Book Impression: Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship

Although Loving Someone with Borderline Personality Disorder was published in 2011, I have only recently learned about its existence.   I am very grateful to the therapist who is trained and certified in DBT and who recommended the book to me.  Each time I review sections, I find more insights and will probably update this post as I do.


The author is Shari Y. Manning, PhD, who has been focusing on the treatment of people diagnosed with BPD since 1993.  The book is available in paperback [Guilford Press, 2011] and includes a foreword by Marsha M. Linehan, PhD, who created Dialectical Behavioral Therapy (DBT) and who revealed in the New York Times in June 2011 that she fought BPD, too.  I felt compelled to read the book with the goal of improving my understanding of this diagnosis as well as relating more effectively to a person with the diagnosis.

As with other posts, I've highlighted some of the things I gained from reading the book.  This isn't a true book review. 

Synopsis:  Shari Manning provides us - parents, family members, partners, and therapists - with the tools to help us stay grounded as well as coach our loved ones away from distressing thoughts and harmful behaviors towards living a more productive and serene life.
 
The book's underlying premise - one that I had not heard before and that provides a very different view of what's going on - is found on p.3 of the introduction, and that is,

 "....The truth as you'll learn in this book, is that your loved one is not a terrible person, as much as he or she may have a pattern of some pretty terrible behavior. It's not that your partner or family member wants to create chaos or make anyone miserable. It's that your loved one can't do the right thing, get along with others, or make the choices that seem so plainly correct to everyone else - because he or she doesn't know how. That may seem awfully hard to grasp. Doesn't everyone just have a feel for what it takes to keep a job or a friend, how much is too much to ask of those who care about us, and how to exercise a little self-control! Wasn't your loved one born with the same instincts and the same opportunities to learn how to navigate the world as the rest of us? As difficult as it is to believe, the answer is no. People with BPD were born with an invisible, innate difference that profoundly changed the landscape for them when they were growing up......." 
 
The author cites research that sounds very familiar to those of us who have believed all along that something "else" is going on for those of our loved ones who develop an eating disorder, the reason I began this blog.   Even if the BPD diagnosis is still unclear, the techniques Manning shares are useful and echo in many ways those provided by Dr. Xavier Amador who I have quoted many times from his book, I am Not Sick, I Don't Need Help and from his theory of communication - LEAP - that is summarized here.

 Manning explains the disorder, introduces the reader to dialectical behavioral therapy, provides extensive examples of how to respond - not react!! - to our loved ones through validation, describes the varying behaviors of people diagnosed with BPD, and (as does Amador's) offers important information on how to deal with crises as well as get help (both for us and for our loved one).  I will touch on these topics below.

As readers of my blog know, I don't like the DSM's terminology Borderline Personality Disorder.   Francis Mark Mondimore, MD, and Patrick Kelly, MD, helped me understand and articulate why not on pages 229-231 of their book, Borderline Personality Disorder:  New Reasons for Hope. The terminology can cause one to think the condition is permanent and this isn't necessarily true.  The terminology also can undermine the person's view of himself/herself.  Two strikes before treatment has even begun!!  For some time I've been calling BPD emotional dysregulation disorder because the person with the diagnosis cannot regulate their emotions and the behaviors that evolve from those emotions.  I also want to move away from this terminology because it conjures up what was thought to be an uncurable condition to the point that many therapists won't accept people with this diagnosis as patients.   Better yet, there are more therapists classically trained in this technique (in my opinion critical if someone with this disorder is to be treated well).   I am grateful that this situation has changed.

Recently, I read and provided my impression of Borderline Personality Disorder:  New Reasons for Hope by Francis Mark Mondimore, MD, and Patrick Kelly, MD.  I want to repeat their distillation (as they term it) (p. 251) of this complicated disorder because this paragraph summarizes background that Manning also provides in great detail:

"Borderline personality disorder develops when a child born with extremes of temperament and a biologically rooted difficulty managing emotions encounters a mismatched childhood environment. This mismatch may be quite subtle or quite pathological but is experienced by the child as inconsistent and unpredictable, leading her to develop a damaged sense of self and the expectation that others will continue to be inconsistent, unpredictable, and ultimately unreliable and abandoning. This in turn causes profound emptiness and hopelessness to dominate her emotional life. To cope with her emotional extremes, and her desperate and painful unhappiness, she develops self-destructive coping behaviors like addictions, eating disorders, and self-mutilation. Frequently, these individuals also suffer from biologically based mental illnesses that exacerbate all their other problems and prevent behavioral and psychological treatments from helping them.
....Borderline personality disorder results from an interaction of genetic and other biological factors, inborn temperament, and childhood experiences and is usually complicated by the development of abnormal behaviors and psychiatric illnesses. All these factors require therapeutic attention, often by different professionals using different approaches."

To help other therapists effectively understand and address what Mondimore and Kelly describe above, Dr. Linehan created a five-part  reclassification/subdivision of dysregulation:

• emotional dysregulation
• interpersonal chaos
• behavioral dysregulation
• loss of sense of self
• cognitive dysregulation

 Most of these are self-explanatory and Manning provides excellent and clear examples; however, the one that I struggled to understand was the loss of sense of self.  Manning defines this by saying (p. 22-23)

"....People with BPD often don't have a sense of what they like, what their values are, or who they are....In the moment, they are unable to identify what their experience is -- what they feel in their bodies, what their thoughts and emotions are.  They often judge themselves very harshly and struggle to develop realistic goals for the future.....Not knowing who you are is a byproduct of the extreme emotionality of people with BPD.... They feel lost and empty."

Very simple - perhaps too simple because the issue is much more complicated - examples of how this sense of self can be lost [when compounded] are hearing, as a child, a person tell them that of course they aren't scared (when they are scared to death in that situation); that brussel sprouts taste good (I sure didn't think so as a kid); to quit crying (as though emotions can be turned on and off on a dime); to stop telling lies (the information is not a lie but because the behaviors they are reporting are unbelievable - such as abuse from another family member - the family member squelches the child's need for support), etc., etc.   Manning provides a much more comprehensive discussion of the development of this aspect of the disorder. 

It's important to remember here that the term used by Mondimore and Kelly - mismatched environment - is a very important piece of the puzzle.  Who really knows how this happens in some and not others or why?  And, as time goes on, we may learn that the emphasis falls more distinctly on inherited traits and less on environment.  The fact remains, though, that studied interaction is very important.   

I've discussed in another post about communication (with links to previous posts) why family therapy really helps parents in particular understand that each of their children is unique.  These are my remarks and not those specifically found in Manning's book but the reader certainly finds similar examples. If, for example, your family isn't as demonstratively affectionate (or less so) as your individual child may need it to be because of his/her own temperament, those who take the time to connect with their child(ren) may find unexpected rewards.   Of if your family's culture is to keep a stiff upper lip in times of terrible sadness such as when a family member or even a beloved pet dies, yet the son's or daughter's sensitivity to such events is profound, how do they reconcile - or can they - their feelings with their family's seeming insensitivity.  One might ask, what's wrong with me or think, I do not belong in this family.

