CPTSD & BPD: Revolutionary Approaches for Trauma-Related Disorders

Foreign I'd like to welcome everybody to today's presentation on emerging understandings of CPTSD and borderline personality. I'm your host, Dr. Donnelly Snipes. In this presentation, we're going to review the characteristics of BPD and cptsd, explore the functions of these symptoms, talk about what may cause these symptoms to develop, explore what might be maintaining these symptoms, and identify interventions to help the person cope more more effectively. So let's start out with personality disorders or trauma. A personality disorder is a pervasive disturbance in how another and how an individual experiences and thinks about the self, others and the world manifested in maladaptive patterns of cognition, emotional experience, emotional expression and behavior. This comes straight out of the dsm. The maladaptive patterns are relatively inflexible and associated with significant problems in functioning that are particularly evident in interpersonal relationships and are manifest across a range of personal and social situations stable over time and long duration. Let's think about that these disturbances people have. How might these disturbances occur or develop as the result of strategies that someone developed to try to to survive trauma or as a result of experiencing trauma? When we experience trauma, it changes how we experience ourselves, how we experience our feelings, how we think about ourselves, others and the world. And when it goes unresolved or unprocessed, however you want to say it, it can result in maladaptive patterns of thinking, emotional experience, expression and behavior. We can develop reactive behaviors to try to protect oursel. Given this broad definition and the requirement of persistent symptoms related to affect, disregulation, distorted view of the self and difficulty maintaining relationships in complex post traumatic stress disorder, individuals with CPTSD usually meet the diagnostic requirements for personality disorders. Now this comes out of the ICD11 and you can go in and after you go down the diagnostic criteria down, sort of about halfway down the page it actually says this. So the ICD11 is starting to say we really need to look at these things that we call personality disorders and evaluate whether they are trauma related disorders. In terms of differential diagnosis, if you will, both CPTSD and BPD are associated with adverse childhood experiences aces including abuse, neglect and disrupted attachment. Now CPTSD can develop at any time. Bpd typically we start seeing the the behaviors emerging in adolescence, early adulthood or sometimes even sooner. They BPD behaviors have been identified in children as young as 10 years old. In any event, CPTSD as opposed to your personality disorders, the trauma can occur at any point in life. So that is a slight difference in diagnosis. If the person had just a fairy tale Childhood and then all of a sudden there was this bad thing that happened or bad things that happened. Then we're going to look at PTSD or cptsd. People who develop complex post traumatic stress disorder during childhood and adolescence. So people who experienced these ongoing traumas, this instability, adverse childhood, during childhood and adolescence often report symptoms consistent with disorders of mood, appetite, sleeping, attention, conduct and separation. So what is that saying? That's saying that there are a lot of problem behaviors that we may identify in children that may actually be manifestations of trauma. A lot of times children and even adolescents don't have the self awareness or the emotional vocabulary to articulate or the vocabulary period to articulate what's going on. So they may somaticize their symptoms, they may act out, they may externalize their symptoms, or they may internalize their symptoms where they start experiencing depression or even self injury. The relationship of traumatic experiences to the onset of symptoms of the co occurring disorder can be useful in establishing a differential diagnosis. If the person had a mood disorder from the time they were, you know, 10 years old and the other behaviors that are required in the diagnosis didn't start developing until 12, 13, well maybe there was a pre existing mood disorder or ADHD. I mean ADHD shows up really early because it's something that h has to do with development. So ADHD symptoms may appear before trauma. And we need to really look at trauma and remember that adverse childhood experiences and attachment disruption are traumatic. A child, a 2, 4, 6, 8 year old can't fend for themselves if they don't know where their next meal is coming from. If they don't know if they're going to be protected or if they're going to be harmed, that's freaking traumatic. They are going to feel persistently unsafe and powerless. So we do want to explore what when we're looking at the onset of symptoms, was there a secure attachment? Were what kind of adverse childhood experiences did this person endure, if any? But most people have had at least one and how did they deal with that? We can experience traumas, we can experience adverse childhood experiences and with the proper support and attention from caregivers, we, we can successfully integrate those and it doesn't always develop into something else. But if the child did not have the support that they needed and they were exposed to these aces, then we do need to consider what was going on. And we want to look back all the way back to infancy. And I know you're saying an infant, they can't remember. Well, maybe not verbally remember, but they do Remember feeling pain, they do remember feeling cold. You know, trust versus mistrust. That's the first Ericksonian stage. And as children they develop a sense of safety when they cry and their needs are met. When they cry and their needs are not met, then they feel unsafe. So we can have attachment disruption starting way back in the infancy period. Other mental disorders can develop following extremely stressful or traumatic experiences. However, additional co occurring diagnoses should not be made if the symptoms are fully accounted for by complex post traumatic stress disorder. And again, straight out of the ICD. 11 this is not Dr. Snipes just pulling stuff out of the air. Why, why are we going to, why do I emphasize that so much and why do I say that every time we talk about CPTSD and bpd? Because there are consequences of what we do. I know. Imagine that. What's the purpose for us of diagnosis? What I call diagnosis stacking. If you end up giving somebody a