How to Disarm a Borderline Part VIII Splitsville

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), Part VI (March 2), and Part VII (April 30). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In today's post, I will discuss how patients with BPD get two or more other people to fight with one another, and how to avoid getting sucked into such fights.

The psychoanalytic concept of splitting has been used by analysts in a few different senses.  The different meanings of the term are clearly connected with each other, but the analysts are somewhat vague in describing in detail what this relationship actually is.  The most common use of the term, as I described in my post A Splitting Headache of 4/24/10, applies to something going on entirely inside the heads of patients with BPD. 

As I described in the earlier post, BPD patients are thought by analysts to be either unable to see both the good and the bad in anything or anyone at the same time, or do not do so because they are using splitting as a defense mechanism.

As is their wont, the analysts seem loathe to look at a mental phenomenon in terms of its interpersonal meanings withing the context of the patient's real relationships.  However, one well-known interpersonal phenomena seen with patients with BPD is often spoken about when analytic therapists converse.  This phenomenon is also called splitting.

When individuals with BPD are hospitalized in psychiatric facility, it is frequently noted that professionals will start arguing among themselves about the patient.  Two doctors, or a doctor and a nurse or social worker, will get into what are at times very heated discussions about the patient's treatment.

Sometimes the entire ward staff becomes divided into two warring camps, with one side thinking that the patient is being treated unfairly with the other side wanting to come down on the troublesome patient with the proverbial hammer.  This situation became known as the infamous staff split.

My first clue as to what was happening in these situations came with the realization that a lot of the aggravating behavior of patients with BPD is a big act that can be turned off and on at will, like a faucet, depending on who they were performing for.  The act can also be greatly altered so that they act one way with one group of people and completely differently with another group.

I was consulted on a hospital patient on a medical (not a psychiatric) floor whose medical condition was clearly being affected adversely by her stress level.  When I first met the woman, she was the sweetest, friendliest, and most pleasant of patients.  We were having a nice chat about her stress level when her phone rang. It was the patient's husband. 

Suddenly I witnessed the most amazing transformation short of a caterpillar turning into a butterfly.  She without warning turned into the nastiest, most shrill harridan one could imagine.  Her comments towards her husband were so unrepentently vicious and venomous that I began to feel sorry for him.  After a short conversation, she practically hung up on him.  As soon as she put down the receiver, however, she turned right back into all sweetness and light in a heartbeat.

Amazing.  Patients who have real mental illnesses cannot do that.  They act pretty much the same way with everyone - and even when they do not realize they are being observed.

The staff split is set up by the patient.  To one group, he or she acts like a damaged, pitiable abuse victim in need of kind understanding. To the other group, like hell on wheels.

Eric Berne, founder of the school of psychotherapy known as Transactional Analysis and author of the best selling book Games People Play, had a name for this whole pattern. He called it the game of Lets You and Him Fight. In other words, the patient acts in ways that essentially picks a fight between other people.  If this game had a professional league, individuals with BPD would be the superstars.



Eric Berne

The solution to the staff split is actually simple and straightforward.  First, staff members have to be aware of the fact that their arguments are being set up by the patient, not by the unreasonableness or stubborness of the other side.  They can then ask each other on what patient behavior they are basing their opinion, and compare notes.  They can then decide on a mutually acceptable course of action and present a united front to the patient, and voila, the patient stops trying to split them.

The relationship between the senses of the term splitting is that the patient acts all good with one group, and all bad with another group.  If pressed, the analysts would probably say that the staff split is just an incidental byproduct of the patient's tendency to see some of the staff as all good and others as all bad. 

I, in contrast, see is at a well planned, although sometimes automatically and subconsciously played, interpersonal strategy designed to create staff wars.  Once again, however, I believe such patients are ambivalent about this and down deep hope that their efforts to provoke fights will fail.  The power to play mommy off against daddy is actually very frightening for them.

When seen in individual therapy, patients with BPD will often make a damaging or incendiary accusation about an important referral source, about a colleague who is well respected or who is even a friend of the therapist, or about a nurse with whom the therapist will have to work. If therapists defend the other person without having an impartial account of what actually transpired, they are invalidating the patient.
 
However, the patient may be exaggerating what happened, making undue inferences about the motives of the accused, or discounting the role of his or her own provocative behavior in the dispute. Also, the therapist should never forget that there really are a few Nurse Ratcheds on psych wards.
 

