- Are There Tools To Predict BPD Decompensation?
QUESTION:
Dear Dr. Heller,
My husband is in recovery from the BPD. Our journey has made me very aware recently that “psychotic” is a “dirty” word, and even people who know better still react very defensively to the idea that someone in their family might be “psychotic” – no matter how much they’ve had to adapt to accommodate their family member’s obvious illness. The “unhappiness” still means something closer to “shameful” than “biological”.
As you know, people with BPD can decompensate. This poses a serious problem for the whole family. Our homes are not psychiatric facilities and we can’t do what a doctor can do to help stabilize our family member. Often, we can’t even risk transporting them ourselves. (As I write this, my husband is recovering from a decompensation due to a medication adjustment. Hopefully, he will be able to make it in to see a doctor tomorrow. It’s been more than a week now.) So, I’m trying to come up with a tool to help myself spot changes in behavior that could help me predict such a crisis. I help facilitate a support group for family members, and I’ve asked the group to look over my (very rough) draft.
We go into this endeavor knowing that we are living with very delicate, sometimes nearly ephemeral phenomena and that we are *not* doctors; that the stakes can be very very high. But, between the invisible and the chaos that can overtake our households, we can (and do) observe so many “predictors”, if you will. My reasoning is, the better observer and communicator I become, the more I contribute to the treatment team. And because most clinicians no longer make house calls – indeed, it’s extremely difficult to find a clinician expert in BPD in a hospital – it is up to me to stay active and to use whatever tools at my disposal to support my husband’s recovery and to ensure the quality of my life at home.
Having said all this, I attach the “checklist” I’m developing. Again, the aim to give family members a tool to help them assess the behavior they are living with and hopefully avoid needless crises at home. It is not meant as a substitute for a medical consultation; rather, it is meant to help a family member assess a potential crisis and also to help them verbalize what they are seeing in their home to the professionals they rely upon. If you can offer any feedback, I’d appreciate hearing from you.
Best regards.
ANSWER:
Psychotic means misinterpreting reality. Individuals with the BPD, when dysphoric, perceive the world the way a trapped, cornered, wounded animal does. From that perspective their behavior makes sense. Self-destructive behaviors are simply techniques that work to stop dysphoria. Dissociative symptoms are psychotic as well. I don’t shy away from using the word psychotic because individuals with the BPD need to fully understand the risks of untreated dysphoria (anxiety, rage, depression and despair). Dysphoria is a horribly painful sensation. The most effective tool I’ve ever encountered is doing mood checks hourly. Because borderlines have felt so bad for so long, feeling bad isn’t something “new” or “abnormal” to them. By checking the mood hourly (1 = the worst they’ve every felt, 10 = the best), they can treat their dysphoria with a low neuroleptic dose (I prefer Haldol 2mg). The dysphoria instruction sheet I use for my patients is available here. The therapist I work with, Mary Sales, helps patients and their loved ones recognize dysphoric spells and the particular “red flags” that warn the BPD patient that they are “crashing.” Decompensating, psychosis, or crashing mean the same thing – there is a seizure like phenomenon occurring in the limbic system (and the temporal lobes when dissociation is present). Treating it as a medical problem with medication is a crucial aspect of recovering from the BPD.