diagnosis of anxiety and ADHD and CPTSD and BPD and the kitchen sink, I mean, you start giving me all those diagnoses, I'm going to feel pretty darn helpless. There is generally no purpose in diagnostics diagnosis stacking. If a particular diagnosis or a couple of diagnoses thoroughly explain all the symptoms. There is so much overlap that a lot of times people get all of the diagnoses that could possibly apply to their symptoms and that's not effective differential diagnosis. And it can contribute to a person feeling hopeless, helpless, broken, unable to recover. It can contribute to a person embracing those diagnoses. So instead of moving towards a rich and meaningful life, they give up or they feel like it's their lot in life to suffer. And that's not what we want. As far as personality disorder diagnoses, yes, they're in the DSM 5TR and they're going to be, they're going to stay in the DSM5TR. The DSM5TR and, and the American Psychiatric association has decided that at this point they're not even considering adding CPTSD to our diagnostic manual. It's in the ICD11 but it's not in the DSM5TR and it's not being considered for the next edition, which may come out in five to seven years. So it's going to be a long time before we in the, in America start acknowledging cptsd. Now I know a lot of clinicians already do, but in terms of having a, an official diagnosis, an F code, it's going to be a minute. Personality disorder diagnoses though are pathologizing many therapists. I hope it's not most anymore, but it probably is. Hear the term personality disorder and think intractable issue. There's nothing I can do to fix this. People who have personality disorder diagnoses are pathologized un. They shouldn't be. They should not be pathologized because these behaviors are communication and these behaviors developed as a way to help the person survive. I realize that you realize that, but the average person, the average whatever, may not realize that. And when people hear personality disorder, when they hear narcissistic personality or borderline personality, it's like, oh gosh, no, run away. Goodness, do we really want to saddle our patients with that if it's not necessary? Now again, obviously there are certain times and conditions where a PD diagnosis might be appropriate. And remember, personality disorder diagnoses generally emerge in childhood, adolescence, sometimes early adulthood, and are persistent over time across situations at home, at work, with friends, with family, with strangers, and persistent across relationships. And they're not flexible. So the way I behave with my spouse is very similar to how I behave with my kids, my friends, and the stranger I meet on the street. That's what we're talking about with personality disorders. You can have people be very, exhibit some of these behaviors in certain situations, like at work or in, in the case of borderline personality in intimate relationships. But in their relationships with their friends or with their co workers, they behave very differently. And so that would beg the question, is that really a personality disorder or is that trauma caused by fear of abandonment that shows up in relationships in which that person feels vulnerable? Post traumatic stress. Well, diagnostic alternatives. Sorry, got ahead of myself. Since we don't have CPTSD in the DSM 5 trip, we can instead diagnose Post Traumatic stress disorder. We can use this code and note additional CPTSD symptoms in the patient's clinical formulation or treatment plan, such as, well, you get what I'm saying. It's important to remember that PTSD's primary feature, everybody with PTSD has exposure to an event or situation either short or long lasting. So this is where that CPTSD can come in. Because CPTSD is generally exposure to a traumatic situation that was ongoing or episodic in which the person felt no ability to escape. So PTSD is an exposure to an, an event or situation that can be long lasting, of an extremely threatening or horrific nature. And again, thinking back to that infant, that 2 year old, that 8 year old who was terrified, not feeling like they would be cared for, not knowing if mom or dad was going to come home. You can also if you don't feel comfortable with PTSD for some reason, you can also choose other specified trauma and stress stressor related disorder. In this case, symptoms are consistent with trauma or stressor related disorders and include features beyond PTSD such as those seen in CPTSD. The DSM 5TR allows us to specify the reason that we're choosing this other specified trauma and stressor related disorder. Also, the other specified diagnosis can be applied if the person somehow doesn't meet all of the criteria for sea for for ptsd. So that gives you a little bit more wiggle room in terms of the causation of trauma. CPTSD typically emerges following a prolonged and repeated trauma such as childhood maltreatment, domestic violence either as a child or as an adult, or institutional abuse leading to disturbances in self organization, emotional regulation and persistent relational difficulties. Borderline personality is often associated with early attachment trauma and those adverse childhood experiences inconsistent caregiving and emotional neglect which contribute to an unstable disturbance of self affect, dysregulation and impulsivity. So you have disturbance of self, disturbance of affect, regulation and CPTSD and the same thing in bpd. So we're starting to see there is significant overlap. Now I know the text is small on this, but I was trying to make a point so hopefully you can see it. In PTSD or cptsd the person has to have all of these characteristics which is unique in the DSM 5TR. Generally it's 3 of 5 or 4 of 9 or something. In the borderline personality diagnosis they have to have five of any of the symptoms. Now why are they colored? Because I wanted to show you the overlap. Re experiencing memories, flashbacks, nightmares, or intense feelings of being overwhelmed or immersed in the same emotions experienced during the traumatic event, with or without a promotive prominent cognitive aspect. So you can re experience. And we've talked a lot in the recent years about somatic experiencing. You can re experience trauma without really remembering the event. It can be a very somatic experience that still qualifies as re experiencing. Now, in borderline personality, re experiencing is not actually a diagnostic characteristic, which is why I have it grayed out and have the little asterisks by it. However, I want you to think about the people that you've worked with that have qualified for a