatment of most patients with borderline disorder. They are effective in reducing the four major groups of symptoms of the disorder. They thereby enhance the rate and quality of improvement derived from psychotherapy. Finally, medications are effective in treating other emotional disorders that frequently are associated with borderline disorder, for example, depression, anxiety/panic attacks, and ADHD, and physical disorders such as migraine headaches. “During brief reactive psychoses, low doses of antipsychotic drugs may be useful, but they are usually not essential adjuncts to the treatment regimen, since such episodes are most often self-limiting and of short duration. It is, however, clear that low doses of high potency neuroleptics (e.g., haloperidol) may be helpful for disorganized thinking and some psychotic symptoms. Depression in some cases is amenable to neuroleptics. Neuroleptics are particularly recommended for the psychotic symptoms mentioned above, and for patients who show anger which must be controlled. Dosages should generally be low and the medication should never be given without adequate psychosocial intervention.” Antidepressant and anti-anxiety agents may be appropriate during particular times in the patient’s treatment, as appropriate. For example, if a client presents with severe suicidal ideation and intent, the clinician may want to seriously consider the prescription of an appropriate antidepressant medication to help combat the ideation. Medication of this type should be avoided for long-term use, though, since most anxiety and depression is directly related to short-term, situational factors that will quickly come and go in the individual’s life.

Treatment for Depression Co-occurring with Borderline Disorder If you think you have the symptoms of either type of depression, immediately alert your psychiatrist. If appropriate, the treatment for depression frequently involves the addition of an antidepressant, an increase in dosage if one is already being used, and/or the use of behavioural techniques. There are no controlled studies on the relative antidepressants for the treatment for depression disorder. However, studies of these disorders in disorder, and experience, suggest that the following may have merit:

effectiveness of different in people with borderline people without borderline initial treatment strategies

Treatment for Depression in Bipolar Disorder-Depressed • Bupropion (Wellbutrin®) • Lamotrigine (Lamictal®) • SSRIs such as fluoxetine (Prozac®) or sertraline (Zoloft®) if bupropion

and lamotrigine are ineffective

Treatment for Depression in Major Depressive Disorder • SSRIs such as fluoxetine or sertraline • Bupropion and lamotrigine if SSRIs are ineffective

Note: It is important in the treatment for depression to recognize that some antidepressants may cause an episode of mania or hypomania in patients with depression who have never experienced such episodes in the past. Cognitive Behavioural Therapy focused on treatment for depression may also prove useful to help identify thought patterns and behaviours that operate as risk factors for mood disorders, and to encourage new, more successful behaviours. * Bipolar I and II, and major depressive disorders occur more commonly in patients with borderline disorder than they do in the general population. Bipolar II disorder is the most common type of bipolar disorder that occurs with borderline disorder. People with bipolar II disorder do not experience manic episodes as do those with bipolar I disorder, but do experience brief hypomanic periods and recurring episodes of depression. Depressions associated with bipolar disorder appear to be related to depressions referred to as atypical depression and seasonal affective disorder (SAD).


Self-Help Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Encouraging the individual with borderline personality disorder to gain additional social support, however, is an important aspect of treatment. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and emotion regulation with people they meet within support groups. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships.

Education and Support During the past decade, an increasing number of educational and support groups have been formed for patients with borderline disorder, and for their families. Many of these have been the result of the efforts of lay advocacy groups dedicated to increasing knowledge about, and reducing the stigma associated with borderline disorder.

Patient and Family Educational Programs A growing number of educational programs are being conducted for people with borderline disorder and their families. These are often co-sponsored by community organizations working with the assistance of consumer and family organizations such as the National Education Alliance for Borderline Personality Disorder (NEA-BPD), the Treatment and Research Advancements National Association for Personality Disorder (TARA), and the National Alliance on Mental Illness (NAMI). A recent addition to the therapeutic opportunities for family members of people with borderline disorder has been the introduction of family educational and training programs.

Family Connections The family education program, Family Connections (FC), is available in multiple locations throughout the US, and at several locations in Canada, Europe and the UK. It operates under the auspices of NEA-BPD with research funding from the National Institute of Mental Health. Experienced family members colead the 12-week manualized series of sessions for other families. These sessions provide participants with the most current information and research about borderline disorder, teach

DBT and family coping skills, and provide an opportunity to develop a support network. Research documents a reduction in family member depression, burden, and grief and an increase in coping skills. No registration fee is required, but in some locations a donation to cover costs of the course materials is suggested.

Family-to-Family The National Alliance on Mental Illness (NAMI) has recently designated borderline disorder as a “priority population.” In doing so, NAMI has now extended its popular 12 week Family Education Program to include this disorder. The course is taught by trained NAMI volunteers in every state in the country. It provides a broad range of information essential to those caring for loved ones with borderline and other serious mental disorders.

Family Training Workshop TARA sponsors an eight session DBT family training workshop in New York City and other cities across the country. The main goals of the program are similar to that provided by NEA-BPD. Each training cycle is limited to sixteen members, and a registration fee is required.

