Borderline Personality Disorder Today Chat Transcript

Richard Moskovitz M.D.:  2/15/03

We were very pleased to have Richard Moskovitz M.D. (author of "Lost in the Mirror:  An Inside Look at Borderline Personality Disorder") provide a chat conference about the borderline personality disorder.  Below are the transcripts.

Terri:   

At this time I would like to introduce to everyone our guest speaker tonight the famous author of "Lost In The Mirror," Dr. Richard A. Moskovitz who has been so kind as to come and talk with all of us about his book and the subject of borderline personality disorder 

Dr. Moskovitz at this time I know you wanted to make a short intro.

Dr. Moskovitz:

 It’s a pleasure to participate in this chat this evening. The treatment of BPD is a continually evolving art, with contributions from many people and multiple disciplines. As I read and attend seminars, my own thoughts about BPD keep changing and my treatment approach acquires new tools.

Since I wrote about EMDR and Dialectical Behavior Therapy in the Second Edition, I have become increasingly aware of the overlap between the two approaches. EMDR is an evolving technique that has moved from directly approaching traumatic memories to incorporate a variety of preparatory steps. Resource Installation is an EMDR approach to developing personal strengths and resources that resembles aspects of the Skills Training part of D

One exciting theoretical development in our understanding of trauma has been the elucidation of the "freeze" response in the face of danger. We have all heard that when faced with life threatening danger, we must choose between flight and fight. We are now learning that we share with the animal world a third response: to freeze. This involuntary response combines immobility and a numbing of sensations and has considerable survival. Finished! 

Snow:

 Do you think it is possible to be cured of BPD?

Dr. Moskovitz:

Yes, particularly as we get more sophisticated in our treatment approaches.

Some studies have looked at how long it takes for people to reach the point that they no longer meet criteria for BPD.

Slyth: ?

Dr. Moskovitz:

The results have varied, but it's not unusual for considerable progress to be made within the first year or two. Finished

Terri:

Slyth your question please.

Slyth:

How would a person know they no longer meet the criteria? Would a person have to stop the meds and see how they feel? Finished

Dr. Moskovitz:

I don't think that it depends upon whether or not you are still taking meds. Some people make tremendous progress, but we continue meds for some time in order to help lock in the gains.

Terri: ?

Dr. Moskovitz:

No longer meeting criteria would include a reduction in impulsiveness, less black-and-white thinking, improved relationships, and more continuity of experience, i.e. less dissociation. Finished

Terri:

Since most people with bpd have more then one mental illness do you think it is beneficial to continue on with treatment even if one doesn't meet the criteria for bpd anymore? Finished

Snow: ? 

Joanna: ?

Dr. Moskovitz:

Absolutely. Even when a lot of the problems have been solved, there may still be problems with depression or anxiety that need to be addressed with meds. Finished

Terri:

Snow your question please.

Snow:

I have encountered many mental health professionals who are of the "old school of thinking"

including one who informed me

that I would never overcome BPD and would spend the rest of my life in an institution

do you see this way of thinking changing- I chose not to believe him but just as easily might not have finished

Patty: ?

Dr. Moskovitz:

I think that most professionals are starting to understand that we can work through many of the impasses to treatment that have stymied therapists in the past. We are coming out of the dark ages.

It is most important in the course of any treatment to maintain hope. I believe that most patients have considerable power to change, particularly once they get in touch with their hidden resources. Finished

Terri:

Joanna your question please

Joanna:

What is dissociation? Finished

Terri: ?

Dr. Moskovitz:

Dissociation refers to a variety of experiences in which we lose the continuity of experience. 

Joanna:?

Dr. Moskovitz:

This can include times when we are aware of what is going on, but are separated from our emotional response to it.

Dr. Moskovitz:

 It can be as simple as getting lost in a reverie while driving and missing your turn and as complicated as losing large chunks of time. There is a whole chapter in LITM devoted to this subject. Finished

Terri:

Patty your question please.

Patty:

Thanks so much for being here with us today Dr. Moskovitz. Most of the time I don't meet the criteria for BPD, HOWEVER I have noticed that when I get highly stressed, the symptoms begin to come back. Is this usual? That's also why I feel lost when you mentioned we can be "cured." What exactly causes the cure vs. my scenario of stress bringing the symptoms back? I also have the Bipolar Disorder.

finished

Dr. Moskovitz:

It is common for symptoms to come and go with stress. It is certainly possible to get much healthier for long periods of time, but slip back into old ways when things get overwhelming.