borderline personality diagnosis. When they were in relationships, when they started to fear abandonment, when they got to that point that they were dissociating or splitting, were they re experiencing the abandonment, abuse and neglect that they experienced with their primary caregiver that they experienced as a child is feeling like, oh my, my current partner is getting ready to abandon me. This reminds me of when I was a little child and my parent abandoned me. So I do want us to consider how people with BPD may very well be re experiencing those traumas. If you want to put it in another phrase, their inner child, their wounded inner child is going, hey, I remember this and this is awful. The next one is avoidance of thoughts, memories, situations that are re reminiscent of the event. Okay, well we recognize that in ptsd. If we want to look at borderline personality, we want to recognize that this person doesn't want to feel abandoned again. This person doesn't want to experience memories of what it's like to be abandoned again, which can contribute to those unstable and intense relationships alternating between idealization and devaluation. That splitting that we see, everything's going well, I love you, things are good, I feel safe, wonderful. That's the idealization. And then I start to notice things that remind me of what it was like when I was a kid and I was abandoned. Okay, no, heck no. Shutting the door, getting out of here. Devaluation. Kick them to the curb. So it was that all or nothing thinking. The way a person with borderline personality may avoid some of these events is by switching to devaluation and. Pushing, sort of pushing the other person away. Even though they desperately don't want to be abandoned, they desperately don't want to feel that pain of abandonment either. The next one, persistent perceptions of heightened current threat. Their hyper vigilant and startle response is just really keyed up. And again, it's not a direct symptom in bpd. However, every patient I've worked with and I, I feel confident saying that every patient I've worked with with borderline personality was extremely hyper vigilant to signs of abandonment or rejection. Whether it was a non verbal or a verbal or something else. They were waiting, they were watching, they were looking for things that reminded them of times they'd been abandoned in the past so they could protect themselves. And I would argue that people with borderline personality do have a lot of hypervigilance. In cptsd, we also have issues with affect disregulation and we've talked in prior videos about the Flat and the Furious. When you experience ongoing trauma, your autonomic nervous system becomes disregulated, your fight orf flight becomes too strong and your relaxation becomes too weak. And then over time, the receptors for the fight orf flight neurochemicals if you will, become tolerant to that stimulation. Just like our dopamine receptors become tolerant to dopamine when people are abusing drugs. Eventually when receptors are worked too hard, they say, no, I'm going on break. And so when they're on break, essentially the person feels flat. There is no excitement because the same neurochemicals that help us feel fear and rage also help us feel excitement. There are excitatory neurochemicals, but those receptors, they're not, they're not playing right now. So the person feels flat most of the time until there is a sufficient threat or perception of a threat to send a tsunami of stress hormones. And then those receptors wake up and oh boy, do they wake up. So we have the flat to the furious or the flat to the frantic. We see the same thing in borderline personality. That's one of the key characteristics is affective instability or emotional dysregulation due to marked reactivity of mood. You have intense episodic dysphoria or feelings of depression, anxiety, irritability, anger and potentially explosive anger. One of the other characteristics is difficulty controlling or explosive anger. And that can come from that affect disregulation. When they're flat and then all of a sudden they start to feel powerless, they may move into that hyperactive state of furious and that's when that anger comes out. It's important to remember that when people are under a lot of stress, when people's stress response is triggered, their prefrontal cortex isn't, they are in emotion based reasoning, they are in fight or flee. So it's hard to rationalize, it's hard to problem solve when we're really stressed out. And people who have lived with CPTSD or traumas that led to the development of BPD felt unsafe, they felt powerless, they were on in fight or flee most of the time. So a lot of these beliefs about self, about others, about the world, about whether I have power to protect myself, are sort of stuck at whatever point. Those traumas really took over because I haven't been able to think clearly enough to rationalize, if you will, since then. So we need to look at the schema and recognize them as if you will, artifacts that developed and helped the person survive until now. But now we need to help them learn new techniques and, and that's important. Another feature of CPTSD is beliefs about oneself as worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event. And I would argue that in borderline personality we have markedly and persistently unstable self image or sense of self. The person's not sure who they are because all they do a lot of times people with bpd, especially early on, will fawn, I will do whatever you want me to do. Just don't leave me. Please don't leave me. And that comes out of a place of, of fear. And it's you're going to leave me because I am not what you want me to be. I am not good enough. I'm not smart enough. I'm not doing the right things. Additionally, in borderline personality we see a sense of chronic feelings of emptiness. Well, if I never felt love for who I was and I was put being a chameleon all the time just to try to stay safe and survive, then yeah, I don't know who I am because I've never gotten to experience that. And if the attach part of the issue is due to attachment trauma, that means somewhere in my psyche I've registered that I failed at being what I needed to be in order to be lovable. My own parents didn't love me and or I'm broken due to the the abuse. So you can see how people who experience attachment trauma very often have beliefs about themselves as worthless or shameful or failure as a human being because they weren't enough to be loved by their caregivers. And then difficulties in sustaining relationships and in feeling close to others