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A Compilation by Dean Amory

1. Introduction

1. Cluster B (the "dramatic, emotional, erratic" cluster

a. Antisocial Personality Disorder
b. Histrionic Personality Disorder
c. Narcissistic Personality Disorder
d. Borderline Personality Disorder
2. Cluster A (the "odd, eccentric" cluster)
a. Paranoid personality disorder
b. Schizoid personality disorder
c. Schizotypal personality disorder
3. Cluster C (the "anxious, fearful" cluster)
a. Avoidant personality disorder
b. Dependent personality disorder
c. Obsessive-compulsive personality disorder
4. Personality disorder not otherwise specified

2. Codependence



Are you codependent

Comparison: healthy vs codependent friendship
Help! Can I Fix it?
Helping a person who is codependent
The 12 Traditions / The 12 Steps
Recovery steps
Self Affirmations that work

3. Narcissistic Personality Disorder

Symptoms of Narcissistic Personality Disorder
20 Traits of malignant Narcissistic Personality Disorder

4. Borderline Personality Disorder

Symptoms of Borderline Personality Disorder
Frequently Asked Questions
Guidelines for families, partners and friends
Online Test
Substance Abuse Treatment
Self Injurious Behaviour
Consequences of alcohol and drugs abuse
Anxiety and panic attack symptoms
Attention Deficit Hyperactivity Disorder and Borderline




Most of the personality disorders described in this publication are part of
the Cluster B Personality Disorders. Disorders in this cluster are of a
dramatic, emotional and / or erratic nature. This implies that people
suffering from these disorders have problems with impulse control and
emotional regulation
Cluster B includes:

Antisocial Personality Disorder.

Histrionic Personality Disorder.
Narcissistic Personality Disorder.
Borderline Personality Disorder.

1. Antisocial Personality Disorder

The Antisocial Personality Disorder is
characterized by a pervasive pattern of
disregard for, and violation of, the rights of
other people that often manifests as
hostility and/or aggression. Deceit and
manipulation are also central features.
In many cases hostile-aggressive and
deceitful behaviours may first appear
during childhood or early adolescence and
continue into adulthood.
People with antisocial personality disorder
have been described as lacking empathy
(or the ability to put yourself in someone
elses shoes to understand their feelings),
and they may often be deceitful or break the law. Antisocial personality disorder
is also associated with impulsive behaviour, aggression (such as repeated
physical assaults), disregard for their own or others safety, irresponsible
behaviour, and lack of remorse.

These people may hurt or torment animals or people.

They may engage in hostile acts such as bullying or intimidating others.
They may have a reckless disregard for property such as setting fires.
They often engage in deceit, theft, and other serious violations of standard
rules of conduct.

When this is the case, Conduct Disorder (a juvenile form of Antisocial Personality
Disorder) may be an appropriate diagnosis. Conduct Disorder is often considered
the precursor to an Antisocial Personality Disorder.

In addition to reckless disregard for others, they often place themselves in

dangerous or risky situations.
They frequently act on impulsive urges without considering the
consequences. This difficulty with impulse control results in loss of
employment, accidents, legal difficulties, and incarceration.

Persons with Antisocial Personality Disorder typically do not experience genuine

remorse for the harm they cause others. However, they can become quite adept
at feigning remorse when it is in their best interest to do so (such as when
standing before a judge).
They take little to no responsibility for their actions. In fact, they will often blame
their victims for "causing" their wrong actions, or deserving of their fate. The
aggressive features of this personality disorder make it stand out among other
personality disorders as individuals with this disorder take a unique toll on
2. Histrionic Personality Disorder
Persons with Histrionic Personality Disorder are characterized by a pattern of
excessive emotionality and attention seeking. Their lives are full of drama (socalled "drama queens"). They are uncomfortable in situations where they are not
the centre of attention.
The central features of histrionic
personality disorder are intense
expressions of emotion and
behaviour. People with histrionic
personality disorder often seek
uncomfortable when others are
receiving attention. They may
often engage in seductive or
sexually promiscuous behaviour,
or use their physical appearance
to draw attention to themselves.
They also may demonstrate
rapidly shifting emotions and
express emotion in a very dramatic fashion.

People with this disorder are often quite flirtatious or seductive, and like to
dress in a manner that draws attention to them.
They can be flamboyant and theatrical, exhibiting an exaggerated degree
of emotional expression.
Yet simultaneously, their emotional expression is vague, shallow, and
lacking in detail. This gives them the appearance of being disingenuous
and insincere.
Moreover, the drama and exaggerated emotional expression often
embarrasses friends and acquaintances as they may embrace even casual
acquaintances with excessive ardor, or may sob uncontrollably over some
minor sentimentality.
People with Histrionic Personality Disorder can appear flighty and fickle.
Their behavioural style often gets in the way of truly intimate relationships,
but it is also the case that they are uncomfortable being alone.
They tend to feel depressed when they are not the centre of attention.
When they are in relationships, they often imagine relationships to be more
intimate in nature than they actually are.
People with Histrionic Personality Disorder tend to be suggestible; that is,
they are easily influenced by other people's suggestions and opinions.

3. Narcissistic Personality Disorder

Narcissistic personality disorder is characterized by an inflated sense of selfimportance. People with narcissistic personality disorder often believe that they
are special, require excessive attention, take advantage of others, lack
empathy, and are described by others as arrogant.
People with Narcissistic Personality
Disorder have significant problems with
their sense of self-worth stemming
from a powerful sense of entitlement.
This leads them to believe they
deserve special treatment, and to
assume they have special powers, are
uniquely talented, or that they are
especially brilliant or attractive. Their
sense of entitlement can lead them to
act in ways that fundamentally
disregard and disrespect the worth of
those around them.

People with Narcissistic Personality Disorder are preoccupied with fantasies

of unlimited success and power, so much so that they might end up getting
lost in their daydreams while they fantasize about their superior
intelligence or stunning beauty.

These people can get so caught up in their fantasies that they don't put
any effort into their daily life and don't direct their energies toward
accomplishing their goals.
They may believe that they are special and deserve special treatment, and
may display an attitude that is arrogant and haughty.
This can create a lot of conflict with other people who feel exploited and
who dislike being treated in a condescending fashion.
People with Narcissistic Personality Disorder often feel devastated when
they realize that they have normal, average human limitations; that they
are not as special as they think, or that others don't admire them as much
as they would like.
These realizations are often accompanied by feelings of intense anger or
shame that they sometimes take out on other people.
Their need to be powerful, and admired, coupled with a lack of empathy for
others, makes for conflictual relationships that are often superficial and
devoid of real intimacy and caring.
Status is very important to people with Narcissistic Personality Disorder.
Associating with famous and special people provides them a sense of
importance. These individuals can quickly shift from over-idealizing others
to devaluing them.
However, the same is true of their self-judgments. They tend to vacillate
between feeling like they have unlimited abilities, and then feeling
deflated, worthless, and devastated when they encounter their normal,
average human limitations. Despite their bravado, people with Narcissistic
Personality Disorder require a lot of admiration from other people in order
to bolster their own fragile self-esteem.
They can be quite manipulative in extracting the necessary attention from
those people around them.

4. Borderline Personality Disorder

BPD is associated with
relationships, self-image,
and thinking.
People with BPD tend to
characterized by a lot of
conflict, arguments and
have difficulties related to the stability of their identity or sense of self. They
report many "ups and downs" in how they feel about themselves. Individuals with

BPD may say that they feel as if they are on an emotional roller coaster, with
very quick shifts in mood (for example, going from feeling OK to feeling
extremely down or blue within a few minutes).
BPD is associated with a tendency to engage in risky behaviours, such as going
on shopping sprees, drinking excessive amounts of alcohol or abusing drugs,
engaging in promiscuous sex, binge eating, or self-harming.
Borderline Personality Disorder is one of the most widely studied personality
disorders. People with Borderline Personality Disorder tend to experience intense
and unstable emotions and moods that can shift fairly quickly. They generally
have a hard time calming down once they have become upset. As a result, they
frequently have angry outbursts and engage in impulsive behaviours such as
substance abuse, risky sexual liaisons, self-injury, overspending, or binge eating.
These behaviours often function to sooth them in the short-term, but harm them
in the longer term.

People with Borderline Personality Disorder tend to see the world in

polarized, over-simplified, all-or-nothing terms.
They apply their harsh either/or judgments to others and to themselves
and their perceptions of themselves and others may quickly vacillate back
and forth between "all good" and "all bad."
This tendency leads to an unstable sense of self, so that persons with this
disorder tend to have a hard time being consistent.
They can frequently change careers, relationships, life goals, or residences.
Quite often these radical changes occur without any warning or advance

Black-and-White Thinking and Emotion Deregulation in Borderline Personality

People with Borderline Personality Disorder tend to view the world in terms of
black-and-white, or all-or-nothing thinking. Their tendency to see the world in
black-or-white (polarized) terms makes it easy for them to misinterpret the
actions and motivations of others.
These polarized thoughts about their relationships with others lead them to
experience intense emotional reactions, which in turn interacts with their
difficulties in regulating these intense emotions.
The result is that they will characteristically experience great distress which they
cannot easily control and may subsequently engage in self-destructive behaviours
as they do their best to cope.
The intensity of their emotions, coupled with their difficulty regulating these
emotions, leads them to act impulsively.

