Title: The All-or-None Phenomenon in Borderline Personality Disorder
1The All-or-None Phenomenon in Borderline
Personality Disorder
2DSM-IV Criteria for BPDMust have five or more of
the following
- Frantic efforts to avoid real or imagined
abandonment - A pattern of unstable and intense interpersonal
relationships characterized by alternating
between extremes of idealization and devaluation - Identity disturbance markedly and persistently
unstable self-image or sense of self - Impulsivity in at least two areas that are
potentially self damaging - Recurrent suicidal behavior, gestures, or
threats, or self-mutilating behavior - Affective instability due to marked reactivity of
mood - Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty
controlling anger - Transient, stress-related paranoid ideation or
severe dissociative symptoms
3A Three Factor Model
- Impulsivity
- Lab studies find inattentiveness, a tendency
toward action, disinhibition. Sensitive to
rewards, insensitive to punishment. - Disturbed relatedness
- Studies show more hostile representations,
insecure attachment style, lower likelihood of
being married, more break-ups, shorter duration
of friendships, lack of romantic partner, fewer
social activities. - Affective Dysregulation
- Lab studies find hypervigilance for negative
emotional stimuli.
4Clarence Schulz, M.D.
- Schulz, C. G. (1980a). All-or-none phenomena in
the psychotherapy of severe disorders. In J. S.
Straus, M. Bowers, T. W. Downey, S. Fleck, S.
Jackson, I. Levine (Eds.), The psychotherapy of
schizophrenia (pp. 181189). New York Plenum
Medical Book. - Expands on the psychoanalytic concept of
splitting-seeing objects as all good or all
bad - A useful construct in the treatment of patients
with Borderline Personality Disorder. - A valuable construct for therapists who are
Psychodynamic or Cognitive-Behavioral
5Schulz All Or None AttitudesAll-or-none
Integrated
- Rigid overcontrol vs. loss of control
- Attack entire problem vs. avoidance of problem
- Now or never
- Murderous rage or total denial of anger
- Infatuation or denial of dependency
- My way or your way
- Optimism vs hopelessness
- Impulsivity vs. failure to act
- Extreme attachment vs. rejection of object
- Harsh disapproval, self-injury vs. absent moral
constraint - Narcissistic ideal expectation vs. despair of
accomplishing anything - Instant recovery vs. no progress
- Modulated expression of affect
- Breakdown problem into manageable parts
- Ability to tolerate delay
- Partial expression of anger
- Mature object dependency
- Shared responsibility, cooperation
- Realistic appraisal of limitations
- Appropriate decision making
- Stable interpersonal relationships
- Fairly consistent moral regulations
- Reasonable, stable goals
- Improvement by small increments
6Clinical Examples of All-or-None Thinking
- Patient with addiction who vacillates between
being hopeless about recovery and speaking as
though sobriety will be easy. - Patient who wanted something from boss. Couldnt
handle the suspense of not knowing whether he
would get it. Assumed boss would be withholding.
Verbally attacked boss as being unsupportive.
When confronted, berated himself for not being
good enough. - Patient whose wife berates him, comes home from
work saying, Im not going to get angry
tonight, only to explode and yell at her later.
7Evidence-Based Treatments for BPD
- Incorporate Schulzs concept of all-or-none
thinking - Dialectical Behavior Therapy-Linehan utilizes the
concept of dialects to conceptualize the thinking
of patients with BPD - Transference-Focused Psychotherapy-Kernberg
focuses on splitting in the transference
8Dialectics in DBT
- Acceptance vs. change
- Unrelenting crisis vs. inhibited grieving
- Emotional vulnerability vs. self-invalidation
- Active passivity vs. apparent competence
- Being blameless vs. totally flawed
- Willingness vs. willfulness
9Transference Focused Psychotherapy
- Therapy is focused on the patients transference
reactions to the therapist - Dont interpret the past-You are experiencing me
like your mother will be met with you are just
like her - Here and now focus
- Help patient integrate split all good and all
bad images of the therapist
10Kernberg Treatment Model
- Transference Focused (Here and Now)
- Primitive transferences are distorted, rapidly
shifting, reflect part object relations - Goalbring good and bad part objects together
- Examples
- Though you began our session by mentioning that
you lost your job and may have no place to live,
you now sit here beaming at me as if all your
troubles are over. - You seem to be hinting that your life is falling
apart, and yet, I hesitate to bring this up
fearing that you might experience it as
intrusive. On the other hand, I also fear that
if I dont bring it up, you will experience me as
indifferent. Im wondering if this reflects some
conflict about your dependency on me. - You seem to be experiencing me as cold and harsh
right now.