is the third criteria for complex PTSD which takes us back up to borderline personality. Both categories or people with either diagnosis have difficulty in relationships. Now people with borderline personality tend to get into relationships that become extremely intense extremely quickly. People with CPTSD may have difficulty feeling close to others. Now they they're terrified of abandonment but and and they don't want people to leave but they have difficulty connecting in a certain way. These diagnoses may also include other symptoms. Both CPTSD and borderline personality both often include symptoms of mood disorders. Anxiety, guilt, anger, shame, depression. Both PTSD and CPTSD include dissociative symptoms especially in relation to stress. Somatic complaints is somewhat unique to PTSD and CPTSD but it I wouldn't be surprised to see it in borderline personality. Suicidal ideation and self injurious behavior often seen in cptsd. Also often seen in borderline personality and excessive alcohol or drug use to avoid re experiencing this is sort of dissociating without dissociating again. In borderline personality we may see impulsivity in at least two areas that are potentially self damaging. That can include substance Abuse. So going back to can the issue be fully explained by cptsd? And by my estimation all of the diagnostic criteria and borderline personality can be represented by diagnostic criteria in PTSD or cptsd. Part of that is due to the fact that both ptsd, CPTSD and borderline personality and emanate their root cause is trauma and disregulation of the autonomic nervous system and then all of the fallout in every piece of life that results from that. Borderline personality disorder has been found to be associated with high rates of various forms of reported childhood abuse and emotional neglect. In terms of CPTSD and ptsd, the onset of PTSD symptoms typically occurs within three months. But and this is really important, there was somebody that was in the class, gosh, a few weeks ago that was saying that their therapist had told them that what they were experiencing as a stressor, as a trauma that had been triggered. Well, that couldn't be it because if it was going to cause PTSD or stress symptoms, it would have happened right after the trauma. That ain't so. Symptom onset, and this is from the DSM 5 TR. Symptom onset can occur even years after exposure to a traumatic event or in response to an acute stressor. So if the person was abused as a child, they may be kind of going along in this half numbed phase for a lot of their life and then they have a child and all of a sudden it awakens that trauma in them. Or if the abuser or neglectful caregiver dies or comes back into their life, either way it can trigger the onset of those, those symptoms because all of a sudden it's like oh my gosh, now I'm remembering all this. Manifestations of CPTSD may include increased frequency and intensity of temper tantrums, separation anxiety, regression and skills, exaggerated age associated fears. So if the trauma occurred when the child was three or four, we may see a lot more separation anxiety and fears of monsters. If the trauma occurred when the child was a little bit older, then we may see more age associated fears of peer rejection or, or what have you. There also may be excessive crying, acting out protective or rescue strategies, reluctance to engage in new activities and excessive reassurance seeking. Now for each of these, each of these behaviors, I want you to think from a child's standpoint, if I don't have the words to communicate what's going on, or even from an adult standpoint, if I don't have the words to communicate what's going on, I may behaviorally Communicate what's going on. A temper tantrum. What is that saying? And temper tantrums can say a lot of different things. So don't get me wrong, but in the case of trauma, sometimes a temper tantrum is saying, I don't feel safe and I need somebody to help reign me in. Separation anxiety. If I cry and, and like freak out when my, my significant other leaves or my caregiver leaves, it may be a sign that, hey, I'm saying I'm afraid you're not going to return. Even though in my cognitive development I'm way past that phase of object permanence, I may still have that fear, so my anxieties may arise. Regression and skills again. Oftentimes this is the child's way or the person's way of saying, I need somebody to take care of me. I can't do it anymore. I need you to show me that you're going to help take care of me. Acting out protective rescue strategies. You can go through each of these and if you think of it from the standpoint of a child or an adolescent who may not have the words to say, I'm terrified and I need someone to help me feel safe. I need someone to help me figure out what to do next and to, to feel like I'm, I'm worthwhile and I'm lovable, then a lot of these behaviors make total sense. The course of borderline personality or CPTSD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity and suicidality. So we have a lot of emotional. Teenagers themselves have a lot of affect regulation. But teenagers and, and adolescents with BPD or CPTSD often have much more pronounced affect, dysregulation and impulsivity. As they become adults, it may switch to maladaptive interpersonal functioning and enduring functional impairments with periodic remission and relapses. The belief is that as people get older, remember I said the prefrontal cortex isn't really activated when you're in fight orf flight all the time, but it is activated a little bit and people learn skills, they modify their behavior or their behavior is modified through experiences. So they learn as they start interacting with, as a, as an adult, with adults, they start learning what behaviors may help them. So we do tend to see more, we, we tend to see less in the way of temp, temper tantrums and widespread affect dysregulation. Bpd, BPD and CPTSD symptoms tend to wax and wane and presentation depends on contextual factors. As the person gets older, when they are feeling less stressed, when they're less vulnerable, they tend to be able to keep a lid on it to maintain things. They may not feel good, but they're holding it together. When they are exposed to triggers or they're feeling very vulnerable for some reason, then the symptoms tend to be exacerbated. These behaviors seem to develop to help the person survive dangerous or threatening situations when other options were not available. And and again, remember, symptoms often can be understood through the lens of trauma. What happened that led to the development