NAMI National Convention, San Francisco
July 2015
Borderline Personality Disorder:
Demystified and Destigmatized
NAMI National Convention
San Francisco, July 2015
Alan E. Fruzzetti, Ph.D.
University of Nevada &
National Education Alliance for BPD
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Education and Understanding
Can Demystify
What is Borderline Personality Disorder?
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DSM-5 Criteria for BPD (one axis)
A pervasive pattern of instability of inter-personal
relationships, self-image, and affects, and marked
impulsivity, beginning in early adulthood and
present in a variety of contexts, as indicated by five
(or more) of the following:
1. Frantic efforts to avoid real or imagined
abandonment
2. A pattern of unstable and intense interpersonal
relationships characterized by alternating
between extremes of idealization and
devaluation
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
BPD criteria, continued
3. Identity disturbance: markedly unstable selfimage or sense of self
4. Impulsivity in at least two areas that are
potentially self-damaging (e.g.,substance abuse,
binge eating, & reckless driving)
5. Recurrent suicidal behavior, gestures, or threats,
or self-mutilating behavior
6. Affective instability due to marked reactivity of
mood (e.g., intense episodic mood usually
lasting a few hours and only rarely more than a
few days)
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BPD criteria, continued
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty
controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical
fights)
9. Transient, stress-related paranoid ideation or
severe dissociative symptoms
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Multiple Sources of Stigma for BPD
1. Frequently inaccurate diagnosis
2. Treatments didn’t work, the field blamed
patients for treatment ineffectiveness
3. Most early models for BPD pejorative
4. Difficult to understand skillful behavior one
minute and unskillful the next
5. High negative emotional arousal can be
upsetting to others
6. Extreme behaviors are scary
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Diagnostic Confusion
•
•
•
•
•
•
•
•
•
Depression
Bipolar I or II
Eating disorders
PTSD
Anxiety disorders
Dissociative disorders
Substance use disorders
Conduct & ODD
Other personality disorders
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What do we know?
• Prevalence: 0.8% to 4.5% of population
– 10% of outpatients, 20% of inpatients
• Dangerousness is very high:
– 10% complete suicide
• Co-morbidity or co-occurring disorders
– Not specific, highly heterogeneous
• Utilization of services (& costs) very high
• Stress on families is very high
• Emotion dysregulation is a central process
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Borderline Personality Disorder:
A Disorder of Emotion
Dysregulation
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Low SelfEsteem
Problems in
Relationships
Impulsive
Behaviors
Attempts
to Avoid
or Numb
Anxiety
About
Emotion &
Dysregulation
Emotion
Dysregulation
Fears of
Abandonment
SelfJudgments
Problems
Thinking &
ProblemSolving
Transactional Model: Factors Influence
Each Other (Reciprocal)
Individual
Emotion
Dysregulation
Invalidating
Responses
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Transactional Model for Emotion
Dysregulation
Event

Heightened
Emotional Arousal
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Transactional Model for Emotion
Dysregulation
High
Vulnerability
to Emotion
Dysregulation
Event


Heightened
Emotional Arousal
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Different Kinds of Vulnerabilities
1. General vulnerability, or diathesis
– Factors are static, no reciprocal influence
– EX: hay fever, general hypersensitivity
2. Specific vulnerability
– Still static, but more specific
– EX: extreme heat or cold reactions
3. “Mis-matching” vulnerability
– Factors are not static, may change and influence
each other reciprocally
– Vulnerable to specific factor (e.g., social
environment) and perhaps not others
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What about genetics,
epigenetics, and neurobiology?
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Sources of Vulnerability to Dysregulation
1. Temperament: combination of all three:
a) Sensitivity
b) Reactivity
c) Slow return to baseline
2. Present biology
a) Sleep, diet, exercise, illness, pain, caffeine,
medicines and drugs, etc.
3. Current baseline
a) Influenced by recent events & reactions
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Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability

Event

Judgments

Heightened
Emotional Arousal
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Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Judgments
Heightened
Emotional Arousal
Dysregulated
Behaviors:
- Self-harm
- Suicide attempt
- Substance use
- Eating disorder
- Angry outbursts
- Withdrawal
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Judgments
Heightened
Emotional Arousal*
“Inaccurate” Expression
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Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Judgments
Heightened
Emotional Arousal*
“Inaccurate” Expression
Invalidating Responses
20
Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Judgments
Heightened
Emotional Arousal*
“Inaccurate” Expression
Vulnerabilities
Invalidating Responses
Judgments
Emotional
Arousal
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Judgments
Heightened
Emotional Arousal*