The bottom line, once this disorder takes hold,  is that people struggle with varying states of this dysregulation every single day.

Their solutions to deal with the fall-out of this disorder range from cutting to impulse buying or even shoplifting to alcohol and/or drug abuse to running away to shattering a beloved relationship to suicide attempts.  These behaviors can help the person release the pain they are feeling but the release, even though it may feel "good" in the moment, provides negative reinforcement, meaning that it is rewarding in a negative way.

What we all want to happen instead is for the person with this diagnosis to learn to substitute other positive behavior so they can get on with a happy, productive life.  

Marsha Linehan came up with the "how". She developed dialectical behavioral therapy (DBT) to (p. 27)

"....provide an alternative in the form of specific skills that help them maintain good relationships, tolerate distress and survive crises, and learn to use their emotions as the important resource they were designed to be [emphasis mine.]"

Emotions are part of what makes us human.  Manning distinguishes three emotional tendencies of those with emotional dysregulation:

• extreme emotional sensitivity
• emotional reactivity (no pausing; just acting) 
• slow return to baseline - perseveration

Imagine the physical and psychological energy this must consume! 

So, you might ask, where do I come in?  What can I do without trying to take on the role of a therapist for which I am not qualified?  How can I avoid fragilizing my loved one [Manning's term and a descriptive word!].   As family members, we want to encourage and praise our loved one's growing competence as they employ the principles of DBT.   Believe and remember that this competence can develop.  And we also need to understand, according to Manning, where our loved one is in the process so we can provide appropriate support as needed.  She provides tools to help us accomplish this, too.

Your task is to (p. 48)

 "Understand the tasks of emotional regulation that your loved one [and you!] needs to be able to perform."

Think about the above statement for a moment.  How helpful can you be if you, too, are emotionally reacting to whatever it is your loved one has said or done.

How do you help your loved one [and you] (p. 48):

• reorient attention
• Up-regulate or down-regulate our physiological arousal
• Stop ourselves from doing whatever it is our emotion and mood tell us to do
• Have a life with goals in it that are independent of emotion

 To cope with the ups and downs of living, everyone needs to put these four points into action.   Throwing temper tantrums as a two-year-old or losing one's temper as an adult are not effective ways (well, maybe they can be but at what cost in the long run if the person perpetuates this behavior) to get what one wants. 

As the person who wants to maintain a relationship with your loved one, you can take the steps provided in this book that are the basis for an extensive discussion, especially about validation,  and Manning provides exercises and examples to help you do this.  To elaborate on the concept of validation, Manning incorporates Linehan's six levels of validation and I've provided a link to an article about the levels that also appeared in Psychology Today.  As I've said, I encountered some of these in Amador's book.  I also learned aspects of this in a mediation course.  Dispute resolution includes some of this as well.

Here are the suggested steps for you to take to help your loved one:

(p. 51)

1. Assess: ask [objectively] what has happened.
2. Listen actively; don't contradict, judge, or say your loved one is overreacting.
3. Validate: find something in what happened that makes sense and is understandable, that you can related to; say what that is.
4. Ask if you can help, not to solve the problem, but to get through the moment.
5. If your loved ones says no, give him or her space and remember the emotions of emotionally vulnerable people last longer.

 Having gotten through the first three of these steps [the first three because I had not been coached in steps 4 and 5], I had asked (so as to put the responsibility onto the person needing to solve the problem),  "what are you going to do about it?"

Thanks to Manning, I've come to understand - going back to the five areas of dysregulation - that those with BPD may not know what to do about it.  This can be shocking.  Accept that just maybe your loved one needs a complete retraining or even an introduction to problem-solving skills in a variety of settings  that are applied to many aspects of life to make a successful go of it.  If you wonder about the veracity of this possibility, you can arrange for neuropsychological testing that will identify deficits that need attention.

So, what are effective problem-solving steps?  Manning reviews seven suggested steps and also enhances the discussion on Active-Passivity (getting someone else to solve the problem).  (p. 138):

1. Define the problem: What are you trying to solve here?  What are your goals?
2. Analyze the problem: What are the facts about the problem and/or the problem situation?
3. Generate solutions: Purely brainstorm.  Don't exclude any ideas because they are ridiculous or unrealistic.
4. Choose a solution: Narrow down the solutions to the one you think will best get you to your goal, will solve the problem, and is the most realistic to implement.  [Even this can be quite a bit of work for your loved one.]
5. Troubleshoot the solution: What could get in the way of achieving the goal?  How will you overcome these obstacles?
6. Put the solution into action:  Try the solution.
7. Evaluate the solution:  Did it work?  If not, choose another solution from the "generate solutions" list and implement it.

In addition to problem solving and Active-Passivity, the second section of the book addresses other faces -- the experiences -- of BPD; for example, self-invalidation, conflicting feelings, shame,  and apparent confidence.

There's a wrinkle that Manning defines as she examines the concept of apparent confidence.  The easiest and simplest way to describe this is to think of a dog learning to sit.  In your home or with you in your backyard, your pet doesn't have many distractions and after some practice (with treats), sits when asked.  So, off you go to the pet store with your companion on a leash only to find that your pet doesn't listen to your sit command -- doesn't seem to listen at all --  when other dogs and people are present in what to your pet is a new -- and often noisy -- environment.

The same disruption can occur for those with BPD.  In a one-on-one conversation or exercises, what comes next having taken these steps appears to be simple and easy for the person to tackle.  But add many more people, some of whom might be viewed as being judgmental, noise, the stress of believing that the "right" decision needs to be arrived at, and so forth and suddenly everything seems impossible. 

Manning writes, (p. 150)

People with BPD seem to have more trouble generalizing behaviors than others largely because, as with so many of their other problems, emotions interfere with learning....If your loved one seems unable to do something in one context that she can do in another, it's not that she isn't trying hard enough, it's that the behaviors literally are not in her repertoire of behaviors for that specific environment.

As you might imagine, shame figures hugely in all of this, too.  Going along day after day under these circumstances is incredibly difficult.

Once you are aware of and have accepted all this information, the next step is to take action or depending on your relationship or energy level,  to find a trained/certified life skills coach.

Absorbing and putting into practice the information that Manning includes in her book takes time, hard work, practice and thoughtful communication on the reader's part.  I'm participating in some training sessions, too.

Manning provides the reader with lists, examples and exercises to help you respond effectively.  In fact, she suggests that you xerox pages and have them handy.  One table is on p. 72 and lists the Five Steps to Responding Effectively to Borderline Behavior:

1. Regulate your own emotion.
2. Validate [yourself] (do this at every step).
3. Ask/assess.
4. Brainstorm/troubleshoot.
5. Get information on your role (if any) and what you can plan on hearing about the outcome.