That doesn't mean that you are back where you started from. It is a challenge to search your experience for the strategies that have been successful in meeting past challenges.

Sometimes, when people have reached a point of peace in their lives, symptoms will suddenly creep back in, but often in attenuated form and for shorter times than before.

I call this the "curtain call" for the illness.

I think that it is our way of testing the solidness of recovery and practicing new skills. It is a part of the healing process. Finished

Terri:

Dr Moskovitz can you explain to me what EMDR is all about I know of it somewhat but am interesting in knowing more about it, I do understand that it is one form of therapy, how is it different from any other form of therapy, how is it helpful and is it more helpful then say DBT skills or is it better to combine both therapies?

finished

Dr. Moskovitz:

Wow! Huge question Terri. I'll try to address it as briefly as possible. OF course, there is more information about it in LITM Second Edition.

EMDR stands for Eye Movement Desensitization and Reprocessing.

It was originally developed as a treatment for trauma. It combines imagery and eye movements in a way that helps the brain to interrupt the stereotyped way that traumatic memories are experienced.

It is different from other therapies by virtue of the physical element of using eye movements while processing information.

EMDR isn't for everybody. I don't think that one therapy is necessarily better than another for everybody. It depends upon the patient and upon the experience and skills of the therapist.

LittleD:

Dr. Moskovitz:

There are overlapping elements among all the therapies. DBT relies on Skills Training in the beginning stages of treatment to begin to establish safety.

EMDR uses "Resource Installation" to accomplish similar things. Finished

Terri:

Joanna your question please.

Joanna:

Does dissociation mean that I have forgotten part of my life history? Finished

Dr. Moskovitz:

That can certainly be one aspect of dissociation. Many people with BPD have huge holes in their memories, particularly for childhood events. 

In order to develop a cohesive identity, it is certainly helpful to have a narrative of our lives that is more or less continuous.

Of course, nobody remembers everything that ever happened to him or her. It is normal to forget some events.

Our memories of early childhood are naturally more spotty than out memories of things that have occurred later. Finished

Terri:

LittleD your question please.

LittleD:

Is there any chance of being "cured" without any treatment? Finished

Dr. Moskovitz:

Interesting question. Studies have suggested that many people do get better as they get older. Particularly some of the more self-destructive behaviors get less frequent or drop out altogether.

I think that it is narrow to think that formal therapy is the only way that people can heal.

We have certainly learned from the course of many physical illnesses that people have natural forces within them that tend toward health when circumstances permit.

We don't cure colds, but we provide a reasonable environment in which recovery can happen.

Joanna: ?

Dr. Moskovitz:

I think that good, healing relationships can occur with people other than healers. I have seen people get better when they have had healthy partners with good boundaries who can provide unconditional love. Finished.

Terri:

Dr. Moskovitz how can family members best help the one they love with bpd to get assistance and build a better healthier life. Finished

Dr. Moskovitz:

I think that the key word is boundaries. 

Families have to balance caring and loving with the understanding that people are responsible for their own change.

In Twelve Steps parlance, it would be important to avoid enabling behaviors that are self-defeating. That means not rescuing family members from the consequences of their behavior, but helping to guide them toward healthier choices.

Slyth: ?

Dr. Moskovitz:

One dilemma in this regard is who pays for treatment. While patients are not always capable of supporting their entire treatment, I think that it is important for them to bear whatever part of the cost that they can. That way, they own their own treatment. It's not being done for someone else.

We've known for years that in therapy, people usually get what they pay for. IF they've paid nothing, they feel entitled to nothing and that's what they end up with. Much more to say about families, but let's go on to another question. Finished

Terri:

Joanna your question please.

Joanna:

Sometimes I think I don't want to be cured of BPD. Is that common with people with BPD? I've suffered from symptoms since I was four. I'm now 19.

Dr. Moskovitz:

Very common, indeed.

It's human nature to want to stay with what's familiar. Being cured means trying on new behaviors and encountering unfamiliar situations.

Being cured may also mean giving up some things that go along with being sick. If you've been in long-term treatment with a therapist, you may fear losing that relationship.

You may also be getting taken care of by others in ways that could change or end if you get better.

Relationship all change considerably as healing occurs. You may even outgrow some relationships that you felt you would always need. So resisting change is very natural. It takes a decision to begin to heal. Finished

Terri:

Slyth your question please

Slyth:

Is there a generic form of Zoloft? It’s very difficult to afford $140.00/month on top of other meds. At this time I have no med insurance/ finished

Dr. Moskovitz:

Unfortunately not yet. The patent on Zoloft has another year or two to run. Then it will get much cheaper.