“Inaccurate” Expression
Invalidating Responses
22
Validating vs. Invalidating Responses
20
19 Stress
Negative Emotional Arousal
18
17
Validation
Invalidation
16
15
14
13
12
0
1
2
3
Time Periods
4
Shenk & Fruzzetti, 2011
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Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Judgments
Heightened
Emotional Arousal*

Dysregulate
d Behaviors
“Inaccurate” Expression
Invalidating Responses
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Transactional Model for Emotion
Dysregulation
High Emotion
Vulnerability
Event
Pervasive History
of Invalidating
Responses
Judgments
Heightened
Emotional Arousal*
❺
“Inaccurate” Expression
Invalidating Responses
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Transactional Model
High Emotion
Vulnerability
Event
Pervasive History
of Invalidating
Responses
Judgments
Heightened
Emotional Arousal*
“Inaccurate” Expression
Invalidating Responses
(cf. Fruzzetti, Shenk, & Hoffman (2005); Fruzzetti & Worrall (2010)
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Empathy & Compassion
Can Destigmatize
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Healthy Emotional Processing
• “Bump” into stimulus  “primary” emotional
response
• Notice and allow the primary emotion
• Approach it with interest & self-validation
• Others validate, offer instrumental support
• Problem-solve the situation, if needed
• Arousal goes down (natural course)
• Go on with life; “negative” counter- balanced by
“positive”
• “Bump” again, and again…
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What Goes Wrong
• Too many big negative bumps (too few +)
– Stress, too much conflict, too little closeness
• Avoid situations, ignore reactions (suppress, selfinvalidate)
• Judgmental about others, self, situation
• Jump to “secondary” emotions
– Not obviously connected to what happened
– Easier to misunderstand, invalidate
• Others invalidate, increase demands
• Get stuck in secondary emotion
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Emotion Dysregulation is PAINFUL
≠
High Arousal or Being Upset
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Understanding a Validating or
Invalidating Family Environment
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Invalidating Family Environment
• What it does not mean
– Necessarily mean, cruel, abusive
– Necessarily neglectful, uncaring, dysfunctional
– Necessarily pathological
• What it does mean
– Valid behaviors, especially wants, emotions, are
regularly missed (not attended to), disregarded,
misunderstood, criticized, pathologized, etc.
– Invalid behaviors, especially passive or dangerous
behaviors, are legitimized
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Parent Responses to
Adolescent Children (~BPD)
5
Parents of Clinic
Children
4.5
4
Parents of NonClinic Children
3.5
3
2.5
2
1.5
1
Validation*
Invalidation*
*p<.05
Copyright 2015 Alan E. Fruzzetti
Shenk & Fruzzetti, 2014
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NAMI National Convention, San Francisco
July 2015
But, there is hope!
Parent skills make an
enormous difference!
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Teen Rating of Parent Invalidation
8
7
6
5
4
Pre-FC
3
Post-FC
2
1
0
Invalidation
(C) Alan E. Fruzzetti 2015
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Teen Rating of Parent Validation
38
36
34
32
30
28
Pre-FC
26
Post-FC
24
22
20
Validation
(C) Alan E. Fruzzetti 2015
Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
It is easy to invalidate another
person’s private behaviors
(experiences, wants, emotions, etc.)
when they are not expressed
accurately, or when they are very
different from your expectations or
your own experiences.
37
How People Transact in Healthy
Relationships: Two-Steps
1.Accurate
Expression
2.Validating
Responses
38
Heightened emotional arousal
Inaccurate self-expression
Invalidating responses
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Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
July 2015
Lowered emotional arousal
Accurate self-expression
Validating responses
40
Individuals with severely
dysregulated emotion
need help.
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Family members need help.
42
Copyright 2015 Alan E. Fruzzetti
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NAMI National Convention, San Francisco
(C) Alan E. Fruzzetti 2015
July 2015
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Alan E. Fruzzetti, Ph.D.
Professor & Director,
Dialectical Behavior Therapy and
Research Program
Department of Psychology 296
University of Nevada
Reno, Nevada 89557
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Family Education and Skills - BPD
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Copyright 2015 Alan E. Fruzzetti
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