To illustrate the way black-and-white thinking, emotional dys-regulation, and

poor impulse regulation all merge and culminate to create interpersonal conflict
and distress, let's use an example:
Suppose the partner of a woman with Borderline Personality Disorder fails to
remember their anniversary. Black-and-white thinking causes her to conclude,
"He doesn't love me anymore" and all-or-nothing thinking leads her to (falsely)
conclude, "If he does not love me, then he must hate me."
Such thoughts would easily lead to some pretty intense emotions, such as feeling
rejected, abandoned, sad, and angry. She has a hard time tolerating and dealing
with these intense feelings and consequently becomes highly upset and
overwhelmed. The intensity of her negative feelings seems unbearable.
Next she has a powerful impulse to "do something" just so that these feelings will
go away. She might angrily accuse her partner of having an affair and she might
plead with her partner not to leave her.
Meanwhile her partner is baffled by this extreme reaction, particularly since he is
not having an affair, and he readily recalls all his other recent loving gestures.
Her partner might also become angry at these wild accusations of infidelity and
so the conflict escalates and things get more intense.
Alone after the fight, the woman feels overwhelming self-loathing or numbness
and goes on to intentionally injure herself (by cutting or burning herself) as a way
to cope with her numbness.
When her partner learns about this self-harm behaviour he can't understand it
and concludes he is being manipulated. He expresses his strong concern for her
well-being but also his anger. In turn, she feels misunderstood.
Clearly, the Borderline Personality Disorder with its combination of distorted
thought patterns, intense and under-regulated emotions, and poor impulse
control is practically designed to wreak havoc on any interpersonal relationship.
It is important to remember that everyone can exhibit some of these personality
traits from time to time. To meet the diagnostic requirement of a personality
disorder, these traits must be inflexible; i.e., they can be regularly observed
without regard to time, place, or circumstance.
Furthermore, these traits must cause functional impairment and/or subjective
distress. Functional impairment means these traits interfere with a person's
ability to functional well in society. The symptoms cause problems in
interpersonal relationships; or at work, school, or home. Subjective distress
means the person with a personality disorder may experience their symptoms as
unwanted, harmful, painful, embarrassing, or otherwise cause them distress. The
above list only briefly summarizes these individual Cluster B personality

disorders. Richer, more detailed descriptions of these disorders are found in the
section describing the four core features of personality disorders.

Which Other Personality Disorders are defined in the DSM-5 ?

The four defining features of personality disorders are:

Distorted thinking patterns,

Problematic emotional responses,
Over- or under-regulated impulse control, and
Interpersonal difficulties.

These four core features are common to all personality disorders. Before a
diagnosis is made, a person must demonstrate significant and enduring
difficulties in at least two of those four areas: Furthermore, personality disorders
are not usually diagnosed in children because of the requirement that personality
disorders represent enduring problems across time. These four key features
combine in various ways to form ten specific personality disorders identified in
DSM-5 (APA, 2013). Each disorder lists asset of criteria reflecting observable
characteristics associated with that disorder. In order to be diagnosed with a
specific personality disorder, a person must meet the minimum number of criteria
established for that disorder. Furthermore, to meet the diagnostic requirements
for a psychiatric disorder, the symptoms must cause functional impairment
and/or subjective distress. This means the symptoms are distressing to the
person with the disorder and/or the symptoms make it difficult for them to
function well in society.
Furthermore, the ten different personality disorders can be grouped into three
clusters based on descriptive similarities within each cluster. These clusters are:
Cluster A (the "odd, eccentric" cluster)
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
P.M. : Cluster B (the "dramatic, emotional, erratic" cluster)
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C (the "anxious, fearful" cluster)
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder

Oftentimes, a person can be diagnosed with more than just one personality
disorder. Research has shown that there is a tendency for personality disorders
within the same cluster to co-occur (Skodol, 2005). Later, this issue of cooccurrence will be discussed in greater detail. The alternative model of
personality disorder, proposed for further study in DSM-5 (APA, 2013), hopes to
reduce this overlap by using a dimensional approach versus the present
categorical one. These different models are discussed in another section.
Now let's look at how all four core features merge to create specific patterns
called personality disorders.
Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders
Cluster A is called the odd, eccentric cluster. It includes Paranoid Personality
Disorder, Schizoid Personality Disorder, and Schizotypal Personality Disorders.
The common features of the personality disorders in this cluster are social
awkwardness and social withdrawal. These disorders are dominated by distorted
The Paranoid Personality Disorder is
characterized by a pervasive distrust and
suspiciousness of other people. People
with this disorder assume that others are
out to harm them, take advantage of
them, or humiliate them in some way.
They put a lot of effort into protecting
themselves and keeping their distance
from others. They are known to preemptively attack others whom they feel
threatened by. They tend to hold grudges, are litigious, and display pathological
jealously. Distorted thinking is evident. Their perception of the environment
includes reading malevolent intentions into genuinely harmless, innocuous
comments or behaviour, and dwelling on past slights. For these reasons, they do
not confide in others and do not allow themselves to develop close relationships.
Their emotional life tends to be
dominated by distrust and hostility.
The Schizoid Personality Disorder is
characterized by a pervasive pattern of
social detachment and a restricted
range of emotional expression. For
these reasons, people with this disorder
tend to be socially isolated. They don't
seem to seek out or enjoy close
relationships. They almost always chose


solitary activities, and seem to take little pleasure in life.

These "loners" often prefer mechanical or abstract activities that involve little
human interaction and appear indifferent to both criticism and praise.
Emotionally, they seem aloof, detached, and cold. They may be oblivious to social
nuance and social cues causing them to appear socially inept and superficial.
Their restricted emotional range and failure to reciprocate gestures or facial
expressions (such a smiles or nods of agreement) cause them to appear rather
dull, bland, or inattentive. The Schizoid Personality Disorder appears to be rather
Persons with Schizotypal Personality Disorder are characterized by a
pervasive pattern of social and
experience acute discomfort in social
settings and have a reduced capacity
for close relationships. For these
reasons they tend to be socially
isolated, reserved, and distant. Unlike
the Schizoid Personality Disorder,
they also experience perceptual and
cognitive distortions and/or eccentric
These perceptual abnormalities may include noticing flashes of light no one else
can see, or seeing objects or shadows in the corner of their eyes and then
realizing that nothing is there.
Personality Disorder have odd
beliefs, for instance, they may
believe they can read other
people's thoughts, or that that
their own thoughts have been
stolen from their heads. These
odd or superstitious beliefs and
fantasies are inconsistent with
cultural norms.
Schizotypal Personality Disorder tends to be found more frequently in families
where someone has been diagnosed with Schizophrenia; a severe mental
disorder with the defining feature of psychosis (the loss of reality testing). There
is some indication that these two distinct disorders share genetic commonalities
(Coccaro & Siever, 2005).

Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality

These three personality disorders share a high level of anxiety.
The Avoidant Personality Disorder is characterized by a pervasive pattern of
social inhibition, feelings of inadequacy,
and a hypersensitivity to negative
evaluation. People with this disorder are
intensely afraid that others will ridicule
them, reject them, or criticize them. This
leads them to avoid social situations and
to avoid interactions with others. This
further limits their ability to develop
social skills. People with Avoidant
Personality Disorders often have a very
limited social world with a small circle of confidants. Their social life is otherwise
rather limited..
Their way of thinking about and interpreting the world revolves around the
thought that they are not good enough, and that others don't like them. They
think of themselves as unappealing and socially inept. These types of thoughts
create feelings of intense anxiety in social situations, along with a fear of being
ridiculed, criticized, and rejected. The intensity of this fearful anxiety, and the
discomfort it creates, compels them to avoid interpersonal situations. They might
avoid parties or social events, and may have difficulty giving presentations at
work or speaking up in meetings. Others might perceive them as distant or shy.


They likely come across as stiff and restricted. All this will likely interfere with
their ability to make friends, or to move ahead professionally.
The core feature of the Dependent Personality Disorder is a strong need to be
taken care of by other people. This
need to be taken care of, and the
associated fear of losing the support
of others, often leads people with
Dependent Personality Disorder to
behave in a "clingy" manner; to
submit to the desires of other people.
In order to avoid conflict, they may
have great difficulty standing up for
themselves. The intense fear of losing
a relationship makes them vulnerable
to manipulation and abuse. They find
it difficult to express disagreement or
make independent decisions, and are
challenged to begin a task when nobody is available to assist them. Being alone is
extremely hard for them. When someone with Dependent Personality Disorder
finds that a relationship they depend on has ended, they will immediately seek
another source of support.
Persons with Obsessive-Compulsive Personality Disorder are preoccupied
orderliness. This preoccupation with
perfectionism and control is at the
expense of flexibility, openness, and
efficiency. They are great makers of
lists and schedules, and are often
devoted to work to such an extent
that they often neglect social
relationships. They have perfectionist
tendencies, and are so driven in their
work to "get it right" that they
become unable to complete projects
or specific tasks because they get
lost in the details, and fail to see the "forest for the trees." Persons with
Obsessive-Compulsive Personality Disorder tend to be rigid and inflexible in their
approach to things. It simply isn't an option for them to do a "sub-standard" job
just to get something done. Often, they are unable to delegate tasks for fear that
another person will not "get it right." Sometimes people with this disorder adopt
a miserly style with both themselves and others. Money is regarded as something
that must be rigidly controlled in order to ward off future catastrophe. People
with this disorder are often experienced as rigid, controlling, and stubborn.