There are, however, generic forms of Prozac and Luvox, both similar drugs to Zoloft, and these are far cheaper. That doesn't mean that you should switch, though.

Joanna: ?

Terri:

I can assist him with drug free programs, Dr. Moskovitz.

Dr. Moskovitz:

For some people, any of the SSRI's will do an equally good job. For others, one is much better than another. It would be worth talking with your doctor about your medication history and discuss options. Finished

Terri:

Joanna your question please.

Joanna:

Dr Moskovitz, I don't wash myself often or clean my teeth or visit the dentist at all. I won't do my hair much. Is this typical of BPD behavior?

Dr. Moskovitz:

Oh, yes. Most of the drug companies have Patient Assistance Programs that will provide free drugs to people in need. Finished

Slyth:

It took such a looong time to figure Zoloft worked better than others for me... I would like something similar to it for less $$.

Go to www.needymeds.com and you can get hold of the drug company's there through your pdoc and get any drug free

Thank you so much, even a discount would be better than what I’m paying now. THANK you.

Dr. Moskovitz:

I would not consider that typical of BPD behavior. Neglecting personal hygiene, however, is very common with depression. It goes along with the more general loss of interest in things and loss of energy. Even simple everyday tasks can seem monumental. Finished

Snow: ?

Slyth:

Do I write to your address and ask for access to the bulletin board?

Terri:

Snow your question please

Snow:

Is anxiety commonly associated with BPD or a separate problem? Finished.

LittleD: ?

Dr. Moskovitz:

Anxiety is a very common symptom of BPD. It often derives from intolerance of other emotions.

One of the crucial tasks of treatment in BPD is helping people to become comfortable with feelings that typically generate anxiety, such as anger, shame, and guilt.

Many of the impulsive self-destructive behaviors in BPD are designed to escape from feelings that generate anxiety. Finished

Terri:

LittleD your question please

LittleD:

This is hard to word....I have been diagnosed with BPD, yet excluding SI, I have no idea what other behaviors I am guilty of that have caused me to fall under the category of BPD. So, my question is, if I were to attend treatment, such as DBT, would I learn specifically what those behaviors are? Finished

Slyth: ?

Dr. Moskovitz:

Yes, the beginning of any treatment process is to define the problems that need to be solved. Certainly self-injury is a serious problem and one that I hope you would want to solve. 

Caltex ?

Dr. Moskovitz:

You might go through the DSM-IV criteria listed on pages 8-9 of LITM to see what other symptoms you may have. Perhaps unstable relationships? Or other impulsive behaviors? Finished

Terri:

Slyth your question please

Slyth:

Have you ever seen cases of BPD where the person has an uncanny and eerie sense of... I don’t want to say esp… but they are SO UNBELIEVABLY tuned in to other people that it's "abnormal"? I can’t think of another word to use. But not esp... more like reading facial expressions and the SLIGHTEST body language movement or something. I really can’t not describe this/finished

Dr. Moskovitz:

Absolutely. In fact, in LITM I describe this and compare it to the characters on the original Star Trek series (with Kirk and Spock...dates me) called Empaths. These creatures were so tuned into the feelings of others that they sometimes died when someone close by was in pain. finished

Terri:

Caltex your question please

Caltex:

Sorry, I missed the beginning of the chat so I hope my question is in the right context of what is being discussed here. In talking about anxiety as being a big part of BPD, is part of the intolerable pain experienced by a person with BPD the battle between being compulsive and impulsive at the same time?

Caltex:

They seem to be opposites but coexist at the same time

Dr. Moskovitz:

I don't think I understand the question. Finished

Terri:

Are you finished with your question caltex? If so please type the word finished when done (finished).

Snow:?

Caltex:

Being compulsive and impulsive at the same time seems to be a contradiction to me - is that part of the dilemma? Finished

Dr. Moskovitz:

How are they opposites? Both refer to behaviors that are difficult to resist. Finished.

Slyth: ?

Terri:

Caltex would you like to say something else about that, finished

Dr. Moskovitz:

By compulsive, do you mean cautious?

Dr. Moskovitz:

That would make more sense. 

Caltex:

Compulsive as in cannot help it - (as in OCD) but impulsive, is without thinking. Hard to explain, please go on with others, but thank you, finished

Terri:

Snow your question please

Snow:

I have been on neurontin to help with the anxiety and am presently trying to come off of it. I am down to 400mg and have noticed some decreased thresholds to anxiety. Do you think that at 400mg it is actually a placebo effect since the dosage is so low? finished

Dr. Moskovitz:

It's difficult to predict what doses a given individual will need with any drug.