of this behavior? From a purely behavioral perspective, we have reinforcers and we have punishers. And people exhibit a behavior and it's either reinforced so it continues or it's punished and the person doesn't do it anymore or as much. So these behaviors were clearly reinforced somehow as the child grew up. And part of that reinforcement may have just been, hey, you get to survive today. Neurological aspects. This is some of the new information. Childhood trauma may increase the risk of BPD or CPTSD due to alterations in the autonomic nervous system. Our fight orf flight response versus our rest and digest fight orf flight becomes too strong and rest and digest, our parasympathetic nervous system becomes too weak. This is the result in very oversimplified, again, often of poor vagal tone. That vagus nerve isn't sending the right signals to the brain and it's having a hard time turning down or turning off the fight or flight response. Working with people to help them strengthen their vagal tone. And I, I know we've talked about this literally for the past five weeks, every week. Encouraging them to do things like go out on a brisk walk and then practice slow breathing or doing something else. So they physically, manually basically force their heart rate and their and their breathing to slow down. So they start gaining control. They're forcing that sympathetic nervous system to turn down. It's not advised to start out doing this with stressful things. We want to start out with physical activities that increase the heart rate and then helping them bring it down. Before we go into talking about trauma. When you're in a session with somebody, if they start to get excessively upset, if it seems like they feel like they're starting to spiral, we can have them stop and engage their down regulation skills or their distress tolerance skills, whatever you call them, to, to strengthen that vagal vagus nerve, to down regulate that sympathetic stress response. Because yes, what they're thinking about is stressful and awful. And they are safe objectively in the present moment. So instead of feeling like this, where they feel not only there are they revisiting that trauma, but they also feel like they're unsafe and powerless and spiraling out of control. Yes, they're revisiting that traumatic moment and they're safe in the present. So we're toning down, we're tuning down, we're not tuning out. We also see people. There is a high correlation. People with bp, BPD and CPTSD have high markers of systemic inflammation. Both conditions have high levels of inflammatory cytokines in their system, which indicates that that stress response is out of control. We also see alterations in thyroid and gonadal hormones, typically, hypothyroid and gonadal hormones, typically. We see higher levels of androgens. Really high correlation between borderline personality disorder and polycystic ovarian syndrome. I would guess that there's a really high correlation between polycystic ovarian syndrome and CPTSD as well. There just wasn't any research on the neurotransmitter levels. When our fight or flight, when our autonomic nervous system gets out of balance, it negatively impacts the balance of our neurotransmitters. It negatively impacts the balance of the microbes in the gut that help balance our neurotransmitters. In particular, dopamine and serotonin tend to be very out of balance in people with both, either, both or either of these diagnoses. The endogenous opioid system also is disregulated and well, in people with BPD and cptsd, which may mean they seek out things that are going to increase dopamine because increases in dopamine are also associated with increases in endogenous opioids. So we can see a little bit of self medication that way. Neuroplasticity is also negatively impacted. The changes that we see in the non traumatized child's brain are not as pronounced as the changes or are more pronounced than the changes that we see in the traumatized child's brain. The trauma child, Traumatized child's brain does not make those adjustments and grow like it's supposed to. Brain areas involved in the stress response in both of these conditions are also affected. We see hyperactivity of the amygdala where you've got fear processing and again reduced activity in the prefrontal cortex and reduced thickness of of the prefrontal cortex. Brain cells died because of the toxic environment in the brain because of the neuroinflammation. Because of the overactivity of that stress response, the prefrontal cortex, the thinking part of the brain, the executive functioning part of the brain, actually shrinks. And it, it can be bolstered. We can induce neurogenesis in people, but we do need to recognize that it's not just necessarily hormonal or cognitive or neurotransmitters, but we also have notable changes in the size and structure of the brain. All right, so the recovery process, trauma, whether it's due to abuse, neglect, abandonment, or other causes, leaves the person feeling unsafe and powerless. We need to help them feel safe and personally empowered. What happened back then was awful, and you were powerless back then. In the moment. Right now, you're safe and you are empowered. Help them mindfully separate the past from the present. When they start feeling somatically stressed, when they start re experiencing that, help them recognize, okay, this is where it's coming from. In the present, I am safe. Grounding activities are wonderful. They can do five things that are green, or they can do five things they see, four things they hear, three things they smell, two things they can feel or they can just do. Who, what, when, where, why? Who am I? What am I? Where am I and why am I? Why? Is a little bit ambiguous. But helping them recognize where they are, they are not back there. They are an adult in the present, in this, in my home, surrounded by my pets, where I feel safe. We can help them learn how to unhook, recognizing that feelings and thoughts aren't reality and. And same. Maybe that's not exactly what I wanted to say. Feelings and thoughts feel real for the person, but they're just feelings and thoughts. So I'm having this feeling that I'm terrified. Okay, so this feeling is right here. I'm going to unhook from it. I don't have to carry it with me. When, what am I going to do with this feeling? Am I going to ignore it? Am I going to address it? What am I going to do? I'm having this feeling that people hate me. Okay, well, it's a feeling, doesn't mean it's a fact. So let me evaluate. What am I going to do with that? Am I going to believe it, or am I going to evaluate it