Life in Distress
What the treatment for Borderline Personality Disorder can teach everyone.
Posted Jun 12, 2018
Heightened Distress Reactivity in BPD
Patients with Borderline Personality Disorder (BPD) often report high stress sensitivity. To explain what that means I want to illustrate it with an example. Let’s classify distress on a scale from 0 (completely relaxed, you on a beach in the Caribbean’s with a Pina Colada in your hand) to 100 (complete panic, the house is on fire and you cannot escape).
Lets say Lisa is mentally healthy and Ella has been diagnosed with BPD.
Lisa wakes up with a stress level of 10 before she goes to work. She is making breakfast and her coffee spills on her last clean blouse that she wanted to wear to the office. This makes her stress level rise to 30. She decides to not let it affect her and continues to get ready, with her anxiety level decreasing to 10 again by the time she is in the car. Lisa hits traffic and realizes she will be half an hour late to an important meeting. Her stress level is back at 35 until she reaches the office, to see that her colleagues are still chatting about the weekend and her stress level decreases back to 20. She has to hold an important presentation which let her anxiety levels rise to 65, but she calms down quickly after and is relived that it went well.
Ella wakes up with a stress level of 30. She doesn’t even know what its like to wake up with a level of 5, 30 is her normal. When she spills her coffee on her last clean blouse her stress level goes up to 45, and it stays that way. She continues to get ready and goes to the car. Ella hits traffic and she realizes she will be half an hour late to her important meeting. Her anxiety goes up till 55 and continuously rises the longer she takes. When she sees the meeting hasn’t started, she struggles to calm down and stays relatively tense. Her anxiety peaks during the presentation, and even after she can’t get rid of the tension in her chest and she stays stressed for most of the day.
As illustrated in this example, patients with BPD have a higher stress level at baseline. They also react even stronger when put into stressful situations and take longer to get back to their baseline stress level, than people without BPD. Lisa was able to stay in “the green” area most of the day, meaning she might have had moments of distress but they weren’t overwhelmingly stressful and passed by quickly. Ella on the other hand was in “the yellow” area all day, which means she was constantly stressed and tense. Stress reactivity is a topic common for many BPD patients and thus, part of Dialectic Behavioral Therapy (DBT; the most common treatment for BPD) is learning how to handle highly distressing situations within the dialectical framework.
Distress Tolerance Skills
Everyone enters stressful situations. Everyone knows what it is like to feel overwhelmingly stressed. Although, the majority of people do not suffer from BPD or any other mental disorder, I strongly believe that the skills taught in DBT are useful for everyone.
Distress tolerance skills aim to help individuals in highly stressful situations to accept and tolerate the distress of the moment. In essence, they help you to bear the pain. I understand that it must seem odd to give someone tools to “bear the pain” instead of helping them to solve the problem. However, these skills are not intended to be a long term solution, rather a short term emergency kit.
We know that pain and distress increases the more we fight it. Like when you can’t fall asleep and your thoughts about not being able to sleep make you more and more alert and the likelihood of you falling asleep decreases even more. Therefore, it is important that one accepts that there are painful and distressing moments in life. That it is normal to experience pain. That everyone experiences emotional pain at some point in their life.
Secondly, if one wants to change, this is always accompanied with some sort of distress. For example, if someone wants to quit smoking or start exercising more often, this will at first be accompanied by distress or pain. Distress tolerance skills can allow accepting this discomfort in the short term in order to reach our long term goals.
DBT teaches 6 categories of crisis survival skills. In the following weeks I would like to introduce a few of these, that I find useful for everyone, not just patients with BPD. So when you find yourself in painful events, urges or strong emotions that you cannot change right away, the following distress tolerance skills taught in DBT might be a useful emergency kit.
The skill that I will be talking about now is useful when you are in a situation that is highly stressful and you want to prevent to acting on your first impulse. When would that be useful?
One example would be when you are at a concert with your kids and someone bumps into you and takes your seats. Your immediate reaction might be to get angry and yell at the person. However, this reaction might lead to an escalation of the situation because you don’t know how the person is going to react. Especially having your kids there with you, it would be more beneficial to act in the STOP skill, that helps you to distance yourself from the situation and to reevaluate what is going on before acting on your first impulse.
In DBT, a lot of acronyms are used that are intended to help remembering the skill when needed.
STOP stands for Stop, Take a step back, Observe, Proceed mindfully
This emergency kit tool should be used whenever one finds themselves in an emotionally overwhelming situation.
When you are in an overwhelming or stressful situation the first thing you should do is. Stop. Literally, freeze. Just don’t react at all. Not acting on your first impulse is the first step in regaining control over the situation. You might also find it helpful to engage in peaceful breathing to control your arousal level.
Take a step back
You don’t always have to act immediately. Give yourself some time to first calm down and reevaluate the situation. So first take a step back, whether this is physically or emotionally, and gather your thoughts first. So, either leave the room until your thoughts on what is going on are clear again or engage in relaxing breathing exercises as long as you need to. When you are in “the red area” of emotional distress it is normal to feel overwhelmed by emotions, so only proceed with the situation at hand once you feel back on track and in control of what you are feeling
When you are caught up in emotions you often lose track of what is actually going on. Take a moment to observe. What is happening around you, gather all the facts. What is going on within you. Be mindful.
Try to think about what final outcome you would most desire. What are your goals. Once you figured that out, it is much easier to act mindfully and proceed in a way that the situation demands and is most functional.
Like in therapy, it takes practice to efficiently learn this skill. It is likely going to be trial and error and we might not find the right skill for each situation right way. And that is okay.
By the end of 6 months DBT patients will have learned a whole bunch of skills. Skills for different situations and different demands. It is not enough to just learn and know one skill, many are needed to be ready for the struggles that life has to offer. I am not saying that DBT is the ultimate and only solution to eternal happiness. But I do belief that DBT skills are not only useful for patients with BPD but for everyone. Over the following blogs I will introduce a few more skills as part of the distress tolerance module in DBT. If you have any questions or are familiar with DBT and would like me to talk about a specific skill, don’t hesitate to comment below.
Linehan, M. (2014). DBT® skills training manual. Guilford Publications.