Taking care of oneself is important, too.  Manning provides suggestions in another short but effective table about identifying and communicating limits.  Boundaries often is another term people use to describe limits.  All these points need practice.

Hopefully, your loved one is also working at least one hour or even two hours a week with a competent certified DBT therapist.   Expect this therapy to last at least six months, possibly a year, and to eventually include group work with others who are motivated to change.   What I mean by competent is someone who has taken the training and applies the training completely rather than inserting aspects of it into another form of therapy and who recertifies often, possibly once a year.  Your role is to support the work that your loved one is doing as he/she applies his/her learning to the real world.  Again, your role is NOT to be the therapist.

If your loved one also has an eating disorder, find a therapist who is willing to work with the DBT therapist to enhance the value of ongoing treatment.  Addition here:  remember, that some with BPD will deliberately create the idea of good therapist/bad therapist and interfere with his/her own recovery as a result.  This manipulation often is subconscious so if another therapist is added to the equation, s/he and the BPD therapist MUST work together and inform their patient that they are working together.  In addition, ask the DBT therapist if s/he seeks regular guidance from another DBT therapist in order to stay grounded and not drawn into the whirlwind that someone with BPD can create.

Part III of the book focuses on the practicalities of dealing with crises and getting help. Here Manning thoughtfully helps the reader reflect on his/her feelings, experiences and actions -- fear, guilt, despair -- leading up to this point.  She provides an in-depth section on your loved one's potential for self-harm as well as suicide and in addition examines the pros and cons of inpatient versus outpatient treatment.  Finally she provides the names of other resources including organizations developed to provide help to families and those diagnosed with BPD.

In summary and to close, here's a quote from the "Praise for" section of the book by the parents of an adult child with BPD.  Jim and Diane Hall who are also family educators for the National Alliance on Mental Illness (NAMI) and the National Education Alliance for Borderline Personality Disorder (NEA-BPD) state:

The title says it all!  Dr. Manning explains what she has learned about the true nature of BPD from the experts themselves -- those who have the disorder.  She shows family and friends how our instinctive responses to the crises associated with BPD are frequently ineffective or even harmful, and illuminates what we can do differently, providing practical, incisive, step-by-step guidance.  The book helps readers understand their complicated relationship with a person with severe emotion dysregulation.  It provides valuable tools for dealing with self-harm, suicidality, and hospitalization decisions.  Of crucial importance, Dr. Manning clearly affirms that BPD -- and the pain experienced by those who suffer -- is real.  We highly recommend this book.

The Buddha and the Borderline: A Memoir

Normally I would write a substantive essay before posting here; however, I want to highlight Kiera Van Gelder's book, The Buddha and the Borderline - A Memoir:  my recovery from borderline personality disorder through dialectical behavior therapy, buddhism, and online dating (New Harbinger Publications, Inc., Oakland, CA, 2010) now and write more about the book later after I figure out how I'm going to present it in terms of being a family member.

After perusing Kiera Van Gelder's work but setting it aside late last Spring to read and review Borderline Personality Disorder: New Reasons for Hope by Francis Mark Mondimore, M.D. and Patrick Kelly, M.D., earlier this week I picked it up again and read it word for word  because I wanted to get a first-hand up-to-date look at BPD from the perspective of a person who takes the reader on her journey with BPD (meaning she introduces the reader to BPD, to the effective (for her and why) therapies used, and how her life has played out - at least until 2010 when the book was published).

I learned so much from this book! and recognized my loved one's behaviors more times than I can convey here.  I highly recommend this book, too, as do many well-recognized to the field of BPD people among them (from the pages just inside the cover) Robert O. Friedel, MD, author of Borderline Personality Disorder Demystified; Perry Hoffman, Ph.D, president (2010) of the National Education Alliance for Borderline Personality Disorder; Blaise Aguirre, MD, medical director of the Adolescent Dialectical Behavior Therapy Residential Program at McLean Hospital in Belmont, MA.; Tami Green, internationally recognized speaker, life coach and advocate for those in recovery from mental illness, Roy Krawitz, author of Borderline Personality Disorder The Facts; Randi Kreger, author of Stop Walking on Eggshells and The Essential Family Guide to Borderline Personality Disorder -- this latter book by Randi Kreger helped me a lot!) and several more.

As Robert O. Friedel, MD, notes - "A must-read for people with this disorder, their families and loved ones, and mental health professionals."

I hope to illustrate why and how Kiera spoke to me through her writing.

More later.

Traits...... introversion and extroversion and how this information meshes with family-based therapy

Yesterday one of my favorite bloggers connected her readers with another TED talk session.  After watching a remarkable presentation by Elyn Saks (Yale Law School Graduate; Professor, USC College of Law; and MacArthur Fellow among other accomplishments) and about her life's journey with schizophrenia, I decided to browse around and see what else I could find before dinnertime.

I noticed that Susan Cain had been a presenter (more than 2 million views at this point) - The Power of Introverts - and I remembered that I had not yet finished reading her book, Quiet - The Power of Introverts in a World that Can't Stop Talking (Crown Publishers, 2012).  In fact, I'd barely started a few weeks ago.  After watching her talk, I vowed I'd pick up her book again.  So, this afternoon, I did.

I'm not finished yet, actually.  But I am quite grateful to Charlotte for leading me to the TED site and for a few minutes of my own yesterday afternoon, because I've learned more not only about myself, but have come to understand a lot more about introverts, developmental psychology, and perhaps even about my family member.

I don't think I would have picked up the book this afternoon if I hadn't also attended my usual Saturday morning meeting and realized how far I'd come in the program (and how much more work I needed to do).  I know myself far better than I did eight years ago.  I've also come to understand at a much deeper level how different my family member and I are.

She's an extrovert.  In fact, she confirmed this yesterday when we talked.  I'm an introvert.  And, Susan Cain has helped me to understand better what these two words mean developmentally and how we differ.

I've also just realized how this knowledge fits so aptly into the concepts of family therapy and communication, topics that I've written about on my blog (links provided earlier in this sentence) - e.g. "All in the Family and Elsewhere."  Susan Cain provides terrific examples of how both children and adults respond to experiences, depending on this part of who they are.   For example, I rarely have either the television or the radio on.  Sometimes I'll listen to music while doing something.  My husband, also an introvert, often remarks about the peacefulness of our home and how much he looks forward to coming home after a long, busy, interactive day.  When my family member comes to visit, however, her first comment is something along the lines of "it's too quiet here!"