It is important to remember that everyone can exhibit some of these personality
traits from time to time. To meet the diagnostic requirement of a personality
disorder, these traits must be inflexible; i.e., they can be repeatedly observed
without regard to time, place, or circumstance. Furthermore, these traits must
cause functional impairment and/or subjective distress. The above list only briefly
summarizes these individual Cluster A personality disorders. Richer, more
detailed descriptions of these disorders are found in the section describing the
four core features of personality disorders.
Personality disorder not otherwise specified
Personality disorder not otherwise specified, also referred to as personality
disorder NOS, is a diagnostic category in the Diagnostic and Statistical Manual of
Mental Disorders, fourth edition (DSM-IV-TR).
In current clinical practice, recognized mental health conditions and disorders are
grouped by a general category then by specific clinical diagnosis.
Under Mood Disorders for example, we have Major Depression, Dysthymia,
Bipolar Disorder (several types), Cyclothymia, and even Mood Disorder NOS.
Personality Disorders is one of the general categories. This category is often
given to individuals who have a long history of personality, behaviour, emotional,
and relationship difficulties. This group is said to have a personality disorder
an enduring pattern of inner experience (mood, attitude, beliefs, values, etc.) and
behaviour (aggressiveness, instability, etc.) that is significantly different from
those in their family or culture.
These dysfunctional patterns are inflexible and intrusive into almost every aspect
of the individuals life. These patterns create significant problems in personal and
emotional functioning and are often so severe that they lead to distress or
impairment in all areas of functioning. (Source: DSM-IV.)
In my observation, Personality Disorders often have core personalities of selfpreoccupation, insensitivity to others, a refusal to accept personal responsibility
(its always someone elses fault), and a tremendous sense of entitlement.
If a person has been diagnosed with a mood disorder, e.g. Bipolar l (Mixed) and a
Personality Disorder NOS, than this is a way of saying that while that person
requires treatment for Bipolar Disorder, the clinician suspects that he may have
long-standing personality features that may complicate the treatment and/or
The NOS diagnostic category is reserved for a clinically significant problem in
personality functioning that does not fit into any of the other existing personality


disorder categories. It suggests that a full pattern of a specific personality

disorder may not be present. This person may have a few symptoms of one type
of personality disorder, but not enough to meet diagnostic criteria. Or perhaps
he has some symptoms of one personality disorder and a few symptoms of
another type.
In either case, the provider has decided that while the symptoms are not a
perfect match for any existing personality disorder category, they are important
enough to warrant a diagnosis of PD-NOS.
In treating such a patient, while this diagnosis sounds like a bunch of labels, its
very important. The diagnosis means that the patient will need a combination of
psychiatric treatment for the Bipolar Disorder and counselling/therapy to address
the Personality Disorder features. Furthermore, treatment for Bipolar Disorder
focuses on emotional and social stability preventing both depressive and manic
episodes. When treating individuals with personality disorder features, medication
noncompliance is higher. Cluster B folks are more difficult to treat due to their
emphasis on excitement and emotional drama. If the patient has Borderline
Personality Disorder features, there is an additional risk for self-harm.

The Ten Personality Disorders: Cluster B by Authors: Simone Hoermann, Ph.D.,
Corinne E. Zupanick, Psy.D., & Mark Dombeck, Ph.D. - EDITOR: MATTHEW S.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders DSM-IV-TR Fourth Edition. American Psychiatric Association: 2000.
DSM-5: The Ten Personality Disorders: SIMONE HOERMANN, PH.D., CORINNE E.
Recently Diagnosed Personality Disorder NOS. What Does That Mean?
Dr Joseph M Carver, PhD

A compilation of Public Domain
Publications about CODEPENCE.
More compilations by Dean Amory
are available at:

Dr. Irene Matiatos Ph.D.
Daniel Ploskin, MD
Royane Real
Melody Beattie
Patty E. Fleener M.S.W.
Wikipedia Encyclopedy


2. Codependence
By Dr. Irene Matiatos Ph.D.
Some of the nicest people I know are codependent.
They always smile, never refuse to do a favor. They are happy and
bubbly all the time. They understand others and have the ability to make
people feel good. People like them!
So, what is wrong with this?
Nothing, really, unless the giving is
one-sided and so excessive that it
hurts the giver. Then, the giver is
showing the signs of codependence.
Partners who go out of their way
Only relatively healthy people are
relationships, which involve give and
It is not unhealthy to
unilaterally give during a time when
your partner is having difficulty. You
know your partner will reciprocate
Interdependency also implies that
you do not have to give until it hurts.
By comparison, in a codependent
relationship, one partner does almost
all the giving, while the other does
almost all the taking, almost all of the
By giving, codependent people avoid the discomfort of entitlement.
Giving allows them to feel useful and justifies their existence. Rather than simply
approving of themselves, codependent people meet their need for self-esteem, by
winning their partner's approval. Also, because they lack self-esteem,
codependent people have great difficulty accepting from others. One must feel
deserving and entitled in order to accept what is offered.
Codependent behaviour is not easy. It requires a lot of work.
It hurts. These individuals typically suffer with low self-esteem, depression,
anxiety, and especially guilt, as well as other painful thoughts and feelings. They
judge themselves using far stricter criteria than they use to measure the
performance of others. While they are brutally critical of their own misbehaviour,
they are very good at justifying and excusing the misbehaviour of others.


Codependent people misplace their anger.

They get angry when they shouldn't, and
don't get angry when they should. They have
little contact with their inner world and thus
very little idea about how they feel. Usually,
they don't want to know because it gives rise
to painful emotions. It is easier to stay on the
surface and pretend things are peachy keen,
rather than deal with the stuff going on
If they were to look inside, they would
find their emotional starvation.
They are busy taking care of others. Yet, they
do not meet their own needs!
They may put up with abusive relationships or
relationships that are not fulfilling because
any warm body beats (gasp) no warm body.
Being alone is perceived as scary, empty,
depressing, etc. After all, who will deliver
their emotional
supplies? Who will distract them so there is no time to deal with their inner life?
Even an abusive relationship is better than no relationship.
These loving, giving people find interesting ways of explaining their
behaviour to themselves.
Loyal to a fault, a codependent individual is likely to rationalize a loved one's
disrespectful behaviour by making excuses for them. "He doesn't mean it." "It
was not done with malice." "It is the best he can do." "She had such an awful
childhood." Etc., etc., etc.
The central concept is that the codependent individual "takes it" and
understands," despite feeling hurt.
Waiting for brownie points in heaven, or for a loved one to be magically healed
through their persistent love and care taking, they accept disrespect from others.
It does not occur to the codependent person that it is not OK to "take it" and "put
up" no matter what!
Much of this abuse acceptance occurs without the codependent
individual feeling abused!
More accurately, these individuals do not feel OK enough to expect respectful
treatment at all times, and to notice when it is not forthcoming. Having grown up
in a home where a parent or sibling demanded inordinate attention (due to
addiction, illness, anger, or other problem), the codependent person is trained to
care for others. Having grown up in a difficult environment, a negative emotional
climate is experienced as normal and familiar.
This is why there is often little recognition of disrespect. If their partner is angry
or upset, the codependent individual will implicitly assume that they did
something to cause the anger. It does not occur to them that it is their partner's
responsibility to deal with their problem and to treat others respectfully. It does
not occur to them that it is their responsibility to themselves to stop another

person's demeaning behaviour toward them. But, how can stop disrespect when
misbehaviour is not perceived as disrespectful or abusive? Disrespect is normal.
An unfortunate side effect of the codependent person's willingness to
ignore, excuse, or otherwise allow the
partner's abuse or disrespect, enables
the misbehaviour directed at them to
continue and intensify.
Implicit or explicit permission to continue
codependent partner "understands."
approval-driven, they cannot stand it when
others are angry at or disappointed with
As such, they unwittingly place themselves in
a position to be taken advantage of. The
more approval is needed, the less likely is
the individual to realize the extent of their
self-sacrifice in favor of tending to the needs
of the other. This hurts ("Ouchhh!"), and
creates or maintains depression and low selfesteem, in a vicious, downward spiral.