11All-or-None Thinking
- Researchers view emotion dysregulation as being
at the root of BPD. - From a Cognitive-Behavioral perspective,
all-or-none thinking leads to emotion
dysregulation. - From a psychodynamic perspective, all-or-none
thinking is a manifestation of splitting, where
patients with BPD cannot simultaneously hold
positive and negative images of self or others.
Images are all good or all bad.
12Countertransference and All-or-None Thinking
- Patients who respond in extreme ways tend to
provoke the strongest countertransference. - Therapists think about BPD patient outside of
treatment - Staff more likely to cross boundaries with BPD
patients - Projective Identification-the patient behaves in
ways that provoke the therapist to feel what they
are feeling. They externalize their conflict. - BPD patients cannot contain.
13Projective Identification
- Projective identification on the inpatient unit
(Gabbard) - Occurs at unconscious level
- Pt views and treats staff differently
- Staff react to pt as though they were the
projected aspect - Staff assume highly polarized views of pt
14Projective Identification
- Function of projective identification (Gabbard)
- Active mastery of passively experienced trauma
- Maintenance of attachments
- A cry for help
- A wish for transformation
- Goals in dealing with projective identification
- Engage and react
- Polarized staff communicate-process the
projections - Projections are given back to pt in modified form
15Examples of Projective Identification
- Patient afraid at the time of discharge behaved
in ways that left me conflicted about whether to
re-hospitalize her. - Patient angry with mother reports mothers
behavior and I feel angry with mother. Patient
denies being angry with mother.
16 Schulz Countertransference Symptom
Overidentification Observation Rejection
Unstable intense relationships Sides with split aspect, accepts as reality Keeps split parts communicating sees pt as pitting staff against each other
Impulsivity, substance abuse, acting out Vicariously enjoys the behavior curbs acting out, sees it as a communication Punishes acting out, removes from therapy
Affective instability Becomes frantic with pt, insists on meds Empathy, confident of resolution Ridicules pts feelings, premature use of meds
Intense anger, rage Seeks justification in pts anger, sides with pt Sensitive to precipitants Retaliates or untouched by anger
Recurrent suicidal threats, self-mutilation Anxious response, assume responsibility Responds with support and explore behavior Ignores threats or terminates treatment
Identity diffusion, negativism Feels rejected by pt, decides things for pt Optimal distance with engagement Rejects or opposes pt
Emptiness, boredom Tries to entertain pt Defense against affects of achievement Sees it as pts problem
Avoidance of abandonment Dependent gratification Fosters mature dependency Insists on autonomous functioning
17Helping Patients with All-or-None Thinking
- Tension between
- Empathy and interpreting distortion
- Engagement and non-reactivity
- Acceptance and desire for change
- Being supportive and fostering independence
- The environment should
- Tolerate intense affect
- Non-judgmental, but with a healthy respect for
the potential damage caused by acting out - Integrate splits
- Communicate well
- Encourage modulated verbal expression of feelings
18Treatment Techniques
- The Basics
- Put your feelings into words
- Challenge all or none thinking-help them
integrate splits, modulate affect - Be engaged enough to get sucked in, then
reflect on it - Treatment team understands projective
identification and continues to communicate - Progress-two steps forward and one back
- Defense against the affects associated with
achievement, fear of destructive side - Countertransference-self-protective cynicism vs.
naïve optimism
19Treatment Techniques
- Idealization
- Point it out-predict disappointment
- Positive and negative sides to it
- Avoid being saintly, recognize the splitting
process - Open to the perspective of those being devalued
- If you overindulge pt, acknowledge this, and
process it - Devaluation
- Non-defensive without being defenseless
- Remain in communication
- Confident in problem resolution
- Aware of pts disorder, real suffering
- If you respond angrily or become avoidant,
acknowledge this, and process it
20Negative Transference
- Negativism-the search for a bad object
- Warmth through friction-Schulz
- Seeks negative response-pt isnt the only angry
person in the room - Staff acknowledge feelings or pt will escalate,
acknowledging anger makes anger acceptable - Explore why pt wants to elicit such feelings
- Requires staff to feel, then reflect
21All-or-None Thinking
- Useful focus of treatment for patients with BPD
- Fits nicely into a psychodynamic or
cognitive-behavioral treatment - Patients find it easy concept to grasp
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