アンカー 1

Borderline Personality Disorder

Attention:　

Psychologists in Japan cannot diagnose individuals for mental health disorders. Self diagnosis is very dangerous, too.

The purpose of this page is not to give you a diagnostic tool, but to help you decide on the next step that you may want to take. For a formal diagnosis, please visit a psychiatrist near you.

9 criteria for Borderline Personality Disorder by DSM-V

Were you told by your loved one that you might have borderline personality disorder? Do you feel that way yourself?

You must be very disturbed in this very moment not knowing what is happening to you.

Diagnostic and Statistical Manual of Mental Disorder Fifth Edition (DSM-V) issued by American Psychiatric Association posits nine criteria for the diagnosis of borderline personality disorder.

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 behavior, gestures, or threats, or self-mutilating behavior.
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.

How DBT organizes the symptoms

Borderline Personality Disorder (BPD), Dr. Linehan says, is one of the most stigmatized disorders as individuals are seen to be all over the place manipulating people around them. On the contrary, Dr. Linehan sees BPD symptoms as skills deficit rather than intentional misbehaviors. In other words, individuals do not know how to conduct themselves in any other way in given moment. From the consept of skills deficit, Dr. Lihenan reorganized the DSM criteria into 5 areas of dysregulations.

Emotion dysregulation: High sensitivity to stimuli, high intesnsity of emotional expression, and slow come back to the emotional base. (1,6,8)
Bahavior dysregulation: Impulsivity to highly riskly or undesirable behaviors (including self-harm) on one hand (1,4,8), and avoidance of painful experience on the other (9)
Cognitive dysregulation: Polarization of thoughts such as black and white thinking, inflexibility, paranoia, or disociative responses (9). Often suicidal ideation (5).
Interpersonal dysregulation: Chaotic relationship with someone very close to them on the one hand, and the fear of abandonment on the other (2).
Self dysregulation: Difficulty dealing with a fragile image of self and rigid self-imposed rules (such as perfectionism) that goes with the image (3,7).

Disorder of Polarization

Individuals with borderline personality disorder can look very contradictory to the eyes of others. If all behaviors are on the spectrum, they demonstrate both extremes of the spectrum. They choose to act one extreme way or the other without being able to take the middle path or to tolerate the contraditions. Following are some examples of polarized behaviors.

They are over taken by emotions, or they are too logical and cold. Individuals with BPD have high sensitivity to stimuli. Anything and everything in their environment can trigger their emotional reaction. They are particularly sensitive to perceived expectations and evaluations from others. For them, the intesnsity of their emotional response is congruent to the intensity of the event. Yet people tell them that they are over reacting, having paranoia, or being difficult. They feel like they are living a parallel reality because no one understands their reactions. Over time, they lose confidence in their perceptions of reality and start feeling ashamed of their emotions, which leads to self-criticism. They scan how other people react to an event, and they wonder why their reaction is so different from that of others. And they flip. As they lose confidence in their emotions, they reosort completely to reasons and idealization. Once in that space, they place impossibly high expectations on themselves in all aspects and do not accept anything but perfection.

They feel so competent at work/school, and so helpless in a close relationship. When their mood is stable, they behave without any traits of BPD. They might be considered as excellent employees at work. They can be thanked for helping others solve their problems . In the therapy, they can show complete understanding of new skills learnt. At the same time, in the hight of emotional crisis, individuals with BPD tell others that they are helpless and they can't solve their problems. They overly depend on others and demand solutions from them. If people don't respond, they magnify the problem so that it is taken seriously. This is probably why individuals with BPD are seen as manipulative and have difficulty staying in an close relationship. Their apparent competence in some areas of life disguises the magnitude of their problems, which they only show to the close family members, partners and friends.

They are in unrelenting daily crises while not facing deep grief. Because of the emotional volunerability, individuals with BPD get triggered by what seems to be meaningless event to others. Because it happens so often, they cannot recover fully from one crisis before the next one hits. They then use maladaptive solutions to call for help such as self-harm, suicidal communication, anger outburst, etc. Deep in their soul, on the other hand, they often have "unprocessed" traumatic emotional experiences. They avoid the cues related to that specific experience by all means because they can't tolerate reliving the experience. These unresolved traumatic events accumulate, and contribute to their very fragile self image. In a way, attending to daily crises compensates for not dealing with the trauma.