She likes to be with people a lot; I need time-outs and relish days at home after spending other days with groups of people in meetings.  One might ask, how does this translate into what you daughter or son needs as part of their recovery?  their experiences at home following a stint in a residential treatment center?  These are important questions for the family to address before their loved one returns home.

Backtracking a bit, I wrote a piece on States and Traits after hearing Dr. Kate Tchanturia's talk on Cognitive Remediation Therapy at the NEDA Conference in New York City a couple of years ago.  I hadn't thought much about traits lately until I listened to Susan Cain's talk.  I'm thinking a lot more about traits now that I've read her book and about the research of scientists like Dr. Jerome Kagan.

Dr. Kagan's studies have revealed that one can pretty much forecast whether one will become an introvert or an extrovert from infancy and that fMRI's and the work of one of his colleagues, Dr. Carl Schwartz, have shown that the processing of the adult brain really hasn't changed that much  - in other words the traits are fairly intact in spite of a lot of other things we call environment.

I'm still reading (Chapter 6 and sensitivity as well as empathy) and will probably come back here with more to say.  In the meantime, I've found reading Cain's book to be very helpful as I unravel the puzzle of my family member's journey.

Book impression: Borderline Personality Disorder - New Reasons for Hope

As readers here know, in 2007 our family finally was provided with information that explained years of illness, sadness, and failed treatment.  Two psychiatrists at two different institutions diagnosed Borderline Personality Disorder (BPD) and gradually, since that diagnosis, so much has fallen into place.
  

Like many parents, I began to read and digest as much as I could about BPD and you'll find several books on this topic in the list of books I've provided here on my blog.  I've also written several posts on the topic.   Early on I came up against the same themes as many parents have when the myths about causes of autism and schizophrenia and now eating disorders were discussed.  As time has gone on, the term "biologically based" has been added to the framework.  Environment, I believe, is an important factor, too, if for no other reason than to support the concept of family education to assist the person with a diagnosis of BPD to get on the road to recovery.  I've written quite a bit about this concept as it relates to eating disorders and BPD on my blog, particularly under the topic of communication.

Randi Kreger's book, The Essential Family Guide to Borderline Personality Disorder:  New Tools and Techniques to Stop Walking on Eggshells (Hazeldon Press, 2008) was the first book to help me understand the ramifications of this diagnosis as well as what positive things I could do as a parent to help.

About a month ago, I came across a reference to a book published just last year (2011) by the Johns Hopkins University Press as part of the Johns Hopkins Press Health Book Series.  It's available in paperback, which is a wonderful decision on their part because the book is affordable for parents keen on learning more.  For that matter, it's also a valuable book for the person diagnosed with BPD, as an entire chapter is directed towards that person - "If You've Been Diagnosed" (pp. 215-228).

The book is Borderline Personality Disorder - New Reasons for Hope by Francis Mark Mondimore, M.D. and Patrick Kelly, M.D.

This extensive and grounded work incorporates the latest research about and treatment of this diagnosis (dx). The book is directed not only to the therapist but also to the person diagnosed with BPD as well as to those who are family members, friends and even employers and co-workers. 

The book is divided into four sections: Understanding the Problem including clinical discussion as well as "personality"; Causes - encompassing an enormous array of information from genetics to environment; Treatment, particularly with emphasis on the difficulties when a person has co-morbidities and the sometimes ineffectiveness of medication (some believe that medications are inappropriately administered and in fact, some like the benzodiazepines compound the problems inherent in addiction) under these circumstances while looking harder at the necessary therapeutic relationships and need for truly understanding this disorder; and finally How to Cope, How to Help - written for the person with the dx and for parents, partners, friends and co-workers. 

The chapter for the person with the dx is especially frank but also supportive with solutions, an approach that I liked very much, particularly the attitude that the person needs to engage, take responsibility, accept and commit.  The section titled, "Looking for Happiness in All the Wrong Places" offers (p. 226) "...a psychiatrist or psychotherapist cannot reveal to you the meaning of life, or tellyou why your life is worth living.....Treatment for borderline personality disorder can help you learn how to cope with setbacks and disappointments better, negotiate relationships more successfully, rein in impulsiveness, make peace with a traumatic past and put it behind you, and many other important skills and lessons.....But your happiness is your responsibility, just as it is for everyone else."

The authors emphasize that the tide is turning about the dx for the dx is now being called "the good prognosis diagnosis."  They promote the idea that the nomenclature is incorrect. Not only that, but they believe the nomenclature fosters the person with the dx to think something is inherently _wrong_ with them since the word "personality" conveys such a strong definition of self.

The authors include a section titled, "International and Cross-Cultural Considerations" that trounces what some have proposed as a dx only found in the United States.  Clearly there is more at work than just environment. 

The book, to me as a layperson, is very dense in the initial sections (meaning one needs to "chew" on what one is reading)  but well-written and includes a terrific definition with examples of "splitting", something I had a hard time understanding from previous books that I've read. 

The epilogue as well as the text emphasizes, given the complexity of this diagnosis -- meaning the many aspects of emotions and behaviors, that a team of professionals skilled in differing areas must be assembled to treat the person.  It's unlikely that one professional can because, as I've been told by several people now, one who treats this illness must receive ongoing support and counseling themselves to avoid being drawn into the whirlwind created. 

The authors "distill" the disorder by writing (p. 251),

"Borderline personality disorder develops when a child born with extremes of temperament and a biologically rooted difficulty managing emotions encounters a mismatched childhood environment. This mismatch may be quite subtle or quite pathological but is experienced by the child as inconsistent and unpredictable, leading her to develop a damaged sense of self and the expectation that others will continue to be inconsistent, unpredictable, and ultimately unreliable and abandoning. This in turn causes profound emptiness and hopelessness to dominate her emotional life. To cope with her emotional extremes, and her desperate and painful unhappiness, she develops self-destructive coping behaviors like addictions, eating disorders, and self-mutilation. Frequently, these individuals also suffer from biologically based mental illnesses that exacerbate all their other problems and prevent behavioral and psychological treatments from helping them.
....Borderline personality disorder results from an interaction of genetic and other biological factors, inborn temperament, and childhood experiences and is usually complicated by the development of abnormal behaviors and psychiatric illnesses. All these factors require therapeutic attention, often by different professionals using different approaches."
 

As I wrote above, I am encouraged by this new approach to this illness and enlightened by how important it is to bring therapists up to date on the treatment of this disorder (sounds familiar, I am sure, to those promoting a change in the way eating disorders are treated).  Valuable techniques are included for therapists.

I also was pleased to just come across (May 2013) this book review by the esteemed researcher in the field of BPD, Joel Paris, M.D., Professor of Psychiatry at McGill University in Montreal.  The review appears in Psychiatric Times, Volume 29 #4.