for its validity? We want to help people learn distress tolerance skills, help them develop the ability to recognize. I can feel these feelings, the somatic experiencing, and it won't overwhelm me, it won't consume me. I can feel distress and continue to move toward my rich and meaningful life. We want to help them reframe behaviors as survival skills. Because so often they've been told that these behaviors are. Are pathological. These behaviors are problems. Everything in your life is your fault because of these behaviors. So the person has started to feel very powerless, very guilty, very hopeless. We want to reframe these behaviors and help say, hey, were they the best way to deal with the situation? Probably not. But they helped you survive until now. This tells me you want to survive. And think about how much strength and courage it took to live up until now with these memories, with these feelings, with this albatross that you're carrying around your neck. Wow. You know, so let's look at what you can do instead. But recognizing you're not a bad person for these behaviors. These behaviors were formed, were shaped over time to protect you, and maybe they were reinforced in unhealthy environments. We want to help people identify vulnerabilities in each piece of life. Remember, vulnerabilities are things that make you more prone, more likely, more vulnerable to being triggered, to feeling overwhelmed. All of us have our vulnerabilities. For me, if I am sleep deprived or if I'm not feeling well, I am more vulnerable to being cranky, to being impatient, to being triggered Than if I am fully, fully nourished, fully rested, you know, fully healthy. I can handle a lot more when I'm on my a game. But helping people recognize that every day is a different day. And you do have vulnerabilities most days. Sometimes it's just a couple, and they're very minor. Sometimes there's a lot. And being compassionate with yourself and recognizing that you're going to be able to tolerate less on those days that you're more vulnerable, and figuring out how to deal with that is important. So this first part of the recovery process is just helping people reframe their behaviors and start to understand why some of these things seem to come from out of the blue or why it feels sometimes like they don't have control over these behaviors. And to get them to start developing very basic downregulation skills so they can start strengthening that parasympathetic nervous system, Strengthening that vagal tone, and essentially weakening that stress response so they're more imbalanced. Next stage is looking at progress. Have the person identify three presenting symptoms. They may have seven. Have them identify the three that are most problematic or the three that they want to work on. All right. Then we're going to have them track the frequency, intensity, and duration of those symptoms throughout the week. So, for example, re Experiencing. If that's one of the symptoms I want to track, then in my little log book, I'll just have a little tiny logbook I keep with me. And each time I have an episode of re experiencing, I'm going to note it with a hash mark. I am going to rate the intensity on a 1 to 4 scale. 1 being barely noticed at 4 being completely overwhelmed by it. So, so I'll rate the intensity and then I'll identify the duration. When I used my skills, whatever. It lasted 30 minutes. Okay, that's fine. So I, I'm having nine re experiencing episodes a day. The intensity is a three on average, and they tend to last about 30 minutes. Great. It's a great baseline. Then we want to start seeing that go down. It can. And in any one area, if the frequency starts to go down but the intensity and the duration stay the same for a little while, that's okay. That's still improvement. If the frequency stays the same but the intensity goes down to a two, oh my gosh, that's progress too. Or if the frequency and the intensity stay the same but they get shorter, it's like I feel really overwhelmed. But it only lasts for like five minutes each time. Super. That's progress. And we want to help people track this so they can see their own progress over time. When they have bad days, it's easier to focus on the bad day. And it may be hard to look back and go, okay, well, the last nine days were really good. Today happened to be a bad day. Let's figure out what's different. Motivational enhancement strategies help them define their rich and meaningful life. Who, who's important in their life, what's important in their life, what experiences, etc for each one of those things, have them get a picture. Either print something offline or draw it or whatever. On the back of each picture, define what that looks like. If I want to have an improved relationship with my daughter, I will write down what that looks like. If I want to have. If I want to feel happier most days, I'll define what that looks like. On another sheet, I'm going to identify the ways that having a bad relationship with my daughter or being anxious and depressed keep me from moving toward my rich and meaningful life. That'll help me remember why this is important to work on. And then on the back of that sheet, I'm going to describe strategies to address those problems. The so I know what I want my relationship with my daughter to look like. I know what, how a bad relationship with my daughter is keeping me from moving toward my rich and meaningful life and I can identify ways to start addressing that so I can make that vision of a good relationship come to light. As therapists, then we need to sit down with people and help them identify any skills that they may need to learn in order to make that happen. If they had the skills, they'd probably already be doing it. So we need to help them identify those skills and then discuss with them how they're going to divide their energy. It's kind of like a large garden. I have a really large garden. I can't weed the entire garden in any one day. So I break it down into segments and I'll weed, you know, this part today and I'll do the next part tomorrow. And then at the end of the week I water everything and you know, I have different tasks for different days. And dividing your energy to nurture all the things in your rich and meaningful life needs to be accomplished sort of methodically like that because you don't have enough energy or time in the day to nurture everything that's important in your rich and meaningful life every day. So think about like, think about it like the garden and encourage them to mindfully reflect on their rich and meaningful life each morning. What's important