But aren't we all like that sometimes?

Going back to DSM-V, personality traits are patterns of perceiving, relating to, and thinking about the environment and onself. So, all of us can feel and act like what is described above sometimes in life without having borderline personality disorder. Only when similar patterns started showing up before early adulthood, and when these patterns are inflexible, deviate markedly from the expectations of one's culture, are demonstrated in many social situations, and are causing significant social distress in you and people around you, it is diagnosed as disorder. Personality change can occur in the course of psychotic disorders, anxiety, depression, PTSD, accute stress disorder, substance use disorders or due to another medical condition such as stroke. Behavior traits might be also due to developmental disorders such as autism and ADHD. So, please do not jump to conclusion that you have borderline personality disorder just because you can relate to the behaviors described above. Seek help from a psychiatrist to diagnose you properly if "wondering" is adding to your distress.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Linehan, M. (1993). Diagnosis and treatment of mental disorders. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

アンカー 2

Invalidating Environment

Dialectical Behavior Therapy (DBT) proposes biosocial model for the development of borderline personality disorder. The bio side of the model is explained in the page, "borderline personality disorder. " Here, the social side of the model is explained.

Role of the environment in emotional development

All babies are born with emotions but without names to describe them, or elaborate tools to communicate them. It is the people around them who give babies the names and tools to communicate their emotions. This learning continues throughout individuals' life. When there is a goodness of fit between individuals and their environment, individuals can tolerate and meet the environment's behavioral expectations in each life stage. When one's behaviors deviate significantly from the norms and expectations of one's culture, on the other hand, those behaviors are deemed unacceptable and dysfunctional.

How does invalidation happen?

Well meaning parents, partners, co-workers, friends, classmates, and even us, mental health professionals, can inadvertently invalidate individuals' experiences. This happens usually when the environment fails to understand the individuals' private experiences, and respond to their communication in erratic, dismissive or punitive manner.

Imagine that a teenage boy just finished an important presentation at school and said, "I blew it." Average responses from his friend can be like, "Oh it wasn't so bad," "I'm sure you did OK," "Don't be so hard on yourself, " or "Well, that happens." If the boy is highly sensitive, he may feel that his heart-felt disappointment about his own performance was not taken seriously. Instead of saying "thank you" to his friend, he might frown, cross his arms and say, "what do you mean?" His friend reacts to the facial and body expression and say, "hey, I was just being nice, and you don't have to attack me like that." The boy reacted to the word "attack" and the two boys had a very ugly argument and didn't speak to each other for a week.

What happened here? While the boy did not think he did well in the presentation, his friend said he did OK, which made him question his own perception. His friend probably wanted to help the boy come out of his negative thoughts and bad mood. There was no malicious intention, and at the same time, the boy feels that his disappointment was denied and dismissed. The boy remembers this as an experience of invalidation.

When these feedbacks are given repeatedly over time, individuals get confused about their experiences, and learn not to trust their perceptions. The consequence is the extreme suppression of their emotions at first to play by what seems to be the social convention, followed by extreme emotional outburst to get the wanted response from the environment.

Role of the family in particular

Since the personality traits start showing before the early adulthood, the family environment in which individuals grew up is a particular interest. Dr. Linehan's seminal book in 1993 suggested that individuals' childhood experiences of invalidation in families could be largely grouped into three types.

a) Parents were largely unavailable when the child needed emotional support.
b) Parents discouraged or even prohibited negative emotional talks at home. Only positive sharing were encouraged and praised.
c) Parents' message was that growing up meant becoming more reasonable and less emotional. The child was told to regulate emotions by being reasonable.

Again, often families mean well. Many people who have similar childhood experiences do not develop borderline personality disorder either. As a result of transactions between a particular individual and his/her/their environment however, slightly more sensitive child in slightly more invalidating environment can become highly sensitive to emotional stimuli.