Finally, thanks to the Epilogue, I learned that this month (May) was established by the United States House of Representatives - unanimously - in 2008 as "Borderline Personality Disorder Awareness Month."  How fitting that I discovered and read this book this month.  How important it is to promote what the authors have assembled for our increased ability, as parents, to advocate for our loved one(s).

Aimee Liu - Restoring Our Bodies, Reclaiming Our Lives: Guidance and Reflections on Recovery from Eating Disorders

One of my favorite books is edited by Aimee Liu and the title is Restoring our bodies, reclaiming our lives: Guidance and Reflections on Recovery from Eating Disorders.

Here is a link to more information about the book.

The foreword is written by Judith Banker, past president of the Academy for Eating Disorders (AED) - the underwriter of the wonderful new booklet for doctors and laypeople alike found here: 

I'm going to quote from the Foreword.

"Not one patient I've ever treated for an eating disorder believed at the outset of treatment that she or he was capable of recovering. Not a single one could imagine being free of the relentless obsessing, the perpetual weight-loss algorithms, the self-loathing, shame or despair that accompany these excruciatingly complex and devastating illnesses."

"....In Restoring Our Bodies, Reclaiming Our Lives Aimee again joins the wisdom of personal experience and the knowledge of research and clinical experts to provide a keenly illuminating, in-depth journey in the recovery process....[This book] forges new ground by walking the reader through the entire recovery process, from the initial turning points at the start of the odyssey to the 'wise minds' that reflect on the experience of reclaiming one's life after an eating disorder." 

The review on Amazon to which I provided the link above states, "Author Aimee Liu has woven together dozens of first-person accounts of recovery to create a break-through roadmap for healing from an eating disorder. Restoring Our Bodies, Reclaiming Our Lives answers key questions including: How does healing begin? What does it feel like? What supports and accelerates it? Will I ever be free of worry about a relapse?

Throughout the book are informative sidebars written by leading professionals in the field, addressing essential topics such as finding the right therapist, the use of medications, exploring complementary treatments, and how family members can help"

I bring this here because already in the commentary response to Dr. Ravin's post titled "Got Hope?" and in blogs like those of Extra Long Tail, Giant Fossilized Armadillo, and Ed-Bites (all shown as blogs I follow, found on the right hand side of this site), people are sharing their own experiences and paths to recovery - what works and what doesn't. An admirable thing, indeed.

For example, Extra Long Tail responds to Dr. Ravin's post (and touches on the points noted in the Foreword to Aimee Liu's book):


I had a relapsing course of restricting anorexia nervosa (AN) for 28 years before receiving any help that was of use. During those 28 years I remained significantly underweight (sometimes dangerously so – i.e. BMI < 13) and as time wore on, my physical state became increasingly compromised. I was 'treated' for some of the physical complications of long-term semi-starvation, yet a number of medical professionals deemed me 'chronic', or stated that I would only get better "when I decided to". 

There was no way that I could get better on my own…. It was not that I didn't know what to eat to gain weight; it was that I didn't know HOW to eat more food without feeling panic-stricken. That level of panic was so great at times that I felt suicidal. And it was not 'about' body image. AN in anxiolytic. 

The key to recovery from long-term AN is de-sensitisation to the panic associated with eating and weight restoration. I have had therapy too, which has been enormously helpful, but therapy without weight gain is pointless.

[***And here is an article about the relationship of anxiety to eating disorders, especially anorexia, published late in 2010 in the European Eating Disorders Review.]

[***And here is a link to an article  by Dr. Janet Treasure and colleagues titled "Eating in Eating Disorders"  with the goal of the importance of eating/supported eating back "into the centre of the eating disorder discourse" that includes a wonderful compilation of knowledge to date.]

We can all learn from them.  I know I can, too, because although I am in recovery from bulimia, my path and my make-up have been/are unique in many ways.  Some things worked for me that might not work for others but other things may.  The more we can read what has been written and presented by those in recovery, the broader an understanding we can gain and the more knowledge there is out there to help therapists, psychiatrists, nutritionists, parents, friends and the person fighting the eating disorder.  

There needs to be more of this and more reaching out to those who fear they are forever entrenched so they, too, can get on the path.

As I've said before, the path is wide. There is room to fall down and get up again. The key is to get up again.

New Book: A Collaborative Approach to Eating Disorders

Edited by June Alexander and Dr. Janet Treasure, A Collaborative Approach to Eating Disorders (Routledge, August 31, 2011) will be an important addition to the growing library on family based treatment.

Taking directly from the information provided by the publisher, topics include:

• current research including genetic factors, socio-cultural influences and early intervention
• clinical applications such as family based dialectical and cognitive behavioural treatments
• treatment developments for both adolescents and adults with a range of eating disorders
• building collaborative alliances at all levels for treatment and ongoing recovery. 

June Alexander recently released a book chronicling her own experience - A Girl Called Tim.   Dr. Janet Treasure is a pivotal figure in the study of eating disorders and behavior.  Her work in conjunction with the Maudsley Hospital in the UK has opened the door to a new approach to the treatment of eating disorders.  You can learn more about her work here during an interview on the BBC.  She presented at the NEDA conference in New York City last Fall.

I look forward to reading the book!

Walking in Lock Step - The Parent Trap

I'm reading Bitter Pills: Inside the Hazardous World of Legal Drugs by Stephen Fried.  Fried turned to this subject because his wife, Diane, was prescribed and took one pill of a new [at that time] quinolone called Floxin.  I repeat, one pill.  Quinolones can get past the blood brain barrier, and it did.  Diane's response included the development of bipolar disorder.  Her brain was biologically primed through genetics.  Others who took this drug experienced terrible side effects, as well.  Those who were affected created the expression that they had been "floxed."

Fried went on to investigate just how the FDA worked (and still does) to screen drugs coming to market.  He also delves into the workings of the drug industry and its relationship with the medical professionals who prescribe the drugs as well as the process by which the drug makers do an end run to potential patients and therefore users (something that has continued at much higher levels these days, especially with medications for brain disorders) using, for example, advertisements in newspapers and magazines.

I bring this up because Stephen walked the walk (lived the walk) that so many of us do who care for loved ones with an eating disorder.  I know this following passage will sound familiar and perhaps it will help loved ones understand the process in which they've become entwined.  More importantly, I think this passage illustrates why it's critically important for a family to work with a therapist not only to learn how to deal with the illness but also to learn how to get out of the way of their loved one's efforts to get and stay on the path to recovery as fully functioning as possible.

From page 106:

"I realized it was very easy for me to shift into "emergency mode," but terribly difficult to shift out.  How did you treat a chronic illness if not by declaring a permanent emergency?  I didn't know.  In my family [many of his family members were struggling with illnesses or death of a family member at this time] we just left the siren running and adjusted to the noise.  We're basically loud people: we never really liked the quiet much anyway....