Support Groups In some communities, groups of people with borderline disorder and family members meet on a regular basis, without a therapist or trained and skilled group leader, to help one another. Such support groups typically do not charge members a fee and can be very beneficial for the reasons cited above for therapist-assisted group therapy.

There are two types of support groups: • groups for the person with borderline disorder • groups for their family members

Although it may be helpful, participation in such groups should be approached with caution by the person with borderline disorder or family members. Considerable harm can be done if one or more individuals in the group act in an angry, manipulative, malicious, or otherwise inappropriate and destructive way toward another group member or the group as a whole. Without a skilled leader or facilitator present to step in to handle the situation promptly and properly, a member of the group, and even the group itself, may be exposed to significant trauma. Prior to joining a support group, it is wise to seek recommendations about groups in your community from your nearest NAMI Chapter, or from mental health professionals working with patients with borderline disorder. In addition, it may be helpful to request information from members of such groups before joining.


Symptoms of Borderline Personality Disorder by John M. Grohol, Psy.D. - June 22, 2007

The main feature of borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image and emotions. People with borderline personality disorder are also usually very impulsive. This disorder occurs in most by early adulthood. The instable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar liability (fluctuating back and forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships and the person’s emotion may often be characterized as being shallow.

A person with this disorder will also often exhibit impulsive behaviours and have a majority of the following symptoms: • • • • • •

• • •

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 Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) Transient, stress-related paranoid ideation or severe dissociative symptoms

Details about Borderline Personality Disorder Symptoms

Frantic efforts to avoid real or imagined abandonment. The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, emotion, thinking and behaviour. Someone with borderline personality disorder will be very sensitive to things happening around them in their environment. They experience intense abandonment fears and inappropriate anger, even when faced with a realistic separation or when there are unavoidable changes in plans. For instance, becoming very angry with someone for being a few minutes late or having to cancel a lunch date. People with borderline personality disorder may believ that this abandonment implies that they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviours.

Unstable and intense relationships. People with borderline personality disorder may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficient supports or as cruelly punitive. Such shifts other reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.


Identity disturbance. There are sudden and dramatic shifts in self-image, characterized by shifting goals, values and vocational aspirations. There may be suddent changes in opinions and plans about career, sexual identity, values and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with borderline personality disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations.

Display self-damaging impulsivity Individuals with Borderline Personality Disorder display impulsivity in at least two areas that are potentially self-damaging. They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly.

Display recurrent suicidal behaviour Individuals with Borderline Personality Disorder may also sometimes display recurrent suicidal behaviour, gestures, or threats, or selfmutilating behaviour. Completed suicide occurs in 8%-10% of such individuals, and selfmutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These selfdestructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility. Selfmutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual’s sense of being evil.

Display affective instability Individuals with Borderline Personality Disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with Borderline Personality Disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.

Associated Features and Disorders Individuals with Borderline Personality Disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychoticlike symptoms (e.g., hallucinations, body-image distortions, ideas of reference, and hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure


with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring Mood Disorders or Substance-Related Disorders. Physical handicaps may result from self-inflicted abuse behaviours or failed suicide attempts. Recurrent job losses, interrupted education, and broken marriages are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with Borderline Personality Disorder. Common co-occurring Axis I disorders include Mood Disorders, Substance-Related Disorders, Eating Disorders (notably Bulimia), Posttramatic Stress Disorder, and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder also frequently co-occurs with the other Personality Disorders.

Specific Culture, Age, and Gender Features The pattern of behaviour seen in Borderline Personality Disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance abuse) may transiently display behaviours that misleadingly give the impression of Borderline Personality Disorder. Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers. Borderline Personality Disorder is diagnosed predominantly (about 75%) in females.

Prevalence The prevalence of Borderline Personality Disorder is estimated to be about 2% of the general population, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. In ranges from 30% to 60% among clinical populations with Personality Disorders.

Course There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning.

Familial Pattern Borderline Personality Disorder degree biological relatives of population. There is also an Disorders, Antisocial Personality

is about five times more common among firstthose with the disorder than in the general increased familial risk for Substance-Related Disorder, and Mood Disorders.

Differential Diagnosis Borderline Personality Disorder often co-occurs with Mood Disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the clinician should avoid giving an additional diagnosis of Borderline Personality Disorder based only on cross-sectional presentation without having documented that the pattern of behaviour has an early onset and a long-standing course.

Look-alikes Other Personality Disorders may be confused with Borderline Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Borderline Personality Disorder, all can be diagnosed. Although Histrionic Personality Disorder can also be characterized by attention seeking, manipulative behaviour, and rapidly shifting emotions, Borderline Personality Disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both Borderline Personality Disorder and Schizotypal Personality Disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in Borderline Personality Disorder. Although Paranoid Personality Disorder and Narcissistic Personality Disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns distinguish these disorders from Borderline Personality Disorder. Although Antisocial Personality Disorder and Borderline Personality Disorder are both characterized by manipulative behaviour, individuals with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in Borderline Personality Disorder is directed more toward gaining the concern of caretakers. Both Dependent Personality Disorder and Borderline Personality Disorder are characterized by fear of abandonment, however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline Personality Disorder can further be distinguished from Dependent Personality Disorder by the typical pattern of unstable and intense relationships. Borderline Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct


effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified). Borderline Personality Disorder should be distinguished from Identity Problem...which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder."