What can we do to help?

As individuals learn new skills to regulate their emotions, we would like people around them to learn the mechanism of borderline personality traits and help them regulate their emotions.

In particular, we see validation of each other's communication extremely effective to regulate emotions. Validation means communicating that you understand the other person's experience. Looking for what is valid in what they are communicating and acknowledge them. Validation is not agreement. Validation is not conceding. The only purpose is to encourage the individual to keep communicating so that they learn to understand their own emotions and communicate accurately. This is very important because as soon as the individuals stop communicating, they lose the chance to learn and explore their emotions.

There are six levels of validation. I will write an example of how you can use each level of validation to react to "I blew it" example above in brackets.

Level 1: Stay awake. Don't multitask. Pay sincere attention to what the person is saying with kindness. [Stop what you are doing. Look at him. Nod.]

Level 2: Repeat what you heard by rephrasing and summarizing. Don't over do this, though. [You don't think it went well.]

Level 3: Put the words to observable facial and body expressions. Guess what emotions that they are trying to communicate. If your guess is wrong, don't push and probe. [You sound very disappointed. ]

Level 4: Show your understanding of the person's context, history, etc. Communicate that it is understandable that the person feels the way he or she does given his / her context or history. [You put so much efforts for this presentation, didn't you?]

Level 5: Normalize the person's feeling. [As this was such an important task, everyone wanted to perform the best.]

Level 6: Genuine interaction. When you use your full skills from Level 1 and 5 and when you know you have enough information about what the person is trying to communicate, only then, communicate your feeling, opinion, further questions and suggestions.

We all tend to jump to Level 6 without doing enough of Levels 1-5. Levels 1-5 are the foundation for the level 6 to work. You do not have to follow the order. In the conversation, you mix levels 1-5 accordingly. Validation can not only help individuals calm down, but also improve the relationship.

Reference

Linehan, M. (1993). Diagnosis and treatment of mental disorders. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

アンカー 3

Japan in Social Transition

Japan in social transition

Japan is in social transition. We have long been taught that Japan was largely “mono-culture” and “homogeneous.” Social constructs such as Japanese, family, marriage, men, women, boys, girls, adults, citizen, students, were easily defined and expected to be largely the same, which in turn was believed to be the foundation of Japan’s strengths, uniqueness and identity as a country. Changes and diversification of life styles and expansion of life choices, movement toward gender equity, as well as the increase of foreign residents in the past decades, however, forced Japanese to admit that Japan is no longer so mono-culture as we might want to think. Different value systems and life choices are more and more evident in our daily life.

Clinical Observations

Majority of my clients are not Japanese or would not consider themselves typical Japanese: foreign workers, foreign students, children born in the international union, Japanese married to foreigners, foreigners married to Japanese, Japanese who spent many years abroad, LGBTQ, Single parents, members of a blended family, people who cannot fit in the work environment, victims of various forms of harassments and abuses, etc. Most of them come to see me for depressive or anxious state and would not meet the criteria of borderline personality disorder. I can see, however, many of them struggle with uncontrollable anger outburst, complicated interpersonal relationships at work or in romantic relationship, chronic emptiness, and very fragile sense of self, all of which are the hall marks of borderline personality traits.

Psychology of minority, culture and behavior adjustment

To bridge the two seemingly unrelated topics of emotional suffering among emerging minority groups in Japan and borderline personality traits, I sought theoretical frameworks that would provide insights.

Stress-adaptation-growth dynamic

Dr. Young Yun Kim (2017), a professor of cross cultural communication, explains how characteristics of both individuals and host community play an important roll in cross cultural adaptation. Dr. Kim proposes that there is a transaction between the two parties just like Linehan (1993)’s biosocial theory. Individuals openness, resilience and positivity are known to be the adaptation-friendly profile.

The level of host community conformity pressure, on the other hand, negatively correlates with the individuals’ adaptation. These pressures are often very subtle (Kim, 2017). They will most likely be expressed as confusion at first. As the frustration of the host community increases over time, however, it could be expressed more explicitly as disapproval or stereotyping. The author specifically points out that countries like Japan that is ethnically homogeneous and geographically isolated are less willing to accept non-conformity.