"It seemed that Diane and I were experiencing what my friend Barry Jacobs - a clinical psychologist specializing in medical family therapy with people dealing with traumatic or chronic illnesses - has called the 'locked embrace.'  He describes it as 'a rigid pattern of interaction in which the patient is stuck in an underfunctioning role as other family members overfunction in an effort to protect [her].  It allows the family as a whole to avoid difficult feelings such as anger or overwhelming sadness, but can prevent the patient from recovering to the maximum extent possible.'  I understood that Barry was describing a sort of loving dysfunction, born more of fear than hope, that should be treated with psychotherapy...."

This is a shocking, not easy to read book that is well written and chock full of information.  I am hoping to find a more recent book that will continue this conversation.  The book includes a  chapter titled "Psychopharm" because of the brain disorder his wife developed and what he learned about this aspect of pharmacology while working with folks from NAMI, for example.

As I said in my last post, I am finding myself inadvertently drawn into literature I never dreamed I'd be reading six years ago.  I've always been interested in the medical field and now more so in the workings of the brain and medications.   Fascinating.

Addictions

No, I'm not going to write about ED, although I believe that once those behaviors identified as eating disorders, whatever they are, become entrenched, the person is addicted to them.  Which is why an eating disorder truly is, for a host of reasons, a medical emergency needing immediate attention and treatment.

Instead, I continue to be intrigued by the path I am taking in my reading.  Having read the Immortal Life of Henrietta Lacks by Rebecca Skloot and then a book I posted about here earlier, The Emperor of All Maladies, by Siddhartha Mukhurjee,  I've just become acquainted with the writing of  Dr. Abraham Verghese, who is the author of the acclaimed book, Cutting for Stone.  Dr. Verghese took time out from his life as a professor of medicine to study and then be graduated from the Iowa Writers' Workshop.  We readers are all very lucky, I think.  Having finished Cutting for Stone this week, I looked him up and learned that he has written two other books -- My Own Country and The Tennis Partner.  So I ordered the books and they arrived today.

Not one to allow a book to pass unexamined even if I'm still reading another one, I picked up The Tennis Partner and read the prologue.  And, there it was again:  another viewpoint from another person in medicine who believes that alcoholism and drug addictions truly are diseases that are biologically based disorders of the forebrain.  In addition, the medical doctor speaking to David Smith, an intern addicted to cocaine and the subject of the book, notes on page 5 of the prologue that, "....you have a disease, like diabetes.  And just like a diabetic taking insulin and monitoring blood sugars, every day for the rest of your life, you will need to monitor and treat your disease."  Add eating disorders to this list.

[And here's an article from the New York Times on the subject of addictions, looking at what goes on in the brain.  This article is particularly important, I think, because the author also notes the prevalence of these behaviors in connection with other brain disorders.]

If only this philosophy would make it into federal and state laws and on into the regulations governing insurance companies so that all brain disorders would be treated equitably, without regard to cost and with knowledge of the time it will take to help the person develop new behaviors and the means to avoid old behaviors.  For many, it'll take several attempts before the demon is brought under control and then, as noted, the person will indeed "....need to monitor and treat your disease"...."every day for the rest of your life."

Now back to the book I'm currently reading, which is Bitter Pills - Inside the Hazardous World of Legal Drugs by Stephen Fried.

"Addictive Personality? You Might be a Leader"

I love titles like this one which enticed me to read a New York Times opinion piece this past Sunday morning (July 24, 2011, "Sunday Review", p. 4) at breakfast.  Written by David J. Linden, a professor of neuroscience at Johns Hopkins University School of Medicine as well as author of a book with the startling title, The Compass of Pleasure: How Our Brains Make Fatty Foods, Orgasm, Exercise, Marijuana, Generosity, Vodka, Learning and Gambling Feel So Good.

[I have now (7/28) received the book and the chapter "Feed Me" is one of the best easily understood descriptions of why we get hungry or the reverse that I have read.  As usual, I flipped through the book and looked at the index when I opened the package.] 

One of the sentences highlighted in the New York Times article is, "Traits that make us crave pleasure also contribute to creativity and risk-taking."

Traits and States was a topic at the National Eating Disorder Association's meeting last Fall.   I wrote a piece reflecting on this topic.   Traits are those pieces of us that can be maligned and at the same time raved about, depending on the behavior that comes along with them.  While working at the University of Arizona, I participated in a fascinating job evaluation in which I was asked to look at my traits and qualities and write about the positives and negatives and how these affected my performance.  I learned so much about myself.  I also learned to be grateful for traits that I used to believe were detrimental.  I came to value my behavior better, too.  The affirmations course I took about this time underscored my ability to get ahead.

David Linden takes this positive outlook when he notes that ...."the psychological profile of a compelling leader - think of tech pioneers like Jeff Bezos, Larry Ellison, and Steven P. Jobs - is also that of the compulsive risk-taker, someone with a high degree of novelty-seeking behavior.  In short , what we seek in leaders is often the same kind of personality type that is found in addicts, whether they are dependent on gambling, alcohol, sex or drugs."

Wow!  novel approach here.  Then he delves into the functions of the brain related to pleasure and reward.  Timely, for sure.

He also looks at the medial forebrain pleasure circuit and the role of dopamine in the seeking of rewards.  What could be classified, after all, as a reward?  Well, for starters food.  If one is hungry, one eats.  One gets pleasure from taste and the responses of the body to food.  As a runner-turned-hiker, I can tell you that water is right up there when I'm out in the desert and getting low in the fluids I'm carrying.  He also touches on the point that Dr. Ryan in her lecture noted (in an earlier post here) that one can get pleasure even thinking about things like gambling. 

Dr. Linden, however, proposes that those who have an addictive personality crave things and at the same time actually like them less.  Sounds counter-intuitive.  He also provides a clear (current) explanation about why some become addicts and others do not.  Genes "....account", he says, "for 40 to 60 percent of the variation in the risk for addiction" and that there is "...no one 'addiction gene'."  Their dopamine response is attenuated.  In other words they need higher and then higher levels of stimulation to obtain the same level of pleasure that others gain in moderation. 

Linden goes on to list a few famous addicts; it'd be interesting to learn how many others there are with an "addictive personality" who channel their risk-taking solely into "legal" pursuits.  Must be quite a few, actually.  He counsels search committees to "...look for someone with an attenuated dopamine function:  someone who is never satisfied with the status quo, someone who wants the feeling of success more than others - but likes it less."

Having read this piece, I will read his book.  Surely there are some who get quite a good "high" out of this kind of achievement and who have learned to moderate their behavior so they can continue feeling good about what they are doing..... Or who love the high, continue to go after it, and like what they are doing? ....  or not?