Frequently Asked Questions about Borderline by John M. Grohol, Psy.D. - June 22, 2007

What is Borderline Personality Disorder (BPD)? The main feature of borderline personality disorder (BPD) is a long pattern of instability in their relationships with others, and in their own self-image and emotions. People with borderline personality disorder are also usually very impulsive. The instable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships and the person’s emotion may often be characterized as being shallow. The disorder occurs in most by early adulthood.

How common is Borderline Personality Disorder? It is not very common, and is estimated to be found in 1 to 2% of the general U.S. population at any give time. It is more common amongst people seeking treatment for another mental disorder.

How does Borderline Personality Disorder cause problems? Like any mental health issue, borderline personality disorder causes problems in a person’s social and life functioning by interfering with the person’s ability to reliably maintain these relationships or their everyday living. People with this disorder often cause a great amount of stress or conflict in relationships with others, especially significant others or those who are very close to the person. This can often lead to divorce, physical, sexual or emotional abuse, additional emotional problems (such as an eating disorder or depression), losing one’s job, estrangement from one’s family, and more.

What is the course of Borderline Personality Disorder? There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious loss of emotion and impulsive control, as well as high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and job functioning.

Is Borderline Personality Disorder inherited? Borderline Personality Disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for Substance-Related Disorders (e.g., drug abuse), Antisocial Personality Disorder, and Mood Disorders, like depression or bipolar disorder. Where can I go to learn more about Borderline Personality Disorder? Psych Central has a reviewed list of resources you can consult for further information about Borderline Personality Disorder. We also recommend the following two books to understand more about this disorder: •

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care about Has Borderline Personality Disorder by Paul T. Mason and Randi Kreger


The Stop Walking on Eggshells Workbook: Practical Strategies for Living With Someone Who Has Borderline Personality Disorder by Randi Kreger and James Paul Shirley

For Loved Ones People with borderline disorder have marked difficulties with relationships, especially with the people who are closest to them, such as families, partners and friends. Episodes of anger outbursts, moodiness, and unreasonable, impulsive, and erratic behaviours, which often appear unprovoked, can result in considerable harm to these important relationships. Attempts to engage in a discussion to work out reasonable solutions to problems frequently turn into highly emotional battles. This usually results in responses from family, partners and friends that include anxiety and frustration, attempts to placate, and


angry retorts when the limits of normal patience have been exceeded. Therefore, most loved ones of individuals with borderline disorder are quite relieved to learn that effective treatment is available for the disorder, and that there are ways they can help as well. Two significant advances in the area of borderline disorder have been the recent research on the effectiveness of different educational and therapeutic experiences for families, and the development of consumer and family organizations focused on the disorder.

Guidelines for Families, Partners and Friends If you are a family member, partner or friend of someone with borderline disorder, you probably have developed feelings of anger and resentment towards them that conflict with your feelings of empathy and desire to help. The following are ten specific actions that you can take that will help the person with borderline disorder gain better control over her or his life, and help you in the process.

1. Learn About the Disorder It is essential to understand that the person with borderline disorder is suffering from an illness that is as real as diabetes, heart disease, or hypertension. For most people, physical symptoms are easier to accept as indications of a disease than are behavioural symptoms. However, there is no reason to assume that a complex organ such as the brain is less susceptible to diseases that affect behaviour than are other bodily organs that result in physical symptoms. Recently developed medical research studies demonstrate abnormal brain structure and function in patients with borderline disorder, thus confirming this conclusion. It is also helpful to realize that persons with borderline disorder did not acquire the disorder through any actions of their own, nor do they enjoy having the disorder. Imagine what it must be like to feel that you are frequently at the mercy of forces within you, over which you seem to have little control, and that cause you extreme emotional pain and significant life problems. Therefore, a critical first step in the process of helping them and you is to learn as much as you can about the symptoms and nature of borderline disorder, and the specific situational causes of acute episodes in the member of your family with the disorder.

2. Seek Professional Help Facilitate the process of obtaining optimal help. It may be necessary that you do the initial work necessary to set up the first appointment. It may also be helpful if you agree to go also. Some people with borderline disorder initially refuse to seek professional help. Provide them with a copy of my book and suggest they read the first two chapters. This may help them understand their potential problems well enough to agree to an initial appointment with a psychiatrist. Other people with borderline disorder are steadfast in their refusal of help. This, of course, is a major problem. Dr. Perry Hoffman, the founding president of the National Education Alliance for Borderline Personality Disorder (NEA-BPD) offers this advice: The best way of approaching this problem from my perspective is for one to accept that you cannot get someone into treatment. Timing is important as to when someone might be “open� to hearing the idea. But the bottom line is to free families of feeling guilty, and to understand that they are not so powerful to effect that goal. Along that line, relatives need to get help and support for themselves as they watch their loved one in the throes of the illness.