When individuals are put into a new and unfamiliar environment, Dr. Kim proposes, they experience a continuous adjustment of “draw back to leap” pattern . It is to say, each stressful event will put individuals in regression stage. Even though this draw back generates the energy to leap back, my assumption is that individuals are very confused in this stage and experience unprecedented emotion dysregulation.

Microinvalidation:

In 2007, Dr. Sue and colleagues proposed the existence of racial microaggression in every day life in the USA. They defined racial microaggressions as everyday verbal, behavioral, or environmental humiliations that communicate negative racial slights that are often unintentional and unconscious. The authors call microaggressions as modern and symbolic racism that are pervasive and automatic. Dr. Sue also proposed microinvalidations as a form of microaggression.

Just as Linehan (1993) proposed, microinvalidation proposed by Dr. Sue and his colleagues defines its effect as telling people of color that their reaction to an event is out of proportion, that they are overreacting, and that they are the ones who manipulate the environment to make a non-issue a big issue. In these interactions, the recipient of a microinvalidation is left with the nagging question of whether it really happened, or it is only happening in his head (Spanierman & Heppener, 2004 cited in Sue et al., 2007).

To support newly emerging minority individuals in Japan

Taken together, the stress-adapt-growth dynamics and the microinvalidations theory seem to suggest that there is an overlap between the development of stress reaction among emerging minority individuals and the emergence of borderline personality traits (not disorder). Concretely, below are the hypotheses that I use as my rationale to use DBT to work with these individuals.

Emerging minority groups in Japan find themselves in the process similar to stress-adaptation-growth dynamics defined by Dr. Kim (2017), and they can experience acute emotional dysregulation during the "draw back" state of the process.
Japanese society is experiencing “modern and symbolic” discrimination (Sue et al., 2007) towards newly emerging minority group with covert and unconscious, daily microinvalidations conveyed to the emerging minorities.
Japan’s conformist pressure (Kim, 2017) and microinvalidation (Sue et al., 2007) to the minority groups form a social environment similar to invalidating environment described by Linehan (1993).
This contributes to the development of high sensitivity to the stimuli, highly intensive reaction to the stimuli, and slow come back to the emotional base among those who receive invalidation.
Individuals in the emerging minority groups in Japan, therefore, are susceptible to developing moderate borderline personality traits; especially relentless interpersonal conflicts, dissociative cognitive strategy, and self-invalidation.
DBT is effective to support these individuals because it understands the transaction between the invalidating society and their newly developing identity, and provides concrete skills to navigate the stress-adaptation-growth dynamics.

To support Japanese society to embraces diversity

Japanese society will only diversity more from now on. Japan will be hosting more and more foreign workers and students. Even among Japanese people, value differences and life choices will become more and more clear. Japanese society needs to understand the meaning of social and demographic diversification from the majority-minority power relationship and develop clear awareness that there is a power dynamics that favor the majority. Diversity sounds politically correct, but if taken lightly, both emerging minority groups and existing majority group can fall in a trap of unhappy co-existence without real understanding. My hope is that I use the model above to support Japanese communities to embrace diversity in real sense as the society goes through the transition.

References

Kim, Y. (2017). Cross Cultural Adaptation. J. Nussbaum (Ed.), Oxford Research Encyclopedia of Communication. New York, NY: Oxford University Press. DOI: 10.1093/acrefore/9780190228613.013.21

Linehan, M. (1993). Diagnosis and treatment of mental disorders. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Sue, D.W.et al. (2007). Racial Microaggressions in Everyday Life Implications for Clinical Practice. American Psychologist 62(4); 271-286. DOI: 10.1037/0003-066X.62.4.271

Takaki, M (2020, March). Dialectical Behavior Therapy – Its relevance for Japan in social transition. Think Tokyo 2020. Symposium conducted at the meeting of The Asian Conference on Ethics, Religion & Philosophy (ACERP), Tokyo.