"Cells that Fire Together, Wire Together" - book review of Brain Over Binge

The title of this post, Cells that Fire Together, Wire Together, is the basis (to me) of a remarkable book titled Brain Over Binge: Why I was Bulimic, Why Conventional Therapy Didn't Work, and How I Recovered for Good by Kathryn Hansen.  This expression, found on page 140 of her book, and drawn from page 107 of The Mind and the Brain: Neuroplasticity and the Power of Mental Force by Jeffrey M. Schwartz, M.D. and Sharon Begley (New York: HarperCollins, 2002), sums up what happens when we humans carry out an action enough times that it becomes a habit.

I've attempted to write this review at least three times and because there's so much in her book, I found it difficult to summarize.   So here's my brief synopsis.  I strongly believe buying her book is a good step for those who haven't found an answer to their bulimia.   Her book contains material that I've studied as well as heard from researchers in the field of neuropsychology here at the University of Arizona.  The material dovetails so very well with my own experience, too.  

[update comment July 2, 2015 - I noticed that people are selecting this link.  I've placed a link to this post in my "Of Note" section.]

A good habit obviously is a good thing.  But those with the tendency towards (genetics?) strong reward-seeking behavior that is not tempered by the temporal lobes can run into trouble.  So, what is the solution?  And, can stopping binging and purging be a choice?  I happen to think so but I reached that conclusion long after (in terms of the length of time I battled bulimia) Kathryn did and I reached it because I was sick and tired of being sick and tired. 

Kathryn reached this decision because she encountered a program - Rational Recovery - that worked to steer her into a different perspective and she then spent a lot of time learning about her brain and how it's currently understood to work.  I also know people who've managed to use Alcoholics Anonymous with the same results.  I believe that there is an underlying biological reason for all of these disorders. 

Interestingly enough, I've also learned recently that people during the 1800's used sugar/sweets to get high.  Stop and think about that for a moment.  

The beauty of our brain, as Ms. Hansen eloquently and with considerable research puts it, is that the neurons and other material in our brains can continue to develop new pathways throughout our lives.  The neuroplasticity of the brain -- something I learned about in my class here at the University of Arizona last spring -- is our saving grace in so many ways.  We can learn new habits, we can learn to use a hand or walk  again after a stroke or injury, we can learn to speak new languages, soldiers returning from battle can overcome PTSD, and some can continue to function seemingly normally even with Alzheimer's Disease (as revealed by autopsy following death).  We can quit binging and purging.   Neuroplasticity is a remarkable thing.  Basically, to quote Ms. Hansen, "neuroplasticity refers to the brain's ability to rewire itself."

And she worked hard to rewire her brain.  She decided that she needed to do this.  I agree with her that others can, too.  She takes the reader through her disease and then recovery using knowledge of the workings of the brain as well as her discovery of what was driving her and why. 

She also thoroughly looked at herself through the lens of much of today's focus in eating disorders therapy and she concluded that the therapy doesn't really get at what started her disease in the first place.  She realized that getting to know herself and understanding her behaviors certainly helped in her development/her growing maturity but to her it was not a cure or a means of stopping the binge eating/bulimia.  I, too, turned to therapy after I quit binging and purging and found therapy to be instrumental in my personal development.  But, to repeat, by then I no longer binged and purged, either.  And she also believes, and so do I, that bulimia is triggered by something much deeper and at the same time simpler.

She has taken complicated information and presented it in a way that most should be able to understand.  The brain is complex.  Our anatomy is complex.  The media is also examining the workings of the brain thanks to the efforts I've outlined previously here on my blog in response to the needs of our returning military, of those who have suffered strokes, of those with brain disorders like schizophrenia, depression, and eating disorders, and more recently and quite tragically for us here in Arizona, of Representative Gabrielle Gifford's recovery from a point blank gunshot wound to her brain.

Ms.Hansen speaks an underlying truth that  her eating disorder was indeed about the food!  Or in her case, as with so many, with the results of the lack of it.

My own thinking has gradually come around to her thesis, too, which is that dieting in the sense of purposefully restricting one's caloric intake, sets off a chain of events in the brain that leads to the development of a potentially fatal disease:  an eating disorder.  She focuses on binge eating disorder (BED) and bulima.  

The word diet has been defined in our society not as what one eats daily  but rather the purposeful  change of eating patterns to lose or gain weight but that for some something goes haywire (interesting that the word "wire" is in this expression and the word haywire was used long before the workings of the brain became better understood) and leads to excessive restriction of food or to excessive eating and for some, death.  What is that something?  An imbalance?  An endocrine disorder?  An  immature portion of the brain?  Dr. Cynthia Bulik terms it a "negative energy balance."  Here is a link to Dr. Bulik's paper.

Once food is restricted, she proposes that the rudimentary part of our brain (she calls it the animal brain) recognizes that there is a threat to our organism's survival and the animal brain takes over.  One binges because one is starving.  One goes on to develop the habit of binging because it helps to feel better.  Sure it does!  You're no longer starving!  Remember, cells that fire together, wire together.

One purges because one who develops either BED or bulimia also either develops the habit to purge, in whatever way works, or continues to gain weight because they are caught in the habit of overeating.  The goal is to stop binging by eating rationally in response to the body's needs and therefore to stop purging (by vomiting, exercising, etc.) because one comes to understand -- to "get it" -- that they don't need to any longer.  Again, this can be hard work.  And, it can be done!

It would seem to me that for those who have the urge to binge eat without purging and who have developed the habit of binging, an underlying endocrine disorder in combination with, for some reason an uncontrollable urge to eat, must be addressed at multiple levels.

Some readers (and parents) will question how this process can work for a younger person.  I believe the parent needs to step in and learn about the brain, habits, and nutrition.  This book would be an excellent start.  The parent needs to serve their child as the light along the path and if the parent cannot or is not available, then the person with BED or bulimia needs to enter a residential program or live with a competent, knowledgeable and determined foster parent where s/he is monitored to eat well as well as not to purge until the new behavior becomes not only a habit but also believable.

This is not an overnight thing.  It's absolutely not easy.  But it sure does feel good to no longer be doing something that is so harmful and that interferes with a normal life.  I highly recommend this book as a valuable different perspective on overcoming bulimia and as a means of getting a handle on binge eating.

An important P.S. - this thesis does not address the difficulties encountered by those who are fighting other co-existing diagnoses such as Borderline Personality Disorder, Bipolar Disorder, Anxiety Disorder, or Obsessive-Compulsive Disorder.  I think this is where Dr. James Lock's recently published research will add much to the discussion.
P.P.S. - Kathryn has self-published this book.  It is available on Amazon.

 

Ameliorating Reward Seeking Behavior and, by extension, Eating Disorders

A newly published study in Nature by researchers at the University of North Carolina at Chapel Hill reveals that
 
using a combination of genetic engineering and laser technology, [they] have manipulated brain wiring responsible for reward-seeking behaviors, such as drug addiction. The work, conducted in rodent models, is the first to directly demonstrate the role of these specific connections in controlling [emphasis mine] behavior.