3. Support the Treatment Program Once in treatment, encourage and support your loved one with borderline disorder to regularly attend therapy sessions, to take medicine as prescribed, to eat, exercise, and rest appropriately, and to engage in wholesome recreational activities. If alcohol or other drugs are a problem, strongly support their efforts to abstain completely from these substances, and encourage regular attendance in treatment programs or self-help groups, such as Alcoholics Anonymous. Remember, there is little hope of improvement of the symptoms of borderline disorder if alcohol and drugs are abused. It is very important that you remain persistent in your efforts to do everything possible to help reduce the risk of this behaviour, and not enable it.

4. Respond Consistently to Problematic Behaviours Develop a clear understanding (it may even be written) of the realistic consequences of recurring, problematic, destructive behaviours such as episodes of alcohol and drug abuse, physically selfdamaging acts, and excessive spending and gambling. Also, agree beforehand on how best to respond to threats and acts of selfharm. These and other problematic behaviours are often triggered by stressful events that need to be identified, and a clear plan developed for handling these events and situations more appropriately and effectively in the


future. Such a plan is best developed with the help of the patient’s primary clinician. Experience has shown that responding positively to appropriate behaviours is also very important in encouraging change to new and more successful ways of handling stressful situations. Doing so also reduces the incidence of inappropriate behaviours that then cause additional problems. Issuing spontaneous ultimatums should be avoided.

5. Attempt to Remain Calm Reacting desperately or angrily when there is a flare up of symptoms will often add to the existing problem. Remain calm. Acknowledge that it must be difficult to experience the expressed feelings, even if they seem out of proportion to the situation. This does not mean that you agree with these feelings, or that you think that the actions resulting from them are justified. However, it is reassuring if you listen to their feelings, the pain they are experiencing, and the difficulty they are having in dealing with this pain. Remember that you do not have to defend yourself if verbally attacked, or develop solutions to their problems. If they express thoughts of self-harm, remind them of the plan for dealing with this problem that has been worked out with their therapist. Allow and encourage the person with borderline disorder to attempt to bring their response levels in line with the situation at hand. This may require that you give them a little time alone to collect themselves. Then it may be possible to more calmly and reasonably discuss the relevant issues. In addition, do not be hesitant to express your feelings freely and openly, but with moderation. Recent research suggests that caring involvement with your loved one with borderline disorder is associated with better outcomes than a cool, disinterested approach. Stay involved.

6. Remain Positive and Optimistic It is important to remain optimistic about the ultimate results of treatment, especially when the patient has a setback. The usual course of borderline disorder with optimal treatment is one of increasing periods of time when symptoms are absent or minimal, interrupted by episodes when the symptoms flare up. Over time, the specific causes of relapses can be identified, anticipated, then steps taken to develop alternative, more adaptive and effective responses. Occasional family meetings with the therapist may help clarify the causes of relapses and identify new ways of preventing them. 7. Participate in Educational Experiences About Borderline Disorder It is very important that you learn as much as possible about borderline disorder and your role in the treatment process. Your participation in educational opportunities may benefit both you and your loved one with the disorder. When conducted by skilled and experienced people, such structured and informative experiences may involve both patients and family.

8. Join a Borderline Disorder Consumer and Family Support Organization For information on such consumer organizations, contact the National Alliance on Mental Illness (NAMI) or the National Education Alliance for Borderline Personality Disorder (NEA-BPD). If such an organization exists in or near your community, seriously consider joining it. You will then have available to you a large amount of new information about borderline disorder, what you can do to help the member of your family with the disorder and yourself, and compassionate and understanding support in your efforts. If there is not a group in your area, consider starting one with other family members you have met. Also consider joining one of these national consumer organizations for borderline disorder.

9. Remember: the Person with Borderline Disorder Must Take Charge Remember that it is primarily the responsibility of the person with borderline disorder to take charge of her or his behaviour and life. Although difficult at times, it is important for you to provide the opportunity for your family member with borderline disorder to take reasonable risks in order to try new behaviours. It is also important that you help her or him to be accountable for the consequences of old, destructive behaviours. Excessive dependency on family and friends is not helpful in the long run. Beware of the tendency of people with borderline disorder to act at the extremes. For example, the proper alternative to excessive dependency is not immediate, total independency. The more appropriate responses are to remain engaged and to gradually help move to a more balanced, mature relationship level of mutual interdependency.

10. Take Care of Yourself If you take the time to meet your own needs, when your help is needed most, you will be best able to provide it. Remember that you cannot save your loved one with borderline disorder on your own. If you are the parent, there is a natural tendency to focus much of your attention on the person with borderline disorder. However, make certain that you are not neglecting your other sons and daughters who may appear to be doing well. They have need of your time and attention too, even as they grow into adulthood. You will learn from educational experiences the extent of this potential problem and how best to deal with it.