Nurse Ratched, "One Flew Over the Cuckoo's Nest"

 
My solution: I state, "I was not there, and I have a different impression of him from my other contacts, so I am not in a position to make a judgment on this." I just refuse to take sides in the dispute, and the patient will often then drop the subject completely.

One major exception I make to this is when a patient alleges that a former therapist had sexual intercourse with the patient. (This caveat does not apply when the patient just had the opinion that the former therapist had inappropriate thoughts).  I take this allegation very seriously because, in my experience, patients rarely make unfounded allegations about this subject, and unscrupulous therapists need to be taken out of the profession.  The willingness of the patient to allow the therapist to take advantage of her in this manner is irrelevant.

The next time your friend with BPD tendencies tells a story about someone else that starts to make your blood boil - at the person being described in the story - keep these suggestions in mind and do not take sides.

More Studies Reveal Widely Known Facts to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012,September 17, 2013, June 3, 2014, February 24, 2015, and December 15, 2015, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of the latter. My comments are in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

This last few months has been such a treasure trove of studies of the obvious, my descriptions of the individual studies listed will be a little briefer than usual.

At the end of today's issue of No Sh*t Sherlock is a special section on some new shocking and counterintuitive findings about things we used to think were good for your mental health and well-being - but turned out not to be.

12/15/15. Adolescents Who Abuse Prescription Pain Medicines May Be More Likely To Have Sex, Participate In Risky Sexual Behaviors

HealthDay (12/15, Haelle) reports that adolescents who abuse prescription pain medications may be “more likely to have sex or to participate in risky sexual behaviors,” a study published online Dec. 14 in Pediatricssuggests. 
Impulsive, self destructive people were, I guess, previously thought to be highly selective in which impulses to indulge.

12/15/15. Study Shows Reduced Patient Satisfaction When Computers Are Used Excessively In Exam Rooms

On the front of its Personal Journal section, the Wall Street Journal (12/15, D1, Reddy, Subscription Publication) reports on a study published the previous month in JAMA Internal Medicine, which found that patients whose doctors spent a lot of time looking at a computer screen during examinations rated their care lower. 
And here we thought that patients just hate doctors who pay close attention and listen to them carefully.

12/23/15. College Students Who Smoke Marijuana Appear More Likely Than Their Peers To Skip Classes

HealthDay (12/23, Norton) reports, “College students who smoke marijuana appear more likely than their peers to skip classes – which eventually leads to poorer grades and later graduation,” a study published in the September issue of the journal Psychology of Addictive Behaviors suggests. 
This finding is just so difficult to explain.

1/6/16. Many Single Mothers with Minor Children are Sleep-deprived, CDC finds

The Los Angeles Times (1/6, Kaplan) reports in Science Now that a data brief from the Centers for Disease Control and Prevention’s National Center for Health Statistics reveals that “44% of single moms living with children under the age of 18 fall short of recommendations to get at least seven hours of shut-eye each night.” Thirty-eight percent of single fathers who live with their children “sleep less than seven hours per night,” the report found. 
I just don't understand why these parents can't make their days last more than the usual 24 hours.

1/22/16. Prevention Programs for Youth Most Effective When At-Risk Families Are Clinically Stable

Programs that teach stress management and cognitive-restructuring skills may help to prevent the onset of depression in teens at high risk for depression, but how effective they are appears to depend largely on the mental health of youth and their parents when the intervention begins, according to a study published online this week in the Journal of the American Academy of Child and Adolescent Psychiatry. 
At last the long-sought proof that the more severe a disorder, the worse the prognosis tends to be.

3/2/16. Study Suggests Factors Predictive of Violent Behavior in People With Mental Illness

Results from a meta-analysis in Psychiatric Services in Advance shows that three factors may be associated with an increased risk for adults with mental illnesses to commit community violence in the near future. They are alcohol use, exhibiting violent behaviors, and being a victim of violence within the past six months. 
Booze fuels violence? Past behavior a predictor of future behavior? Who'd'a thunk??

3/16/16. Disruptive Patients may Get Worse Care from Physicians

HealthDay (3/15, Dotinga) reports, “‘Disruptive’ patients may get worse care from physicians,” studies suggest. 
Can't be. Doctors have been trained to be completely unaffected by annoying people. (Well, psychoanalysts anyway).