 

The UNC study, published online on June 29, 2011, uses a cutting-edge technique called “optogenetics” to tweak the microcircuitry of the brain and then assess how those changes impact behavior. The findings suggest that therapeutics targeting the path between two critical brain regions, namely the amygdala and the nucleus accumbens, represent potential treatments for addiction and other neuropsychiatric diseases.

Interestingly, I just completed a course on the brain offered by Dr. Lee Ryan at the University of Arizona as part of the Humanities Seminars Program.  During her three hour lecture with slides on decision making she illustrated the reward path of the brain as beginning in the ventral tegmental area (VTA) that is known for pumping out dopamine that is transmitted to the Nucleus Accumbens and from there to the Prefrontal Cortex.  By infusing minute doses of heroin directly into the Nucleus Accumbens of a rat, researchers observed an increase in the degree of dopamine and its course from the Nucleus Accumbens to the Prefrontal Cortex.  Researchers then electrically stimulated the NA and obtained similar results.  (Once her slides are on line, I'll link them here to illustrate the experiment with the rats.)

The researchers also determined in work with the animal that anticipation of the reward is as good as the reward itself.  This illustrates the increased likelihood that someone who is or was addicted to a substance (heroin, e.g.) or a behavior (such as gambling or binging and purging) will begin to anticipate the reward and indulge in reward seeking behavior as a result unless they have managed to learn how to modify their behavior in this example of a decision making process.

That decision-making process occurs in the Frontal Lobes of the brain where something known as  the Executive Function occurs.  The brain, through training the results of which can become a habit as well, weighs the pros and cons of seeking the reward and hopefully makes the decision, in this case, to reject it.

Research has shown, too, if there is damage to the orbitofrontal cortex, these behaviors to avoid reward are dampened and risk taking as well as reward seeking are increased.  This damage can occur as a result of a stroke.  It would seem (although I have not seen any research yet about this but intend to tap the researching skills of a friend) that starvation during anorexia or electrolyte and therefore chemical imbalance due to binging and purging,  could also lead to the lessening of the positive effects of Executive Function because the brain is starving.  And, of course, genetics can play a role here, too, by increasing likelihood that a person's stimulus/reward system may need balancing through, for example, behavioral modification or medication among other possibilities.

Again, the goal is to develop a habit to reject a stimulus that is harmful.  The researchers in the first report mentioned above are examining ways to interrupt this reward seeking behavior, as well.  For those who for whatever reason simply cannot stop that reward seeking behavior once it begins, the work by those at UNC may lead to a way to stop it.

And, again, a fascinating look at all of these processes can be found in the book Incognito by David Eagleman.  This linked NPR report gives one a sense of the book and includes some material from the first chapter of the  book.

P.S. After reading and then thinking/writing about Brain Over Binge ( Kathryn Hansen's book ) is anorexia another disease or another version of the loss of the ability of a person's executive function to govern eating behavior but in anorexia's case something goes awry in the brain's wiring so that in a perverse way starvation feels good as would a narcotic? 
P.P.S.  After writing the above P.S., Kathryn Hansen sent me a link to an article about the study by Dr. Walter Kaye and his colleagues that indicates those with anorexia feel less anxious when they do not eat; some sort of aberration.  So in a sense starvation does feel good or at least less fear inducing........
And, another PS - Here's an article published in the New York Times on the same subject elaborating on the development of addictions and the brain receptors involved.

The Four Agreements - underpinnings to a better life

We subscribe to Inside Tucson Business, a local weekly business newspaper.  The June 24, 2011 edition carries an article written by Kathy Hibsman in the Women in Business section in which she reflects on the Toltec Four Agreements.  This link provides the full text of the agreements, as well.

I find it worthwhile to review these periodically and the book written by Don Miguel Ruiz sits on my shelf.

Agreement 1:  Be impeccable with your word.

Agreement 2:  Don't take anything personally.

Agreement 3:  Don't make assumptions.

Agreement 4:  Always do your best.

A reminder to those who tend towards perfectionism and get tangled up in it (like myself), doing your best does not mean doing something perfectly.  A wise Al-Anon saying is Progress, not perfection.

Can Eating Disorders be Prevented?

I am reading a fascinating book. The title is terrific: The Emperor of All Maladies. The book is written by Siddhartha Mukherjee and was published by Scribner in 2010. I was listening to NPR one day, heard about it, and then listened to my own therapist tell me what a great book it is. So, I bought it.

Why do I write about it here? Because the book is a biography of cancer and about the very long journey the medical/science professions have endured to find a way to stop it or cure it or at least put it in remission.

I was recently reminded that whatever many of us parents are doing to help our loved one conquer ED, we are not using a cure necessarily, but rather a method. So, for example, I do not believe anyone has called Maudsley a "cure" but rather a "method." One goes "into residential treatment."   Eating disorders are complicated, not simple.

Keeping the word "method" in mind, and knowing that right now the very first step in treatment of an ED must be the cessation of the behavior that is driving the anorexia, the bulimia, the binge eating, EDNOS, exercising, etc, plus excellent nutrition,  there's still that elusive word "prevention" out there in the world of those researching these illnesses.

And preventive medicine in this country at least has taken a very long time to become acceptable.

I am about a little more than a third of my way through this terrifically written and engaging book. Drugs are being discussed, chemotherapy is on the rise, things like radical mastectomies are in decline, receptors have been found, and right now this reader has been taken into a philosophical discussion about mortality.

Mortality.... Here's a quote from the book:

 

"The only intervention ever known to reduce the aggregate mortality of a disease - any disease - at a population level was prevention."

And so far - understandably so - we parents are immersed in methods of treatment rather than of prevention in order to save our daughter's/son's life.

Meanwhile, I continue to be amazed at the numbers of teens who are being diagnosed with a brain disorder (I recently read 1 in 6). I continue to be amazed at the number of teens and younger children being diagnosed with the brain disorder anxiety.

Surely there is a link somewhere in here.  A recent study highlighted the possibility.

The brain of a growing individual keeps changing well into their twenties. So many things can go "right"; so many things can go "off path." Genetics plays an enormous part. Certain areas of the brain mature even more slowly than others. Nutrition is paramount. So is learning behaviors -- patterns if you will --  that keep one on the path to a productive life.

Suppose we all made a concerted effort to educate parents to take their children to the doctor for an assessment of their mental health as well as their physical health. "Teen Screen" is a start.

Perhaps this is one step towards prevention. There are others, too, like paying attention to family dynamics and communication for starters; like taking your child to the doctor when the child is having a difficult time coping. There's even talk now of being able to identify someone who might develop schizophrenia and treat them early enough so that potentially they don't go on to develop the disease.

Imagine if we could do that for those who are vulnerable to eating disorders??   I believe it's possible.