While abuse, disrespect, or unrequited sacrifice angers them, as it

should, codependent people do not realize how angry they are and at
whom they are angry!
Targeting the appropriate person may jeopardize a source of approval and selfesteem. To avoid facing reality, they distort it.
Codependent individuals are likely to somehow blame themselves and rationalize
their "over-sensitivity." They justify the other person's behaviour by thinking they
must deserve the treatment they are getting. This is preferable to facing the
possibility that an individual who provides a measure of their self-esteem is
hurting them.
" a signal that something is wrong and needs attention".
Anger is healthy. It is a signal that something is wrong and needs attention.
However, if the source of anger is not articulated, how can it be fixed?
Codependent people are expert at denying anger and turning it against the self into sadness and depression. Instead of asking themselves why are they are
putting up with... (fill in the blank), they ask themselves how they could have
behaved differently - to obtain a more favorable reaction from their partner!
Unarticulated anger is often misdirected and expressed inappropriately.
Anger may be experienced as resentment, expressed as an aggressive blow-up,
or in passive-aggressive acting out. The cognitive and verbal skills to
appropriately assert oneself are lacking.


Since codependent people are experts at controlling other people's

thoughts, feelings, and behaviour, they feel hurt that others don't
reciprocate and "know" what they need.
"If they really loved me, they would know." Not so! Since codependents do not
have the self-esteem to ask for what they secretly want, they are unlikely to get
it. If they do make a request, it is often a roundabout hint. If their partner cannot
decipher the request, they feel hurt and unloved. They believe they conveyed
their desires, when, in fact, they have not!
Because most codependent individuals are control-oriented, they are
very responsible.
They are great employees. Tasks are done thoroughly and on time. Even parts of
the job that are not theirs get picked up if coworkers are neglectful or slow. They
try to control outcomes, whether those outcomes are completed job tasks or
reactions from other people. Anything for approval.
However, some codependent individuals are very irresponsible, in select
or diverse life areas.
They don't know how to or don't feel the need to take care of some of their own
basic needs, especially if there is another person to care for instead. Why spend
the time trying to figure out what the self needs, when
the self doesn't really matter anyway? It is far more preferable to be out avoiding
one's own issues: out having fun, hunting for a partner, or self-medicating
Codependent people are addiction prone.
They may drink too much, shop too
much, eat too much, etc. Dulling the
senses is a great way to avoid knowing
yourself and dealing with your feelings.
Intimacy is avoided.
Intimate behaviour requires familiarity
and comfort with one's internal world.
Since the codependent person regards
ordinary human needs as shameful,
embarrassing, dangerous, or otherwise
uncomfortable, meeting basic needs are
often dismissed.
Any relationship that ignores the self is superficial.
Unfortunately, superficial relationships are safe...but empty and unfulfilling.
Control is central to the "MO" of the codependent person.
They control their self-esteem by catering to others' needs.
They control by their over-responsible performance, picking up where others
leave off.
They control by avoiding intimacy or by clouding the mind.
They control by advising others on what to do.
These individuals work very hard to control everything and everybody.
Yet, they neglect the one person they do have control over: themselves.

Why Be Codependent?
Why would anybody spend time and energy to control outcomes, while
actively neglecting the inner self? How can they do this and not realize
they are selling themselves short?
The Why: they know no other way;
The How: they received very good training early in life.
Any dysfunction in the family predisposes a child to codependent
Children are biologically programmed
to seek love and approval. They have
to be cared for or they will die.
When a parent or family member is
dysfunctional, the child tends to focus
on this person--rather than on
enjoying a carefree and joyful kid
existence. The child has to worry: if
the caretaker does not care take, the
child dies. For example, in an alcoholic
home, little Sally has to worry about
whether she can bring friends home because daddy may be in a bad mood
and embarrass her.
Such events are training her in
codependent thinking, the art of
anticipating the other person.
If mom is physically ill, Teddy has to worry about exerting her. Who would care
for him if anything happened to her? If daddy is angry and controlling, Timmy
needs to worry about pleasing him to avoid punishment and humiliation - and to
get his conditional love and approval.
Children are naturally egocentric.
That means that they see the world
revolving around them. If mom and
dad fight, children feel that it is
somehow their fault. Julie may try to
make her parents happy by getting
straight As in school in an attempt to
keep the parental marriage together.
Another child may have an abusive,
or simply overactive older sibling.
Since the parents cannot be there at
all times to police the situation, the
anticipate the sib's moods and to
behave in ways that might increase
the probability of "safety." Or,
perhaps daddy is depressed. Jennifer
may tiptoe around him wondering if he is unhappy because she is not good
enough. And so on.


In sum, codependent thinking tends to develop any time a child is

growing up in a home where life is not care free.
Often, addiction can be traced in the family tree of these dysfunctional families,
whether there is an active addict in residence, or not. Nevertheless, these kids
have an adult they have to worry about!
The codependent-in-training is taught to walk on eggshells.
To ensure survival, the child learns to be extraordinarily sensitive in reading the
moods and thoughts of others. The child learns very early to pay attention to and
tiptoe around the dysfunctional family members - at the child's expense. These
interactions take place silently, implicitly. The child learns to ignore the self's
inner needs, instead pretending that all is OK.
When I tell my clients that codependent adults were once children who
had an adult to worry about, some sharply disagree.
They tell me about the loving families they came from and insist that their family
members were "wonderful," etc. As denial melts and self-awareness develops,
they begin to recognize the failings in a caregiver that spawned their selflessness.
Sometimes, both parents were codependent, modeling no other behaviours for
the child to learn.

More About Codependence

(Article by Daniel Ploskin, MD - August 21, 2007 A.O.)

While not recognized as a diagnosable illness in the American Psychiatric

Associations Diagnostic and Statistical Manual of Psychiatric Disorders (a
professional reference used to make diagnoses), codependence generally refers
to the way past events from childhood unknowingly affect some of our attitudes,
behaviours and feelings in the present, often with destructive consequences,
according to the National Council on Codependence. Certain signs can help us
identify a tendency toward codependence.

Self-worth comes from external sources

Codependent people need external sources, things or
other people to give them feelings of self-worth.
Often, following destructive parental relationships, an
abusive past and/or self-destructive partners,
codependents learn to react to others, worry about
others and depend on others to help them feel useful
or alive. They put other peoples needs, wants and
experiences above their own.
In fact, codependence is a relationship with ones self
that is so painful a person no longer trusts his or her
own experiences. It perpetuates a continual cycle of
shame, blame and self-abuse. Codependent people
might feel brutally abused by the mildest criticism or
suicidal when a relationship ends. In his 1999 book,
Codependence: The Dance of Wounded Souls, author
Robert Burney says the battle cry of codependence is:
Ill show you! Ill get me!

Examples of codependency
Health professionals first identified codependence in the wives of alcoholic men.
Through family treatment, they discovered that spouses and family members
were codependent, or also had addictive tendencies. Co-addiction occurs when
more than one person, usually a couple, has a relationship that is responsible for
maintaining addictive behaviour in at least one of the persons.
For example, co-addicted people might believe that, at some level, getting a
partner or family member to become sober or drug-free might seem like the one
goal which, if achieved, would bring them happiness. But on another level, they
might realize they are behaving in a way that enables the addict with whom they
live to maintain their addictions.
For instance, they might never confront the addict about her behaviour. Or they
might become her caretaker, spending limitless time worrying about her. They
might assume its their responsibility to clean up after and apologize for their
loved ones behaviour. They might even help her continue to use alcohol or drugs
by giving her money, food or even drugs and alcohol, for fear of what would
happen to her if they did things differently. Many codependents come to believe


they are so unlovable and unworthy that to stay in a dysfunctional, destructive

relationship is the best and safest way to live.
Codependent people who believe they cant
survive without their partners do anything
they can to stay in their relationships,
however painful. The fear of losing their
partners and being abandoned overpowers
any other feelings they might have. The
thought of trying to address any of their
partners dysfunctional behaviours makes
them feel unsafe. Excusing or denying a
problem like addiction means they avoid
rejection by their partners.
Instead, as in the example above, coaddicted people often will try to adapt
themselves and their lives to their partners
dysfunction. They might have abandoned
hope that something better is possible,
instead settling for the job of maintaining
the status quo. The thought of change
might cause them great pain and sadness.
Codependence works the same way,
whether the addiction is drugs, alcohol or something else, such as sex, gambling,
verbal or physical abuse, work or a hobby. If the addicts behaviour causes worry,
forcing the partners to adjust to and deny the problem, they are at great risk of
becoming codependent. Those who were abused as children face an even greater

Checklist for family members of

people with Mental Health Disorders
(Article by Patty E. Fleener M.S.W.)
I wanted to touch on codependency. It seems like an old subject yet people are
hurt by this "condition" so often and so many of us have these issues and are not
Why do I bring this up in a mental health website? Most person with a mental
health disorder has a family member. If you are the family member, check
yourself out for these behaviours quickly and if you can't relate then move on.
Just because those of us who have mental health disorders may not be a family
member of someone with a mental health disorder, doesn't mean we don't have a
problem with codependency and it is very difficult to work on recovery when our
focus is always on someone else. In fact, downright impossible.
So many family members are focusing completely on the person who has the
mental health disorder that they are not in touch with their own needs at all. This
is not only unhealthy for the family member but for the person with the disorder
as well.