THE WORLD NEEDS PEOPLE... who cannot be bought; whose word is their bond; who put character above wealth; who possess opinions and a will; who are larger than their vocations; who do not hesitate to take chances; who will not lose their individuality in a crowd; who will be as honest in small things as in great things; who will make no compromise with wrong; whose ambitions are not confined to their own selfish desires; who will not say they do it" because everybody else does it"; who are true to their friends through good report and evil report, in adversity as well as in prosperity; who do not believe that shrewdness, cunning, and hardheadedness are the best qualities for winning success; who are not ashamed or afraid to stand for the truth when it is unpopular; who can say "no" with emphasis, although all the rest of the world says "yes." - Charles Swindoll.

ONLINE TEST The following "test" may help you to evaluate the possibility that you or a loved one has borderline disorder. It is simply a check list of the nine criteria of borderline disorder as defined by the American Psychiatric Association in their diagnostic manual, DSM-IV-TR. However, it is reworded so that you may readily apply the criteria to your situation. Please note that you should not use the results of the test to arrive at any fixed conclusion, but rather to provide you with an estimation of the possibility that this disorder, or its traits, may exist. How to Use the Borderline Disorder Test First, read carefully about the symptoms of borderline disorder provided on this website, or as they are described in more detail in my book, Borderline Personality Disorder Demystified. Next, print this page and place a check mark next to those symptoms or behaviours listed below that you believe accurately describe your condition. If you are in doubt, leave the item blank.

The Borderline Disorder Test ___

1) My emotions change very quickly, and I experience intense episodes of sadness, irritability, and anxiety or panic attacks.


2) My level of anger is often inappropriate, intense and difficult to control.


3) I suffer from chronic feelings of emptiness and boredom.


4) I engage in two or more self-damaging acts such as excessive spending, unsafe and inappropriate sexual conduct, substance abuse, reckless driving, and binge eating.


5) Now, or in the past, when upset, I have engaged in recurrent suicidal behaviours, gestures, threats, or self-injurious behaviour such as cutting, burning or hitting myself.


6) I have a significant and persistently unstable image or sense of my self, or of who I am or what I truly believe in.


7) I have very suspicious ideas, and am even paranoid (falsely believe that others are plotting to cause me harm) at times; or I experience episodes under stress when I feel that I, other people or the situation is somewhat unreal.



8) I engage in frantic efforts to avoid real or imagined abandonment by people who are close to me. 9) My relationships are very intense, unstable, and alternate between the extremes of over idealizing and undervaluing people who are important to me.









Score of five or greater: If you have checked five or more items on the above list, you may have borderline disorder. In order to determine if this is the case, you will require an evaluation by a psychiatrist or mental health care clinician who is well trained and experienced in borderline disorder.

Score of one to four: If you have checked one to four items on the above checklist, you may have borderline disorder traits. Depending on the level of severity of your symptoms or behaviours, and the amount of disruption that they cause you, your family, friends and others, you may require an evaluation by a psychiatrist or mental health care clinician who is well trained and experienced in borderline disorder. It is important to realize that you do not have to meet five or more criteria of borderline disorder for these symptoms to significantly disrupt your life. You may still benefit greatly from appropriate treatment.

Guidelines for the Selection of a Psychiatrist and Other Clinicians Once you have located the names of one or more clinicians, you may wish to contact them to determine if they provide the services you are looking for. The following is a list of issues that you may wish to clarify in order to determine if you have a reasonably suitable fit given your individual needs: Primary Clinician: Ideally, in most cases, you are looking for a psychiatrist with experience in borderline disorder who can serve as your primary clinician, that is, perform your initial clinical evaluation and the other tasks of someone assuming this role in your care. If such a person is not available in your community, you should ask other potential providers of care about their level of experience in the area of borderline disorder. Types of Treatment: Determine what forms of treatment they typically use for their patients with the disorder, especially medications and psychotherapies. Most psychiatrists and other clinicians do not typically provide the full range of treatments that we now know are useful for treating the disorder. In other words, you may need several people working with you, for example, one to prescribe medications, another to provide therapy, and possibly a third for group therapy work. Therefore, you will need to ask how your special needs will be met by each clinician. If you will be seeing just one person, be especially cautious if they recommend only one form of treatment for all patients with borderline disorder, for example either medications or psychotherapy, or one specific type of psychotherapy. As noted elsewhere on this site, borderline disorder affects people