4/21/16. Eating Disorders May Be More Prevalent At Schools With A Greater Proportion Of Female Students

HealthDay (4/20, Preidt) reports, “Eating disorders may be more prevalent at schools where a greater portion of the student body is female,” research suggests. 
I just never noticed the higher prevalence of women among patients with anorexia and bulemia.

5/25/16. Severely Obese Children Picked On, Bullied More Than Normal-Weight Kids

HealthDay (5/25, Reinberg) reports, “As early as first grade, severely obese children are getting teased, picked on and bullied more than normal-weight kids,” research published online May 25 in Child Developmentindicates. Researchers arrived at this conclusion after gathering “data on nearly 1,200 first graders from 29 rural schools in Oklahoma.”  
Did these researchers ever go to grade school?

5/27/16. Depressed Patients Who Attempt Suicide Four Or More Times May Have Higher Risk Of Eventually Dying By Suicide, Research Suggests

Medscape (5/26, Brooks) reports, “Depressed patients who attempt suicide four or more times have a higher risk of eventually dying by suicide compared with their depressed peers who have never attempted suicide or who have done so fewer times,” research suggests. 
The fifth time is the charm.

6/2/16. Higher Out-of-pocket Costs Lead to Reduced Adherence

A literature review of 160 articles and abstracts identified a clear relationship between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in out-of-pocket costs and adherence, 85% showed that increasing patient out-of-pocket medication costs leads to reduced adherence. 
Did these researcher ever hear of the law of supply and demand? Guess not.

6/16/16. Hospital Deaths more Costly and Involve More Tests and Procedures than Deaths at Home

On its website, NPR (6/15, Kodjak) reports people who die in hospitals “undergo more intense tests and procedures than those who die anywhere else” and that more is spent on people dying in hospitals compared to people who die at home, according to an analysis by Arcadia Healthcare Solutions. 
I was wondering about that (not!)

7/1/16. Problem Of Missed Medication May Increase With Age, Failing Memory

HealthDay (6/30, Preidt) reports that a study published in the Journal of the American Geriatrics Society “suggests that the problem of missed” medication “rises with age and failing memory, especially for men.” The investigators found that other factors linked to “medication lapses” were “memory deficits” and having “trouble with the tasks of everyday living.” 
Gee, people with memory problems forget things.

And now for the special section that details how we have recently discovered that many things in the environment that were once thought to be sources of tremendous joy and uplift turn out to actually be downers that create various negative feeling states and are risk factors for depression and anxiety.

These include childhood abuse and neglect, poverty, post-partum depression, traumatic experiences, cancer, kids having parents with chronic severe migraine headaches, having your livelihood threatened by a disciplinary action from a licensing board, diabetic retinopathy, having a premature infant, and combat experiences.

I bet you think I'm making this up. Sorry, but you just can't make this stuff up.

3/1/16. Study finds children who face adversity before age 5 struggle in school

Kaiser Health News (2/29, Gillespie) reports a study published in the journal Pediatrics found that “adverse childhood experiences [ACEs] before age 5,” including “neglect, abuse and dysfunctional home lives,” were associated “with poor academic and behavioral performance in kindergarten.” 
These researchers just don't understand that these kids just have ADHD.

3/17/16.  Low-Income People Exposed To Rats In Urban Environment May Be More Likely To Have Depressive Symptoms

According to the NBC News (3/16, Fox) website, a study conducted by the Johns Hopkins Bloomberg School of Public Health and published online Feb. 10 in the Journal of Community Psychologyreveals that “people living in Baltimore’s low-income neighborhoods who see rats as a big problem are significantly more likely to have depressive symptoms such as sadness and anxiety.” 

3/21/16. Women Who Have Had Postpartum Depression May Not Have More than Two Children, Study Indicates

HealthDay (3/18, Preidt) reported, “Women who’ve had postpartum depression may not have more than two children,” the findings of a study published in the January issue of Evolution, Medicine and Public Health suggest. 
Depression was previously thought to be so much fun that everyone wanted to go through it as many times as possible.

4/25/16.  Exposure To Traumatic Events May Be Associated With A Host Of Potential Negative Behavioral And Physical Effects

Medscape (4/25, Melville) reports, “Exposure to one or more potentially traumatic events in a lifetime is associated with a host of potential negative behavioral and physical effects, ranging from mental illness and depression to substance abuse, asthma, and” hypertension, the findings of a new report from the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality indicate. 