You must learn to get your life back and as the author Melodie Beattie says
"lovingly detaching." You are not on this earth to take care of your partner or
your daughter or your cousin, etc. Let me repeat that. You are not on this earth
to take care of your partner or your daughter or your cousin, etc.
That may be a part of your life and a very important part of your life. But that is
not the only reason you are on this earth and that is not the only thing that
defines you. You must find out who you are and become that person once again.
You must be that person you were before you knew "that person" and have that
person in your life as well.

What does it feel like if you have been around someone strongly

I felt violated. My boundaries were crossed. I felt extremely angry and upset. I
felt manipulated and power was taken away from me that belonged to me.
I had always heard that 50% of chemically dependent people are codependent.
My husband who attends AA says the joke there is that it is 100%. So I do not
know what the exact figures are.


Are You Codependent?

By Royane Real - Published: 5/6/2006

Do you feel like you give and give in your relationships but you get very
little back? Are you always trying to save somebody or rescue somebody
that doesnt have their life together? You may be co-dependent. Take
this quiz and find out.

In a relationship between two emotionally

healthy adults, the roles of giving and
receiving help are balanced. Both people
offer help and receive help from each
other in approximately equal amounts.
However, there are some people who
always take on the role of being the
helper, no matter what relationship they
are in. These people give, and give, and
they always seem to get involved with
people who have very serious emotional
problems, such as addiction.
And they
exhaust themselves trying desperately to
tremendous cost to their own health.





These people have friendships that focus

exclusively on trying to solve the problems
of their friends. We sometimes call this
quality "co-dependency", and we may
obsessed with helping others "co-dependent".

A person who is co-dependent will tend to have relationships with people who
have a lot of problems emotional, social, familial and financial. The codependent person may spend much of their own time, money, and energy
helping other people who have problems, while ignoring the problems in their
own life.

Why would somebody be co-dependent?

A person who is co-dependent often suffers from a deep sense of worthlessness
and anxiety, and tries to derive a sense of self-worth by helping or rescuing
others. A person who is co-dependent may not know how to relax and feel
comfortable in a friendship where both people are equals and the relationship is
based on enjoying each others company.
Co-dependent people may even feel anxious if someone they have been helping
gets their life in order and no longer wants their help. The co-dependent person
may immediately look around for someone else they can "save".
If you frequently take on the role of helping the people who are your friends, how
can you tell if you are acting out of genuine kindness and concern, or whether
your behaviour is in fact co-dependency?

When is it healthy to put the needs of other people first, and when is it
There arent really any hard and fast lines between the two.

Here are some questions you can ask yourself to see whether your
"helping" behaviour may actually be co-dependency:
- Do you have a hard time saying no to others, even when you are very busy,
financially broke, or completely exhausted?
- Are you always sacrificing your own needs for everyone else?
- Do you feel more worthy as a human being because you have taken on a
helping role?
- If you stopped helping your friends, would you feel guilty or worthless?
- Would you know how to be in a friendship that doesnt revolve around you
being the "helper"?
- If your friends eventually didnt need your help, would you still be friends with
them? Or would you look around for someone else to help?
- Do you feel resentful when others are not grateful enough to you for your
efforts at rescuing them or fixing their lives?
- Do you sometimes feel like more of a social worker than a friend in your
- Do you feel uncomfortable receiving help from other people? Is the role of
helping others a much more natural role for you to play in your relationships?
- Does it seem as if many of your friends have particularly chaotic lives, with one
crisis after another?
- Did you grow up in a family that had a lot of emotional chaos or addiction


- Are many of your friends addicts, or do they have serious emotional and social
- As you were growing up, did you think it was up to you to keep the family
- As an adult, is it important for you to be thought of as the "dependable one"?
- Do you feel responsible for other people--their feelings, thoughts, actions,
choices, wants, needs, well-being and destiny?
- Do you feel compelled to help people solve their problems or by trying to take
care of their feelings?
- Do you find it easier to feel and express anger about injustices done to others
than about injustices done to you?
- Do you feel safest and most comfortable when you are giving to others?
- Do you feel insecure and guilty when someone gives to you?
- Do you feel empty, bored and worthless if you don't have someone else to take
care of, a problem to solve, or a crisis to deal with?
- Are you often unable to stop talking, thinking and worrying about other people
and their problems?
- Do you lose interest in your own life when you are in love?
- Do you stay in relationships that don't work and tolerate abuse in order to keep
people loving you?
- Do you leave bad relationships only to form new ones that don't work, either?
If you answered "yes" to a lot of these questions, you may indeed have a
problem with co-dependency.
This does not mean that you are a flawed person. It means that you are spending
a lot of energy on other people and very little on yourself.
If it seems that a lot of your friendships are based on co-dependent rescuing
behaviours, rather than on mutual liking and respect between equals, you may
wish to step back and rethink your role in relationships.
If you suspect that your helping behaviour is a form of co-dependency, a good
therapist or counselor can help you gain perspective on your actions and learn a
more balanced way of relating to others.

Let's review some basic codependency behaviours.

What do Codependents try to do?
Control others or situations.
Do they really think they can control others?
Can anyone ever control others?
Do they cross our boundaries?
Do they mind their own business?
Do they manipulate?
Do they know what is best for you?
What do they say when we get angry with them for crossing our boundaries?
I was only trying to help.
What are some reasons they do this?
To avoid their own issues.
To get their mind off of themselves.
What does Al-Anon tell them to do?
Butt out! Mind their own business.
Get the focus off of them and back
on their selves.
What do they do when they can't control you?
Get angry.

Characteristics of Codependency
1. My good feelings about who I am stem from being liked by you
2. My good feelings about who I am stem from receiving approval from you
3. Your struggle affects my serenity. My mental attention focuses on solving your
problems/relieving your pain
4. My mental attention is focused on you
5. My mental attention is focused on protecting you
6. My mental attention is focused on manipulating you to do it my way
7. My self-esteem is bolstered by solving your problems
8. My self-esteem is bolstered by relieving your pain
9. My own hobbies/interests are put to one side. My time is spent sharing your
10. Your clothing and personal appearance are dictated by my desires and I feel
you are a reflection of me
11. Your behaviour is dictated by my desires and I feel you are a reflection of me
12. I am not aware of how I feel. I am aware of how you feel.
13. I am not aware of what I want - I ask what you want. I am not aware - I
14. The dreams I have for my future are linked to you
15. My fear of rejection determines what I say or do
16. My fear of your anger determines what I say or do
17. I use giving as a way of feeling safe in our relationship
18. My social circle diminishes as I involve myself with you
19. I put my values aside in order to connect with you
20. I value your opinion and way of doing things more than my own
21. The quality of my life is in relation to the quality of yours
Melody Beattie, author of Codependent No More developed this check list:

Website Links for Codependents:


What does a healthy friendship look like

compared to a codependent friendship?
I'm just at the beginning stages of
discovering what that's like. From what I
know so far I can say that you should not
have such high expectations of your friends.
You should value the differences you see
in them.
Also, you should not depend on them. You
can depend on them to a certain extent, but
with a healthy relationship it's not life or
death if you are not with them.
Obviously love is a part of a friendship, but
now I'm learning to love others by faith unconditionally. We all fail but you have to
leave room for failure in a friendship because

we're all human so disappointment and mistakes are bound to happen.

I've also discovered that relationships are not all about me. It's about how
loving and serving the other person. Also a good friendship is really about how
we can build each other up.
I have learned a lot about forgiveness too. I had to forgive people in my past for
what they did to me. Now I have to forgive myself for what I did to Anna.
Holding onto my past hurts facilitated a lot of my actions. I know that a healthy
friendship brings freedom. I'm so much more relaxed now. I have lots of
friends but I dont feel as if I really need any friends or one best friend.

How can someone recognize this pattern in their own life?

I think there always has to be a more
dominant person in a codependent
relationship. You could be the dominant
one. I was the dominant one.
dominant one takes the initiative. The
dominant one has all the expectations of
the other person and can feel like the
other person doesn't measure up.
Often as the dominant one I felt sad or
lonely. When I hung out with other people
I would think of her. My heart would not
be fully engaged with other friends. People
considered us to be so close so the
thought of even breaking away from each
other was horrifying. I invested a lot in
her. I shared my emotions with her. I
never got close to anyone as I did with her.

That's another pattern of codependency - only letting that one person get close
and not letting others get close to you.
Even if someone were to show me, I still didn't see at all how I was codependent
on Anna. It is very much a process of discovering on my own the kind of lifestyle
I was living.
I am a stubborn person too. I didn't quite want to give her friendship up, as
unhealthy as it was. I knew I had a problem, but I didn't want to break
from this friendship because I was scared of the unknown.
All I knew was what I was comfortable with and I didn't want to separate myself
from that comfort. I wanted to change my life but it took months and months
before I could take the necessary steps, which made me realize just how
unhealthy my relationship had been.