in many different ways. Therefore, in most cases, effective treatment plans are more complex than can be accomplished by a single type of treatment. Immediate Help: You should establish how the provider handles those times when you may need immediate help, for example who will respond to your telephone calls and under what circumstances. Also, should you require brief hospitalization, what hospital will be utilized, and who will direct your care when you are in the hospital. Communication: If you will have more than one clinician working with you, it is important to establish the degree to which they will work with you and with your family or partner, and with each other. It is important that the team communicate openly. Under most circumstances, it is essential that those people who are very important in your life are included in your treatment. The types and frequency of involvement required are best discussed prior to the onset of treatment. Finding the Right Fit: Ultimately, you are looking for clinicians who appear to be “good fits” for you and your special needs. To some degree this is a subjective quality, and cannot be easily defined further, but patients often sense when they have found the right professionals with whom to work. Credentials: It is very appropriate to ask about the potential provider’s specific credentials: in what mental health specialty do they have their degree; are they certified properly, for example., for psychiatrists, by the American Board of Psychiatry and Neurology; are they licensed to practice in their specific clinical area; and what degree of training and experience do they have with borderline disorder. Payment Information: Finally, you should obtain their fee schedule and method of payment for different services, for example medication checks, and individual and group psychotherapy sessions. Many clinicians accept insurance with copayments, while some require self payment. At the outset of care, remember that your doctor may not be able to determine precisely the most effective treatments for you. Therefore, it seems to me most reasonable to find a psychiatrist, and other clinicians when necessary, who know the relevant medical literature, that have open minds regarding different diagnostic possibilities and treatment approaches, and who communicate well with you and your family. Given our current level of knowledge about borderline disorder, it is likely that such professionals will give you the best help available, now and in the future.


The Diagnosis and Treatment for Depression Co-Occurring with Borderline Disorder by Robert O. Friedel, MD

More than 80 percent of people with borderline disorder suffer from episodes of major depression. Treatment for depression is vital in these individuals. There are two categories of major depressive episodes, those associated with bipolar I and II disorder-depressed*, and those referred to as major depressive disorder. Therefore, if you have borderline disorder, it is important that you know and recognize the symptoms of these disorders. If they occur, you should alert your physician so that you may receive prompt treatment for depression.

Symptoms of a Major Depressive Episode: • • • • • • • • •

persistently depressed or irritable mood diminished interest or pleasure in activities significant decrease or increase in appetite, or weight loss or weight gain increased or decreased sleep decreased mental and physical activity, or increase in such activity as demonstrated by excessive worrying and agitated behaviour fatigue, or loss of energy feelings of worthlessness or excessive or inappropriate guilt diminished ability to think or concentrate, or indecisiveness recurrent thoughts of death and dying, recurrent suicidal thoughts with a specific plan, or a suicide attempt Understand the differences in symptoms of Borderline Disorder, Bipolar Disorder-Depressed and Major Depressive Disorder, and learn about the various plans for treatment for depression. In order to initiate the proper treatment for depression, it is necessary to determine if you are experiencing a decrease in mood associated with borderline disorder, or if you have developed a bipolar II disorder- depressed or major depressive disorder.

Depressed Mood in Borderline Disorder In borderline disorder alone, depressed mood often occurs as follows: • sad, depressed, and lonely feelings are frequently triggered by some life event and are often associated with strong feelings of emptiness, loneliness and fears of abandonment. • symptoms readily improve if the situation causing them improves • sleep, appetite and energy disturbances (if present) are usually related to an identifiable life stress and stop when the stress is managed successfully. • acute suicidal thoughts and self-injurious behaviour are usually the direct result of a personal problem (for example, an argument with a parent, boyfriend, spouse, or boss)

Bipolar II Disorder-Depressed* In bipolar disorder-depressed, the symptoms of a major depressive episode listed above are often characterized by: • increased appetite or weight gain • increased sleep and napping • marked decrease in mental and physical activity • marked fatigue and loss of energy

Major Depressive Disorder In major depressive disorder, the symptoms of a major depressive episode listed above are often characterized by: • decreased appetite or weight loss • decreased sleep with early morning awakening • increased mental and physical activity as demonstrated by excessive worrying and agitated behaviour

Substance Abuse Treatment in Patients with Borderline Disorder by Robert O. Friedel, MD

Two-thirds of people with borderline disorder seriously abuse alcohol, street drugs, and/or prescribed drugs. This is a major factor resulting in poor outcome of people with borderline disorder. Alcohol and drugs are abused by people with borderline disorder to temporarily relieve the severe emotional pain that they experience, especially when under stress. Predictably, this relief is short lived. Even worse, the use of these substances markedly increases many of the symptoms of borderline disorder making substance abuse treatment all the more important. It is possible that some of the genetic alterations that are risk factors in borderline disorder may also be among the group of genes that predispose people to alcoholism and drug abuse.

DSM-IV-TR Criteria for Substance Use Disorders: There are two types of substance use disorders, substance dependence and substance abuse. Substance abuse treatment is important in both types of substance use disorders.


Substance Dependence A pattern of substance use that leads to significant impairment or distress in three (or more) of the following ways: •

• • • • • •

tolerance, as defined by either o a need for markedly increased amounts of the substance to achieve the desired effect, or o a markedly diminished effect with continued used of the same amount of the substance withdrawal symptoms characteristic for the substance, or increased use to relieve or avoid withdrawal symptoms the substance is taken in larger amounts or over a longer period than intended a persistent desire or unsuccessful efforts to cut down or control substance use much time is spent in activities to obtain the substance, use the substance, or recover from its effects important social, occupational, or recreational activities are given up or reduced the substance use is continued despite it causing a persistent or recurrent physical or psychological problem (e.g., current cocaine use despite recognition of cocaine-induced depression)

Self-Injurious Behaviours and Suicidality in Borderline Disorder by Robert O. Friedel, MD

In a recent study, approximately 75 percent of women with borderline disorder engaged in self-injurious behaviours such as cutting, burning and small drug overdoses. Cutting is by far the most common act of this type. About 9 percent of people with the disorder commit suicide. The most frequent means is by drug overdose. Both types of behaviour may occur in the same individual. Cutting behaviours double the risk of suicide in people with borderline disorder.