The dose range of Neurontin is huge---from 100 mg a day to thousands of mg. I've had patients on doses at both ends of the range. For some people, 400 mg would be substantial. It sounds as though you are getting to the point of some breakthrough symptoms and should discuss it with your doctor. Finished

Terri:

Slyth your question please

Slyth:

One of the things that I do that drives myself nuts: I absorb characteristics, phrases, movements of someone I've spoken to or even a movie character. How can I stop? I feel like a shape shifter or something, always taking on other people's uh... I don’t know how to describe this either. I will copy hand movements, the way someone walks, etc. I feel like jello and take different forms without wanting to/ finished

Dr. Moskovitz:

Years ago, before the term BPD was formally defined, someone called people with BPD "as if personalities" because of the very tendencies you describe.

People with BPD often borrow elements of identity from others because they do not have a solidly crystallized sense of their own identity.

Solving this is not a simple process. The most crucial step is to begin to identify characteristics that identify YOU as a unique person. Once you take shape, you will no longer have to borrow from others. Finished

Terri:

Does anyone else have any questions for Dr. Moskovitz at this time? Finished

Patty: ?

Terri:

Patty your question please.

Patty:

I understand that both biology and the environment are the cause of bpd supposedly

Snow: ?

Patty:

I understand about the limbic system, etc. but how could our environment

Patty:

cause a "brain disorder" such as bpd?

finished

Dr. Moskovitz:

It has become very clear that environment and biology are intertwined. Experiences, particularly experiences that are highly charged with emotion, such as a life-threatening encounter, can change the chemistry and the physiology of the brain.

Think about your computer. You start off with hardware and your hardware is probably very similar to mine.

Dr. Moskovitz:

Once you start programming your computer, it begin to behave in its own way, depending upon what programs you've installed and how you've used them.

We also have hardware and software. Our experiences are continually reprogramming the software and change the way the operating system functions.

On a more personal level, I would recommend to you "Waking the Tiger" by Peter A. Levine. This book helps explain what happens during trauma that causes the biology to change. The good news is that the changes are often reversible. Finished

Terri:

Snow your question please

Snow:

You mentioned that hope is a big part of being able to heal from this illness-- I still have flashbacks of being in the state hospital and find myself in times of stress questioning whether this is really real, whether it is really going to last. I am so frightened of ever going back to such depths and having to be committed again. It is like a "ghost" that haunts me. I often hear the voice of that psychologist telling me that

Patty:

Are you done snow?

Snow:

Oh sorry finished

Dr. Moskovitz:

It's sad that you had such a painful treatment experience. It would be important to share this with any current therapist so that they understand your fears. Finished

Terri:

Any other questions for Dr Moskovitz?

Patty: ?

Terri:

Patty your question please

Dr. Moskovitz:

Time for one more question

Patty:

How does the BPD present in males? Is it different in males than in females?

in terms of behavior

finished

Joanna: ?

Dr. Moskovitz:

There are no hard and fast rules about this. Many males show behaviors that are identical to what we see in women. There is perhaps more of tendency, however, for men to direct aggression outward toward others and for women to direct aggression toward themselves. Finished

Terri:

Last question. Joanna your question please.

Joanna:

Does ECT help with the depression associated with BPD? finished

Dr. Moskovitz:

ECT can be a very effective treatment for depression, whether or not it occurs in the context of BPD. It can be helpful in severe episodes of depression that do not respond to medications.

Terri:

 Thank you very much for chatting with us this evening Dr. Moskovitz this has been a pleasure and a learning experience for me. Can you tell us when you next book is due out and the title of it again?

Patty:

Yes thank you very much for taking your time to come and speak with us.

Snow:

Dr. Moskovitz I want you to know that your book was one of the reasons I was able to choose not to believe that psychologist. It gave me a greater and truer understanding of BPD and I cannot begin to tell you how much I appreciate what you have done for me through that book. I am presently a volunteer for email and suggest it to most of the ppl who contact me. God bless you for offering us hope.

LittleD:

Thank you! :-)

Slyth:

Thank you.

Joanna:

Thank you.

Terri:

Once again thank you everyone for making tonight a success! be well :)

Patty:

Thank you Terri for leading this conference

Snow:

I can’t wait to read your novel! I have written a book called beauty from ashes that tells of the spiritual side of my journey through depression if you are interested in more resources for your patients.

Dr. Moskovitz:

Thank you all for your challenging questions. I've enjoyed the evening.