What are some key questions that would help someone realize if
they are in a codependent relationship?

How much time am I spending with this friend? That determines a lot right
Am I neglecting other friends?
Do I think this relationship is healthy? What do others in my life who care
about me think about this relationship?
Are there questions about the past that I need to answer for myself?
Have I forgiven people in my past that have hurt me, and moved on?

What addictive behaviour were you struggling with?

A codependent friendship.

How did it start?

Six years ago I met a person I thought
would be my best friend for life. I was going
through a huge transition in my life coming
home from college and having to start over
graduated, all my friends were still in
college and my old friends from high school
had all changed. It was hard for me to
identify and connect again with my old
I connected with a few of my old friends
from high school, and through one of them
I met Anna.
At the beginning of our friendship Anna and
I connected really well and we had a lot of fun. We spent a lot of time
together right from the beginning. She too had just come home from college
and didn't know anyone.


We started hanging out 2-3 times a week, but I started calling her more and
By the second year of our friendship we hung out every night and were
communicating thoroughly every day.
We became inseparable to the point that people thought we were sisters.
Neither of us had been in an unhealthy friendship before and because we shared
a deeper dimension of life in our friendship (faith and spirituality), we never
thought our attachment to each other was unhealthy.
But, over time, I started becoming more manipulative over her and placed
higher and higher expectations on her. I figured that if she knew me best she
should know how to treat me perfectly.
She was the one that I thought had to give me what I needed and I would get
upset if I didn't get it. I demanded a lot from her and she complied most of
the time with what I needed.

What kinds of needs did you want her to meet?

I was really looking for Anna to
meet my emotional needs.

Why did you feel "addicted"

to this relationship?
Because I felt I needed. It seemed
to be a safe place to go for refuge.
To me, she seemed like a safe
I tried to find my satisfaction and
fulfilment in Anna. But, she could
hardly meet a tenth of what I
expected or thought I needed from

When did you start to see a

problem with your relationship?
Anna's relatives and close friends would say that we hung out too much. But both
of us were too entrenched in our friendship to think anything was really wrong.
We were both needy and we both fulfilled needs in each other. But, at the same
time, we weren't satisfied because there was a void there that we could feel
and sense, especially spiritually.
We began to realize that we were becoming too dependent on each other. At first
there was no way I'd drop her friendship, because she still meant the world to
me. But after spending more time reading books on friendship and
codependence, we were both seeing just how unhealthy the relationship had

Describe what your relationship looked like in its most dependent

Often Anna would get angry easily because I
was manipulative and possessive.
I was outgoing and dominant, and she, being
opposite, was a good follower. Our difference
in personality made it easy for our friendship
to get out of balance.
Throughout this time I was blinded to my
other friends. I didn't see how my other
friends were really important to me. I also
neglected to value my own family. I cared
more about Anna coming over on a family
day more than I cared about seeing my
I wanted to be with her all the time. I would shower her with cards and gifts.
She would do the same for me.
When I was hanging out with Anna I would try to control who she hung out with
and control how deep her friendship with others would get.
I would ask her what she was doing during the week and made sure she spent
the most time with me. I continually re-affirmed in my mind that I was
number one in her life.
Throughout all of this, I didn't realize how manipulative I had become.
Looking back I can see how much of what I did had
an ulterior motive. I wanted what was best for her,
but I was the one who determined that. I figured
what was best for her was to build our friendship.
I tended to see myself as a needed person in her life.
If I wasn't in her life I thought she would be
weakened and not grow to her potential. It was
selfish because I thought I was everything to
But often, our friendship was disappointing. When
we spent time together, I would expect it to look a
certain way and would be angry, sad, or disappointed
when it didn't go the way I expected.
I would analyze our time together and question if our time together was quality
or deep enough. This wore me out and made me anxious. It felt like the end
of the world when we couldn't hang out together. Overall, my self
esteem sucked.


How would you feel if she wanted to

leave you?
We constantly confirmed with each other that
we would never be separated. Any time I
would panic she would always affirm that "I'll
always be your friend, I'll always be there for
But, you can't make promises like that to a
friend because you don't know where you'll
be or how you'll change. We made these
promises to each other to give each other a
sense of stability.

What steps did you have to take to get back out of this
codependent relationship?
Through mentorship and reading books I learned that our friendship was
unhealthy. About 5 months ago she took an important step and asked to take
time away from our friendship. Since then, we haven't communicated or talked.
It was the best thing we've ever done.

Did you notice a pattern of control in your past relationships?

Yes, it started immediately after high school. High school was a crucial time in my
life and I never felt accepted.
I felt rejected basically for
who I was and felt very
alone. I tried really hard,
and was afraid I wouldn't have
any friends. I wanted to
ensure that I had friends so I
was always trying to be in
dependent on friends. But,
this dependency didn't reach
its peak until I met Anna
because at that point I really
wanted a best friend. Anna
was so compliant to go along
with all my suggestions.
There were so many things I
myself. I loved others but I loved wrongly. My love was misdirected.

Help! Can I Fix it?

Good news! You certainly can! You can get control over your life!
You can stop trying to control the lives of others and take charge of

While children are truly not

responsible for their actions,
adults are.
To experience a more satisfying
life, it becomes incumbent upon the
adult to take control of the
unavoidable childhood or presentday
Parents don't set out to hurt their
partners! We get hurt and we in
turn hurt others because we are
imperfect. We may never achieve
perfection, but we can improve.
It is important to remember that
we are in part a product of our
If we mis-behave, we have learned
to do so. The good news is that
what was learned can be unlearned
or modified. The best news is that,
in my experience, codependency
issues are in most cases not particularly difficult problems to deal with.
I find a blend of cognitive behaviour therapy with an emphasis on cognitive and
verbal skills training combined with a 12-Step approach very effective. Many selfhelp resources are available from books to support groups, as well as professional
"Codependence" is cocktail party talk. Walk into your local book store's self-help
or psychology section and look around. Melodie Beattie and Pia Mellody are two of
my favorite authors in the field. Also, check out some of Albert Ellis' cognitivebehavioural work that helps in stamping out irrational codependent thinking.
Self-help groups such as ALANON and CODA are 12-Step programs that have
their own formula help change codependent behaviour.
So, go to therapy. Read, get to a meeting. Get yourself evaluated for medication
if you are depressed. Do whatever you need to do. As an adult, you have options.
You can take control of your life! You are the only one who can take control of
your life.


Helping a Person Who Is Codependent

If someone in your life is codependent -a spouse, parent, child or friend- your
support may be an important part of recovery. Here are some ways you can help.

Begin a dialogue about childhood and
messages your spouses might have
received from his parents that could have
caused shame. You might want to share
your own experiences of shame and how
they affected you. If you are recovering
from an addiction, it might be useful to
discuss how most spouses are affected by
their partners addiction and what might
be helpful to him (Al-Anon Meetings,
Attending therapy with a spouse or buying
a book on codependence and reading it
together are other ways to begin to help.

You might want to get a friend to open up to you by sharing your
own insights with him. You can offer to go to a Codependents
Anonymous Meeting with him or buy him a book to read about
codependence. You also could offer him a place to stay (if he is
living with an addict and could benefit from time apart) or a
referral to a mental health professional. Sometimes making the
first phone call for help can be the first step toward empowering
the person to get well.

Helping a child, unless its an adult child, might not be
appropriate since codependency as dysfunctional behaviour
is hard to distinguish from normal dependency when a child
is still young. If you are the parent of an adult son or
daughter who is now in a codependent relationship, you
could help by telling your child how much you love her and
that getting well is possible. Remind your child of the
strengths and positive qualities that sustained her through
other difficult times. Offer a place to stay or to go to a 12-Step meeting with her.

Helping a parent often is like helping adult children. Parents may resist taking
advice from their children. But if, together, you can go to a 12-step meeting, go
to therapy or read a book on codependence, you may begin to stir up a desire for

Helping a coworker might include sharing information over lunch or inviting her
over for coffee after work. If you are aware of a codependence problem with a
coworker, chances are she already has entrusted you with some intimate
information. However, work might not be the best place to discuss a topic as
personal as codependence. Often, you can help just by offering to listen outside
work or to be an escort to a 12-step meeting.

Treatment Options for Codependence

If you think you have a problem with codependence, treatment is available and
can help you feel better. Healing takes time and hard work, but talking with other
codependents and seeing a therapist are two of the best ways to start your

Treatment may consist of individual
therapy, group therapy and, eventually,
couples and family therapy. A clinical
social worker, psychologist or psychiatrist
with experience treating codependents
and families of addicts can help you
identify and discuss the feelings, thoughts
and behaviours that you and others find

Twelve-step groups
Many advocates of the codependency theory view codependency as a type of
addiction. Therefore, they maintain that codependents can overcome their
symptoms with a 12-step process similar to that used by Alcoholics Anonymous.
Twelve-step recovery programs bring codependents together as a group to talk
about their struggles and share hope and experiences. The 12-step recovery
process involves spirituality and is nondenominational. Codependents Anonymous
meetings can provide participants with a great source of emotional and practical
support. Program recovery involves admitting your life has become
unmanageable because of your codependence. It requires expressing your
feelings, doing what you can to get better and letting go of things you cant
control. Familiar 12-step affirmations include One Day at a Time, Easy Does
It, Let Go and Let God (a higher power).