Self-Injurious Behaviours In addition to cutting and burning themselves, and taking small drug overdoses, people with borderline disorder hit themselves, pull out their hair, scratch their skin to the point they open wounds, and injure themselves in other ways. Most people with the disorder who injure themselves report that they do so mainly to decrease the intense emotional pain they experience. Remarkably, they also often report that the first time they engaged in cutting and other self injurious behaviours, the idea just came to them. Finally, they report that these acts usually do result in brief emotional relief. It is important that family and other loved ones understand that this is the main motive of self injurious behaviours, not primarily to manipulate the situation or the people around them, though this is often a secondary motive.


Risk Factors for Suicidality There are a number of factors that increase the risk that a person with borderline disorder will commit suicide. Although nothing can be done to reverse some of these factors, others are highly treatable, and deserve immediate attention. • • • • • • • • • • • •

co-occurring disorders antisocial personality disorder (higher in males) major depression substance abuse* personality characteristics impulsive aggression poor emotional control hopelessness history and severity of childhood sexual abuse age over 30 years number of prior self-injurious behaviours and suicide attempts no prior treatment, or extensive and unsuccessful treatment history

Prevalence Across the Life Cycle: Self-injurious behaviours do not appear to decrease or “burn out” with increasing age in people with borderline disorder, as do other aggressive and impulsive behaviours

Management of Self-Injurious Behaviours and Suicidality General Treatment Interventions for Injurious Behaviours and Suicidality:

careful evaluation determine the level of intent and risk of self-injurious behaviours and suicide overt and unstated • directly involve the patient and family in the process • treat at the least restrictive level of care for the shortest period of time indicated aggressively treat all co-occurring disorders modify the treatment to accommodate the significant increase in severity of borderline disorder symptoms highly structure the environment identify and promptly address precipitating events assure involvement and coordination of the entire treatment team, including the family continue to balance risk vs. reward • •

• • • • • •


Specific Treatment Interventions: Medications Purposes • •

reduce or eliminate co-occurring disorders, such as major depressive episodes, substance abuse, ADHD and anxiety disorders reduce core symptoms of borderline disorder: e.g., emotional dysregulation; aggressive-impulsivity; and cognitive-perceptual impairment

Specific Treatment Interventions: Psychotherapy (dialectical behaviour supportive therapy)


Purposes reduce self-injurious behaviours and suicidality decrease the hospitalizations



* Note: If you have borderline disorder and have a tendency to abuse alcohol or drugs, it is essential that you obtain help to abstain completely from doing so.

Substance Abuse A pattern of substance use that leads to significant impairment or distress in one (or more) of the following ways: a failure to fulfill major role obligations at work, school, or home recurrent substance use in situations in which it is physically hazardous recurrent substance-related legal problems continued substance use despite having persistent or recurrent social or interpersonal problems caused or worsened by the effects of the substance •

• • •


Consequences of Abuse of Alcohol and Street Drugs in Borderline Disorder dramatic worsening of the symptoms of borderline disorder • marked decrease in the effectiveness of medications and psychotherapy. • addiction to and sustained craving for these substances.

Substance Abuse Treatment Interventions For all of these reasons, for substance abuse treatment purposes, I strongly advise my patients with borderline disorder to not use alcohol, to not take any street drugs, and to take prescribed medications only as ordered by their physicians. In addition, I encourage those patients who have a substance-use disorder to engage fully in a substance abuse treatment program and attend support groups (Alcoholics Anonymous or Narcotics Anonymous). I also suggest to some of them that they may benefit from a trial on a medication appropriate for their specific drug dependency, as this may help reduce craving and use. Conclusions Substance use disorders are major predictors of poor short- and long-term outcome of borderline disorder. There is little or no hope of gaining control over the symptoms of borderline disorder while alcohol and other drugs are being used, no matter how appropriate the substance abuse treatment program is otherwise. Substance abuse treatment is essential if this problem co-occurs with borderline disorder.

Anxiety and Panic Attack Symptoms Co-Occurring with Borderline Disorder by Robert O. Friedel, MD

Have you or a loved one been diagnosed with borderline disorder and are suffering from anxiety and panic attack symptoms? Read the following article and learn more about these symptoms and how they are treated. Anxiety and panic attack symptoms are common in people with borderline disorder. Anxiety disorders occur in almost 90% of people with the disorder. If you have borderline disorder, you may experience heightened levels of anxiety and panic attack symptoms, especially at times of stress. For example, this may occur when you feel you are personally criticized and rejected, or during periods of separation from people who are very important to you. Moderate to severe anxiety may also lead to physical symptoms, such as migraine headaches, abdominal pain and irritable bowel syndrome.