to me, looking at that vision board they created and then each evening, how did I effectively use my energy to move towards these things physically encourage people to regulate their circadian rhythms. Circadian rhythms are set by light, temperature and your activity. Activity is also kind of related to stress. And as stress is high, as cortisol is high, melatonin is low. As cortisol goes down, melatonin goes up. So we want to make sure people aren't doing super stressful things at the end of the day. We want to help them improve their sleep architecture. That means have good sleep hygiene and I've got videos on that. So we're not going to go into deep detail today. We want to help them understand the importance of a diet that is anti inflammatory and has a lot of probiotics and prebiotics for gut health. We can't prescribe a diet, but we can educate about how good nutrition can help stabilize and help their body better produce the hormones and neurotransmitters necessary and can help strengthen that relaxation system by improving the vagus nerves ability to communicate with the brain. We also want to help them recognize how alcohol is inflammatory and will work against them. We want to help them improve their vagal tone like we talked about earlier. A lot of times start out with exercise. But there are a lot of different things you can do. Vagus nerve stimulation, breathing exercises, meditation, whatever it is that person feels comfortable doing in order to strengthen that relaxation response. We want to help people with pain management because pain is a stressor and physical relaxation because muscle tension will lead to pain and stress and poor sleep. We want to help people get into doing some movement, whether it's steps or dancing around the house like a crazy person, whatever they want to moving, getting more oxygen in their system, getting their blood going, and addressing any side effects of current medications they're on. Enter and intrapersonal we want to help them develop and maintain healthy boundaries, exploring their prior experiences in relationships with boundaries being respected or violated. Define what healthy boundaries look like in each piece of life. Your physical boundaries, your interpersonal boundaries, your emotional, cognitive and environmental boundaries. We want to help people learn how to set boundaries because a lot of times they haven't been allowed to set boundaries in the past. So how do I assertively set boundaries and then maintain them? Self awareness and authenticity are important in boundary setting because you don't know if somebody's invading your boundaries if you're not self aware. Attachment Helping them learn about secure attachment. Explore prior attachment experiences and how they cause the person to feel unsafe and powerless. As you're exploring attachment and those prior relationships, it's also important for the person to begin developing a secure attachment with themselves. To be consistent in their awareness of themselves, to pay attention to themselves and actually, you know, recognize and spend time with themselves, to be responsive to their needs, to be encouraging of themselves instead of hateful, and to be safe. Love themselves unconditionally. Self esteem activities, including having self esteem jars in the house, for example, that they other people write things that they appreciate about that person or identifying what characteristics do you admire in your friends and your mentors. Once they've identified that, then say okay, which of those characteristics do you have? Help them handle their inner critic. Their head is their house and they need to learn to tell that inner critic, my house, my rules. And you're not going to talk to me like that. In terms of past and current relationships. Help them identify and explore patterns in people that they are attracted to. A lot of times they're repeating past traumas. They may not be, but explore that issue to see if there are certain patterns in the people that they hook up with. Identify behaviors that caused issues in their relationships like splitting dysregulation or behavioral communication. You made me do this, you made me relapse, you made me. Whatever causes of those behaviors? What causes you to split alternatives to those behaviors? When you start feeling terrified and terrified of abandonment, what can you do instead of splitting and start starting to see the person is all bad? What can you do and what are the benefits and drawbacks to these alternatives and benefits and drawbacks to. To splitting to the current behavior? And how can you remember to engage the alternative behaviors? Oxytocin. We want to encourage that. Encourage them to do nice things for themselves. They haven't had nice things done for themselves, so that actually increases oxytocin. And bonding with themselves as it is, encourage them to occasionally do nice things for others. Open a door, say hi. Smile. It doesn't have to be, you know, huge lavish gifts or something. Weighted blankets. Pressure can release oxytocin. Emotional support animals. Petting an animal has been shown to release oxytocin and they do sell oxytocin nasal spray as an off label compounded pharmaceutical. And that's something that they can talk about with their, with their psychiatrist or their physician. Emotionally encourage compassion for self. That's one thing that you don't see in people with BPD or cptsd. They are often extremely critical of themselves because they're parroting what they've been told to themselves. Instead. Change that script to I'm doing the best I can right now and beating myself up makes me feel like a failure. So when I beat myself up, I make myself feel unsafe and it worsens my emotional dysregulation. Encourage them to recognize the vulnerabilities and triggers that led up to whatever it is they're being compassionate about. So backward chaining. What is it that led me to be to feel exhausted and vulnerable and impatient today? And then forward chaining is figuring out how to prevent that in the future. Positive positivity. Journaling can also be helpful. 