4/28/16. Cancer Diagnosis may be Associated with Increased Risk for Anxiety, depression

HealthDay (4/28, Preidt) reports that research published in JAMA Oncology “details the psychological damage” a cancer diagnosis “often leaves in its wake for patients.” Investigators “found much higher rates of anxiety, depression and even drug and alcohol abuse for those who’ve been told ‘you have cancer,’ compared to healthier people.”  Healio (4/28) reports that the study indicated “the risk for mental disorders appeared stronger among patients whose cancers had poorer prognoses.” 

       

5/31/15. Childhood Trauma May Increase Risk of Adolescent Drug Use, Study Shows

Children who experience traumatic events prior to the age of 11 may be more likely to use marijuana, cocaine, nonmedical prescription drugs, or other drugs as teens, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry. 

6/27/16. For Teens, Living With Parents Who Have Chronic Migraine May Negatively Affect Activities Of Daily Life, School Performance.

Medscape (6/24, Davenport) reported, “For adolescents, living with parents who have chronic migraine has a negative effect on activities of daily life and on school performance and is associated with increased rates of anxiety,” research suggests. 
Parental misery and pain were previously thought to have no effect on their children whatsoever.

7/15/16. Patient Complaints Against Physicians and the Ensuing Complaint Review Process Seriously Affect Physicians' Long-term Psychological Well-being 

and can lead to their practicing defensive medicine, results of a large qualitative survey show. Led by Tom Bourne, MD, PhD, from the Department of Surgery and Cancer, Imperial College London, United Kingdom, the study is an analysis of responses to qualitative questions as part of a larger anonymous survey completed by almost 8000 physicians. 

7/8/16.  Severe Diabetic Retinopathy May Be Associated With Depression, Study Suggests

MedPage Today (7/7, Minerd) reports, “Severe diabetic retinopathy...was linked to depression, and its presence should prompt clinicians to inquire about a patient’s mental health,” research suggested. The findings of the 519-patient study were published online July 7 in JAMA Ophthalmology.  

7/21/16. Parents Of Extremely Premature Infants May Be More Likely To Become Depressed Than Parents Of Full-Term, Healthy Infants

Reuters (7/20, Rapaport) reports, “When babies are extremely premature, parents are about 10 times more likely to become depressed than mothers and fathers of full-term, healthy infants,” research suggests. Included in the study were “113 mothers and 101 fathers of preemies, as well as 117 mothers and 151 fathers of healthy, full-term infants.” The findings were published online July 18 in JAMA Pediatrics.

8/12/16. Female Service Members who Experience Combat may have Much Higher Risk of PTSD than Those Who do Not

Reuters (8/10, Rapaport) reports, “Women in the military who experience combat have a much greater risk than those who don’t of developing post-traumatic stress disorder (PTSD) and other mental health issues,” researchers found after examining “data from post-deployment mental health screenings for more than 42,000 women enlisted in the US Army and deployed in Iraq and Afghanistan from 2008 to 2011.” The findings were published online Aug. 1 in the Journal of Traumatic Stress. 

I wonder how many other things that were once thought to joyful actually are not.

Conventional Wisdom that Seems Obvious Once Again Found to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012, September 17, 2013, and June 3, 2014, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of No Sh*t Sherlock. My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

 

5/28/14.  Physical activity program may reduce mobility disability in seniors.

USA Today (5/28, Painter) reports that for seniors, “losing the ability to walk a short distance often means losing independence.” Now, “researchers say they have found a treatment that, for some, can prevent that loss of mobility,” and that is “a moderate exercise program.” The Washington Post (5/28, Bahrampour) reports that the study, “called the Lifestyle Interventions and Independence for Elders and funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute, was the first of its kind to test a specific regimen of regular physical activity for sedentary older people.” The Boston Globe (5/28, Kotz) “Daily Dose” blog reports that the study, published online May 27 in the Journal of the American Medical Association, “found that elderly people who walked and did basic strengthening exercises on a daily basis were less likely to become physically disabled compared to those who did not exercise regularly.” The study control group consisted of people who were instructed to take health education classes. 

I guess it's still OK for seniors to sit very, very still while posing as nude models for art students.

6/17/14. Study Shows Association Between Mental Illness Severity and Employment and Income.

More severe mental illness appears to be associated with lower employment rates in recent years, and people with serious mental illness are less likely than people with no, mild, or moderate mental illness to be employed after age 49, according to the report, “Employment Status of People With Mental Illness: National Survey Data From 2009 and 2010,” published in Psychiatric Services in Advance.