If you are interested in going to a meeting, contact your local mental health
center and ask where you can find a Codependents Anonymous meeting in your

If you are confronting codependence issues as well as mental illness such as a
depression or anxiety disorder [Link to articles on Depression and Anxiety
Disorder], you might want to see your primary care doctor or a psychiatrist. He
can determine whether medication such as an antidepressant might help you.
Often those who take medication and attend therapy and 12-step sessions find
this combination to be the fastest and easiest way to get well.

Healing shame
The key to healing a wounded self is to change
the distorted, negative perspectives and reactions
to our human emotions that result from having
grown up in a dysfunctional, emotionally
repressive and spiritually hostile environment.
Most therapists agree that part of this healing
process must involve grief. Grieving for the pain
that caused the codependence and for the
difficulties you suffered is a difficult but rewarding
process. Learning to love yourself requires
acknowledging your shame, disowning it, grieving
the emotional damage you have sustained and
healing the emotional wounds.

The Twelve Traditions

The Twelve Steps are accompanied by
The Twelve Traditions of group
governance as developed by Alcoholics
formation. Most 12-step fellowships
also adopted these principles as their
structural governance. In AA, the
empathetic desire to save other
drunks resulted in a radical emphasis
on service to other sufferers only.
Thus the only requirement for AA
membership is the desire to stop
guidelines were adopted by other fellowships, with particular emphasis on
freedom from alcohol because of the formative history of these traditions (note
that alcohol is considered a drug in most substance-related twelve-step groups).

The Twelve Traditions of Alcoholics Anonymous:

Our common welfare should come first; personal recovery depends
upon A.A. unity.
For our group purpose there is but one ultimate authority a loving
God as He may express Himself in our group conscience. Our leaders
are but trusted servants; they do not govern.
The only requirement for A.A. membership is a desire to stop drinking.
Each group should be autonomous except in matters affecting other
groups or A.A. as a whole.
Each group has but one primary purpose to carry its message to the
alcoholic who still suffers.
An A.A. group ought never endorse, finance, or lend the A.A. name to
any related facility or outside enterprise, lest problems of money,
property, and prestige divert us from our primary purpose.
Every A.A. group ought to be fully self-supporting, declining outside
Alcoholics Anonymous should remain forever non-professional, but our
service centers may employ special workers.
A.A., as such, ought never be organized; but we may create service
boards or committees directly responsible to those they serve.
Alcoholics Anonymous has no opinion on outside issues; hence the A.A.
name ought never be drawn into public controversy.
Our public relations policy is based on attraction rather than promotion;
we need always maintain personal anonymity at the level of press,
radio, and films.
Anonymity is the spiritual foundation of all our traditions, ever
reminding us to place principles before personalities.


Meeting Process
characteristics of twelve-step groups is the
requirement that members focus on the
admission that they "have a problem". In this
spirit, many members open their address to
the group along the lines of, "Hi, I'm Pam and
I'm an alcoholic" a catchphrase now widely
identified with support groups.
Attendees at group meetings share their
failures, and provide peer support for each
other. Many people who have joined these
groups report they found success that
previously eluded them, while others
including some ex-members criticize their
efficacy or universal applicability. This varied
success rate, along with the fact that twelvestep programs have been associated with the
belief in a higher power -- a belief often
associated with religion -- has caused some

Twelve Step process

symbolically represent human
structure in three dimensions:
physical, mental, and spiritual.
The disorders and diseases the
themselves in each dimension.
dimension is best described by
reaction" resulting in the
substances after the initial use.
For groups not related to
substance abuse the physical
manifestation could be much
more varied including, but not
forgetfulness, hyperactivity, hypomania, insomnia, irritability, lack of motivation,
laziness, mania, panic attacks, poor impulse control, procrastination, self-injury,
suicide attempts, and stress. The illness of the spiritual dimension, in all Twelve
Step groups, is considered to be self-centeredness. This model is not intended to
be a scientific explanation. It is only a model that members of Twelve Step
organizations have found useful.
In time, the process is intended to replace self-centeredness with a growing
moral consciousness and a willingness for self-sacrifice and unselfish constructive
action. In Twelve Step groups, this is known as a spiritual awakening or religious
experience. This should not be confused with abreaction, which generally only
results in temporary change. In Twelve Step groups, "spiritual awakening" is
believed to develop, most frequently, slowly over a period of time.

In twelve-step programs, a sponsor is a more experienced person in recovery
who guides the less-experienced aspirant ("sponsee") through the process of the
steps as a program of personal recovery. One of the first suggestions newcomers
to 12-step meetings are offered is to secure a relationship with a sponsor. A vast
array of publications from various fellowhips emphasize that sponsorship is a
"one on one" relationship of shared experiences focused on working the 12 steps
Many forms of sponsorship exist. Sponsors and sponsees participate in activities
that lead to spiritual growth as defined by the twelve-step process. These may
include practices such as literature discussion and study, meditation, and writing.
Part of the final of the twelve steps is often interpreted to imply becoming a
sponsor to newcomers in recovery. "Sponsorship, with its continuing interest in


another alcoholic, often develops when the second person is willing to be helped,
admits having a drinking problem, and decides to seek a way out of the trap."
"Sponsors share their
experience, strength,
and hope with their
sponsors role is not
adviser, a banker, a
parent, a marriage
counselor, or a social
worker. Nor is a
sponsor a therapist
offering some sort of
professional advice. A
willing to share his or
her journey through
the Twelve Steps."
from NA's Sponsorship: Revised
Sponsees typically do their Fifth Step with their sponsor. The Fifth Step, as well
as the Ninth Step, have been compared to confession and penitence. Many, such
as Michel Foucault, noted such practices "produces intrinsic modifications in the
person" and exonerates, redeems, purifies them; it unburdens them of their
wrongs, liberates them and promises their salvation.
The personal nature of the behavioural issues that lead to seeking help in 12-step
fellowships results in a strong relationship between sponsee and sponsor. As the
relationship is based on spiritual principles, it is unique and not generally
characterized as "friendship." Fundamentally, the sponsor has the single purpose
of helping the sponsee recover from the behavioural problem that brought the
sufferer into 12-step work[18], which reflexively helps the sponsor recover.

Acceptance of a Higher Power

A primary tenet of 12-step recovery requires a member to surrender willful selfreliance (a characteristic of afflicted persons) and adopt a practice of reliance
upon a "Higher Power" of the member's own understanding. Proponents of
twelve-step programs allege that agnostics and even atheists can be helped by
the program, as a members concept of a Higher Power may focus on the 12-step
group itself. With time, any other entity, thing(s) or object(s) that aid a member
in accepting their powerlessness over their problem, are claimed to become the
Higher Power that will help them to recover. It is colloquially stated that any
Power perceived as being greater than oneself will do, provided the power is not
any other, single individual, or one's own unaided will.

Literature studied in
most 12-step groups
is limited to their own
publications, as these
outside affiliation. The
members of 12-step
distinction that the
groups are spiritual,
Some members of 12step groups are also
members of a wide
variety of religious
bodies. Nearly every
meeting begins with
the Serenity Prayer, a prayer addressed to "God." Some critics also question the
idea of giving up on self-reliance, which, they argue, results in a form of idealized
despair. Others acknowledge a debt to the twelve-steps movement but do not
have a culture of belief in God.

Court-mandated Twelve-step attendance

The success of twelve-step programs in aiding the recovery of chemicallydependent persons is an argument of significance in jurisdictions of some criminal
justice systems. The criminal justice system of the United States has ordered
attendance at 12-step meetings to convicted criminals as well as inmates as a
condition of parole, condition of shortened sentence, or as an element of a
sentence. Four courts have ruled that Alcoholics Anonymous groups are religious
organizations. The New York Court of Appeals ruled in Griffin v. Coughlin, 88
N.Y.2d 674 (1996) that doing so compromises the Establishment Clause of the
United States Constitution on the grounds that A.A. practices and doctrine are (in
the words of the district court judge
Supreme Court of the United States
denied US Legal Certiorari and
allowed the New York court's
decision to stand. Such a denial
"imports no expression of opinion
upon the merits of the case, as the
bar has been told many times."
Missouri v. Jenkins, 515 U.S. 70
(1995). Denial of certiorari means
that no binding precedent is
created, and that the lower court decision is authoritative only within its area of
jurisdiction -- in this case the State of New York. However, the decision does
create a persuasive precedent for other jurisdictions.


These are some versions of the Twelve Steps from different

The 12 Steps of Alcoholics

The 12 Steps of Co-Dependents


1. We admitted we were powerless

over alcohol --- that our lives had
become unmanageable.

1. We admitted we were powerless

over others --- that our lives had
become unmanageable.

2. Came to believe that a Power

greater than ourselves could restore
us to sanity.