20 minutes a day. The other 23 hours and 40 minutes. Think however you want. 20 minutes a day. Or maybe during dinner, if you have a family dinner, all you talk about is the positive things that happened. And that helps turn up the relaxation response as well as suppress that stress response. And it helps balance so the person is becoming more aware of the good and the bad. Behavioral activation. Encourage them to do things that at one point made them happy. Schedule worry time. If they worry a lot, encourage them to acknowledge the worry. If they're safe in the moment, which hopefully they are, say, okay, I'm safe in the moment. I'll handle this later. And schedule 30 minutes a day in the evening or not too close to bed. That they can engage in their worry time, but that keeps it segmented a little bit. Again, encourage them to unhook, recognizing I feel anxious right now. What am I going to do with this anxiety? Carrying it around with me for the next three hours ain't going to do no good. And evaluate feelings based on FitCat. The facts in this context at this time cognitively help them identify schema that relate to fears of abandonment, rejection, criticism, abuse or neglect. And they will have a lot of these schemas because of their prior experiences with abandonment, rejection, criticism, abuse and neglect. Okay, Evaluate where these beliefs came from through objective eyes. If you grew up in a household where your caregiver was just not attentive or was abusive, okay, the child probably internalized it as it's my fault. With objective eyes we can look back and go was it though? And only the person can answer that for themselves. Recognize the person needs to recognize how they're the same and different than they were then. They're bigger, they're independent now. They're not dependent on that caregiver. They need to recognize how that person or situation is the same and different now. Maybe they're exactly the same now. Okay? And maybe they have changed some and develop distress tolerance schema to respond to these distressful schema. When they start feeling rejected or fearing that they're going to be abandoned, what can they tell themselves to counter those thoughts and develop skills for managing intrusive thoughts? In terms of cognitive distortions and I know we're running over here, I'm going to try to get just two more slides. In terms of cognitive distortions. Encourage people to look at each type of distortion and identify how they've used it. Thinking in the past, when have I used emotion based reasoning? When, when have I made a decision based on how I felt, not the facts in the situation? Why did I develop emotion based reasoning? Well, children use emotion based reasoning. They don't think about the facts in this context at this time. So if you experience trauma early on and were never able to develop those fact based reasoning skills, then as an adult you may still engage in a lot of emotion based reasoning and you may have developed it as a way to stay safe. You may not have known exactly what was getting ready to hit the fan, but you could sense it, you felt it and that propelled you into action. How does this thinking style, this cognitive distortion keep you from your rich and meaningful life and what can you do instead? And each of these distortions can be addressed with one of the following fit cat facts in this context at this time, probabilities like catastrophizing, yes, this horrible, horrible thing could happen. But given the facts in this context at this time, what is the probability that that's going to happen? Is it a possibility? Yes, but probably not a probability. What are some alternative explanations for why this happened? Besides me? Somebody scowled or was ugly to me today. Was it that they were rejecting me? Or what are other alternatives? Maybe they got into a car wreck on the way to work, Maybe they're not feeling well. I don't know. There could be a lot of reasons and exceptions. When you start thinking about all or nothing things, you always do this or you never do this. Really rack your brain to find exceptions to this because very rarely do people always or never do something and then environmentally identify triggers, negative triggers, things that trigger distress and those traumatic memories you want to try to mitigate the ones you can't eliminate and eliminate any of the ones you can. And this includes smells, sights, sounds, places, holidays. Now you can't eliminate holidays. You can't completely control everything you smell. So what are you going to do during those times to keep those triggers from causing you to feel like you're spiraling? Other triggers can be non verbals, certain looks that people get you show you, or ways they move their body. Okay, how are you going to deal with that? You can't tell people, well, don't make that face. Well, you can, but may not be very effective or certain verbal phrases. Pump the brakes is one of mine. If somebody says pump the brakes it reminds me of a very dysfunctional relationship and I'm just like, oh no, you know, but recognizing that's a trigger. Okay, well this person has no clue that that's what that means. And I need to separate the past and that horrible situation from the present and then increase positive triggers, triggers in your environment including sight, smells, sounds, places, etc that help you feel safe and empowered. In terms of pharmacology, Abilify has been helpful for producing reductions in anger and impulsivity. Zyprexa has shown small improvements in anger and anxiety. Depakote has shown improvements in anger and depression. Lamictal has shown benefits for impulsivity and anger. And Topamax was effective for impulsivity, anxiety and anger. So a lot of these obviously are targeting those explosive anger episodes and emotional dysregulation. They've also found that omega 3 fatty acids, because they're anti inflammatory, helped improve produce improvements in depressive symptoms. BPD and CPTSD have a strong physiological component, sleep circadian rhythms which regulate your hormones and your sleep timing and everything else. Nutrition and inflammation have to be considered. Additionally, symptoms of BPD and CPTSD often reflect the best way the person found to survive at the time. These behaviors unfortunately often led to more problems and abandonment in the person's life compounding their feelings of worthlessness, unsafeness and powerlessness. Persistent dysregulation of the autonomic nervous system, the fight or flight and the rest and digest prevented the person from effectively learn learning new skills because they were in fight or flight most of the time. Unresolved trauma including attachment trauma and negatively impacts self concept, awareness of self ability to feel safe and empowered and regulate emotions. Recovery requires attending to all of the problems in each piece of the person's life. Maybe not all at once but recognizing the holistic nature of the recovery process and helping them figure out where is it that you want to start because wherever we start is going to start producing improvements.