We now know for sure that employers are not always hot to hire people who are too mentally impaired to perform the work.

6/20/14. Brain Injuries Linked To Higher Risk For Headaches.

HealthDay (6/20) reports that research scheduled to be presented at the American Headache Society meeting suggests that “U.S. veterans of the Iraq and Afghanistan wars who suffered brain injuries are at a much higher risk for headaches, especially migraines.” This “study included 53 veterans who had suffered a traumatic brain injury during deployment and...53 veterans without brain injuries.” Investigators found “that all of the veterans in the brain injury group said they experienced headaches, compared with about 76 percent of those in the control group.” Eighty-nine percent of the headaches in those with brain injuries were migraines, while just 40 percent of the headaches in the control group were migraines.

Now just a minute. Bodily injuries produce pain?? Since when?

9/1/14. The relationship between premorbid body weight and weight at referral, at discharge and at 1-year follow-up in anorexia nervosa. 

European Child and Adolescent Psychiatry, 09/03/2014: Focker M, et al.  In this study, the relationship between pre-morbid body mass index (BMI) percentile and BMI at admission was solidly confirmed. In addition to pre-morbid BMI percentile, BMI at admission and age were significant predictors of BMI percentile at discharge. BMI percentile at discharge significantly predicted BMI percentile at 1–year follow–up. An additional analysis that merely included variables available upon referral revealed that premorbid BMI percentile predicts the 1–year follow–up BMI percentile.

Oh, I did not see it before, but I get it now. More severe disorders have a worse prognosis.

11/25/14. Talk Therapy May Prevent Suicide in High-Risk Patients

Talk therapy may decrease risk for future suicide attempts and completions in patients who have already made a previous attempt, new research suggests. 

God, I should hope so, or I'm in the wrong business!!

1/13/15. Self-injurers experience greater negative emotionality, particularly self-dissatisfaction, compared to individuals with no NSSI history.

Self-injurers also reported less positive emotion, but these effects were smaller. The pattern of results was similar when controlling for Axis I psychopathology and borderline personality disorder.

And here I thought cutters and burners did so because their joy was just soooo unbearable.

1/30/15. Repeated Blows To Head In Boxing, Martial Arts May Damage Brain.

HealthDay (1/30, Preidt) reports that research published in the British Journal of Sports Medicine “supports the notion that repeated blows to the head in boxing or the martial arts can damage the brain.” Investigators studied “93 boxers and 131 mixed martial arts experts,” as well as 22 individuals who had never suffered a head injury. “MRI brain scans and tests of memory, reaction time and other intellectual abilities showed that the fighters who had suffered repeated blows to the head had smaller brain volume and slower processing speeds, compared to non-fighters.”

So I guess I should quit beating my head against the wall trying to get researchers to actually look into things we actually do NOT already know.

1/30/15.  The US Food and Drug Administration (FDA) has approved lisdexamfetamine dimesylate (Vyvanse, Shire) to treat binge eating disorder (BED) in adults.

The drug is the first FDA-approved medication to treat this condition. "Binge eating can cause serious health problems and difficulties with work, home, and social life," said Mitchell Mathis, MD, director of the Division of Psychiatry Products in the FDA's Center for Drug Evaluation and Research. "The approval of Vyvanse provides physicians and patients with an effective option to help curb episodes of binge eating." The efficacy of Vyvanse in treating BED was shown in two clinical studies that included 724 adults with moderate to severe BED, as reported by Medscape Medical News. In the studies, participants taking Vyvanse experienced a decrease in the number of binge eating days per week and had fewer obsessive-compulsive binge eating behaviors compared with patients in a placebo group.

Shocking new finding: appetite suppressants reduce eating.

January 2015.  Alcohol, Depression potent risk factors for suicide.

BERLIN– Alcohol dependence and major depressive disorder are similarly potent yet independent risk factors for suicidal behavior, according to Dr. Philip Gorwood. Although alcohol use disorder and major depression are extremely common and often comorbid, the mechanisms by which they boost the risk for suicidal behavior are very different, he said at the annual congress of the European College of Neuropsychopharmacology.

Insert your own joke here. No prize will be awarded for best gag, but let's see what you got!

And yes, it is OK to joke even about suicide. Black humor often helps us all to squarely face up to very serious issues, and is therefore to be encouraged. 

Did panic lead to JetBlue pilots mid air meltdown