Panic Attacks A panic attack is an acute and severe form of anxiety that occurs in about 50% of people with borderline disorder. Panic attacks are characterized by a discrete period of intense fear in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes: • palpitations, • • • • • • • • • • • •

pounding heart, or increased heart rate sweating trembling or shaking sensations of shortness of breath or smothering feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint feelings of unreality or being detached from oneself fear of losing control or going crazy fear of dying numbness or tingling sensations chills or hot flushes

Symptoms can appear unexpectedly and suddenly, for no apparent reason, and disappear either rapidly or slowly. People who suffer from anxiety and panic attack symptoms may also be fearful of placing themselves in circumstances from which escape may be difficult or embarrassing such as elevators, shopping malls and movie theatres. This is referred to as agoraphobia.


Treatment of Anxiety and Panic Attack Symptoms in Borderline Disorder Effective treatment of disabling anxiety and panic attack symptoms in people with borderline disorder should be initiated promptly when these disorders occur. Such treatment usually consists of the use of medications and behavioural techniques. The use of medications to treat anxiety and panic attack symptoms in patients with borderline disorder must proceed with care. This is so because these disorders are commonly treated with benzodiazepines (Xanax, Klonopin, Valium, etc.), that have been found to be harmful in most patients with borderline disorder because they increase impulsivity and have addictive potential. Therefore, in borderline disorder, other classes of medications are often required, such as a temporary increase in the neuroleptic, atypical antipsychotic or antidepressant medication being used to treat the disorder. Initiating the use of an antipsychotic agent or an antidepressant may prove effective for moderate to severe anxiety and panic attack symptoms if one is not already prescribed. In addition, a course of cognitive behavioural therapy, or of biofeedback, specifically tailored to target anxiety and panic attack symptoms are often considered as part of the long-term treatment of these problems.

The Symptoms and Treatment of Attention Deficit Hyperactivity Disorder in Patients with Borderline Disorder by Robert O. Friedel, MD

Background Attention deficit hyperactivity disorder (ADHD) occurs in about 25% of people with borderline disorder; 5 times more often than it does in the general population. The symptoms of ADHD include decreased attention and concentration, easy distractibility, difficulty in the completion of tasks, and poor management of time and the space area that you use. These symptoms of ADHD result in significantly impaired school, work and social performance, and are described in detail below. ADHD is estimated to occur in about 5% of school age children. It is more common in boys than in girls. There are subtypes associated with hyperactivity and normal activity levels. The hyperactive subtype is much more common in boys, while the inattentive subtype (the subtype with normal activity levels) is somewhat more evenly distributed among boys and girls. The symptoms of ADHD are now known to persist into adulthood in many people, and to require continued treatment. There is often a strong family history of ADHD.

Identifying the symptoms of ADHD in patients with Borderline Disorder is critical for their treatment plan. Symptoms of ADHD Inattention •

• •

• •

• •

fails to give close attention to details or makes careless mistakes in school work, work, or other activities has difficulty sustaining attention in tasks or play activities does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions) has difficulty organizing tasks and activities avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) loses things necessary for tasks or activities (e.g., toys, school assignment, pencils, books, or tools) is easily distracted by extraneous stimuli is often forgetful in daily activities

Hyperactivity • • • • • •

fidgets with hands or feet or squirms in seat leaves seat in classroom or in other situations in which remaining seated is expected runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) has difficulty playing or engaging in leisure activities quietly is often “on the go” or often acts as if “driven by a motor” talks excessively

Impulsivity • • •

blurts out answers before questions have been completed has difficulty awaiting turn interrupts or intrudes on others (e.g., butts into conversations or games)


Treatment of ADHD in Patients with Borderline Disorder It is not uncommon for children, teenagers and adults with borderline disorder who have some symptoms of ADHD to be misdiagnosed with ADHD, and then receive customary treatment with stimulants such as methylphenidate or an amphetamine derivative. People with borderline disorder treated with these medications typically do not do well, and may even do worse than without these medications. If borderline disorder and ADHD co-occur, patients often do worse when treated for ADHD if they first receive a medication for the symptoms of ADHD. Under these circumstances, they may then demonstrate an increase in emotionality and aggressive impulsivity. Fortunately, clinical experience and anecdotal reports in the scientific literature suggest that this problem can be effectively managed in one of two ways. When the symptoms of ADHD are mild, behavioural treatments alone may be effective, thereby avoiding the risk of increasing the symptoms of borderline disorder with a stimulant. However, if medications are required to bring the symptoms of ADHD under optimal control, it appears to be helpful to initiate treatment with a low dose of a neuroleptic or antipsychotic agent for the symptoms of borderline disorder. Doing so then appears to permit the use of a stimulant to produce a beneficial effect on the symptoms of ADHD with a minimal risk of worsening the core symptoms of borderline disorder. *Adapted from DSM-IV-TR. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

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