2. Came to believe that a Power

greater than ourselves could restore us
to sanity.

3. Made a decision to turn our will and

3. Made a decision to turn our will
our lives over to the care of God as we
and our lives over to the care of God
understood God.
as we understood Him.
4. Made a searching and fearless
4. Made a searching and fearless
moral inventory of ourselves.
moral inventory of ourselves.
5. Admitted to God, to ourselves, and
5. Admitted to God, to ourselves,
to another human being the exact
and to another human being the
nature of our wrongs.
exact nature of our wrongs.
6. Were entirely ready to have God
6. Were ready to have God remove remove all these defects of character.
all these defects of character.
7. Humbly asked God to remove our
7. Humbly asked Him to remove
our shortcomings.

8. Made a list of all persons we had

harmed, and became willing to make
8. Made a list of all persons we had
amends to them all.
harmed, and became willing to make
amends to them all.
9. Made direct amends to such people
wherever possible, except when to do
9. Made direct amends to them
so would injure them or others.
wherever possible, except when to
10. Continued to take personal
do so would injure them or others.
inventory and when we were wrong
10. Continued to take personal
promptly admitted it.
inventory and when we were wrong
11. Sought through prayer and
promptly admitted it.
meditation to improve our conscious
11. Sought through prayer and
contact with God, praying only for
meditation to improve our conscious knowledge of God's will for us and the
contact with God as we understood
power to carry that out.
Him, praying only for His will for us
12. Having had a Spiritual awakening
and the power to carry that our.
as the result of these steps, we tried to
carry this message to other co12. Having had a Spiritual
dependents, and to practice these
awakening as the result of these
steps, we tried to carry this message principles in all our affairs.
to other alcoholics, and to practice
these principles in all our affairs.

The 12 Steps to Recovery for

From: Choicemaking by Sharon
Wegscheider Cruse

16 Steps for Discovery and

From: Many Roads, One Journey;
Moving Beyond the 12 Steps by
Charlotte Kasl Ph.D.

1. We acknowledge and accept that we

are powerless in controlling the lives of 1. We affirm we have the power to
others, and that trying to control others take charge of our lives and stop being
makes our lives unmanageable.
dependent on substances or other
people for our self-esteem and security.
2. We have come to believe that a
power greater than ourselves can
2. We come to believe that God /the
restore enough order and hope in our
Goddess /Universe /Great Spirit /Higher
lives to move us to a growth
Power awakens the healing wisdom
within us when we open ourselves to
that power.
3. We make a decision to turn our
lives over to this power to the best of
3. We make a decision to become our
our ability, and honestly accept that
authentic Selves and trust in the healing
taking responsibility for ourselves is the power of Truth.
only way growth is possible.
4. We examine our beliefs, addictions,
4. We make an inventory of ourselves, and dependent behaviour in the context
looking for our mental, emotional,
of living in a hierarchical, patriarchal
spiritual, physical, volitional, and social culture.
assets and liabilities. We look at what
we have, how we use it, and how we
5. We share with another person and
can acquire what we need.
the Universe all those things inside of
us for which we feel shame and guilt.
5. Using this inventory as a guide, we
admit to ourselves, to God as we
6. We affirm and enjoy our strengths,
understood him, and to other caring
talents, and creativity, striving not to
persons, the exact nature of what is
hide these qualities to protect other's
within that is causing ourselves pain.
6. We give to God as we know him all
former pain, hurt, and mistakes,
resentments and bitterness, anger, and
guilt. We trust that we can let go of the
hurt that we cause and receive.

7. We become willing to let go of

shame, guilt, and any behaviour that
keeps us from loving ourSelves and

7. We can ask for help, support, and

guidance and be willing to take
responsibility for ourselves and to

8. We make a list of people we have

harmed and people who have harmed
us, and take steps to clear out negative
energy by making amends and sharing
our grievances in a respectful way.

8. We begin a program of living

responsibly for ourselves, for our own
feelings, mistakes, and successes. We
become responsible for our part in
relationship to others.

9. We express love and gratitude to

others, and increasingly appreciate, the
wonder of life and the blessings we do
10. We continue to trust our reality and


daily affirm that we see what we see,

9. We make a list of persons to whom we know what we know, and we feel
we want to make amends and
what we feel.
commence to do so, except where doing
so would cause further pain for others. 11. We promptly acknowledge our
mistakes and make amends when
10. We continue to work our program, appropriate, but we do not say we are
each day checking out our progress and sorry for things we have not done and
asking for feedback from others in our
we do not cover up, analyze, or take
attempt to recover and grow. We do
responsibility for the shortcomings of
this through support groups.
11. We seek through our own power
and a Higher Power, awareness of our
inner selves. We do this through
reading, listening, meditation, sharing,
and other ways of centering and getting
in touch with our inner selves.
12. Having experienced the power of
growing toward wholeness, we find our
bodies, minds, and spirits awakened to
a new sense of physical and emotional
relief which leaves us open to a new
awareness of Spirituality. We seek to
explore our meaning in life by honest
sharing with others, remember that
BECOMING WHO WE ARE is a lifetime
task which must be done one day at a

12. We seek out situations, jobs, and

people that affirm our intelligence,
perceptions, and self-worth and avoid
situations or people who are hurtful,
harmful, or demeaning to us.
13. We take steps to heal our physical
bodies, organize our lives, reduce
stress, and have fun.
14. We seek to find our inward calling,
and develop the will and wisdom to
follow it.
15. We accept the ups and downs of
life as natural events that can be used
as lessons for growth.
16. We grow in awareness that we are
interrelated with all living things, and
we contribute to restoring peace and
balance on the planet.

12 Steps for Kids

From: Kids' Power: Healing Games for
Children of Alcoholics, by Jerry Moe
1. I am powerless over alcohol, drugs,
and other people's behaviour and my
life got real messed up because of it.

The Twelve Steps of NonRecovery

Evidently originally called the Twelve
Steps to Insanity From the March 1990
Issue of the ACA Communicator,
published by the Omaha - Council Bluffs
Area Intergroup.

2. I need help. I can't do it alone


1. We admitted we were powerless

over nothing, that we would manage
our lives perfectly and those of anyone
3. I've made a decision to reach out for else who would allow us to.
a Power greater than me to help out.
2. Came to believe there was no
power greater than ourselves and the
4. I wrote down all of the things that
rest of the world was insane.
bother me about myself and others, and 3. Made a decision to have our loved
the things that I like too.
ones and friends turn their will and their
lives over to our care, even though they
5. I shared these with someone I trust couldn't understand us.
because I don't have to keep them a
4 Made a searching moral and immosecret anymore.
ral inventory of everyone we knew.
5. Admitted to the whole world the
6. My Higher Power helps me with
exact nature of everyone else's wrongs.
this, too.
6. Were entirely ready to make others
straighten up and do right.
7. The more I trust myself and my
7. Demanded others to either shape up
Higher Power, the more I learn to trust or ship out.
8 Made a list of all persons who had
harmed us and became willing to go to
8. I made a list of the people I hurt
any length to get even with them all.
and the ways I hurt myself. I can now 9. Got direct revenge on such people
forgive myself and others.
whenever possible, except when to do
so would cost us our lives, or at the
9. I talked to these people even if I
very least a jail sentence.
was scared to because I knew that it
10. Continued to take inventory of
would help me feel better about myself. others, and when they were wrong
promptly and repeatedly told them
10. I keep on discovering more things about it.
about myself each day and if I hurt
11. Sought through complaining and
someone, I apologize.
nagging to improve our relations with
others as we couldn't understand them,
11. When I am patient and pray, I get asking only that they knuckle under and
closer to my Higher Power, and that
do it our way.
helps me know myself better.
12. Having had a complete physical,
emotional and spiritual breakdown as a
12. By using these steps, I've become result of these steps, we tried to blame
a new person. I don't have to feel
it on others and to get sympathy and
alone anymore, and I can help others.
pity in all of our affairs.


Twelve-step program
From Wikipedia, the free encyclopedia
A Twelve-step program is a set of guiding principles for recovery from
addictive, compulsive, or other behavioural problems, originally developed by the
fellowship of Alcoholics Anonymous ("A.A.") to guide recovery from alcoholism.
The twelve steps were first published in the text Alcoholics Anonymous ("The Big
Book"). This method has been adapted as the foundation of other twelve-step
programs such as Narcotics Anonymous, Overeaters Anonymous, Marijuana
Anonymous, Crystal Meth Anonymous, Co-Dependents Anonymous and Emotions
Anonymous. Mandated court involvement with 12-step fellowships is a
controversial practice of some governments; as stated in the Twelve Traditions,
Twelve-step fellowships have no opinion as a group on issues other than personal
recovery. As summarized by the American Psychological Association, working the
Twelve Steps involves the following.

admitting that one cannot control one's addiction or compulsion;

recognizing a spiritual higher power that can give strength;
examining past errors with the help of a sponsor (experienced
making amends for these errors;
learning to live a new life with a new code of behaviour;
helping others that suffer from the same addictions or compulsions.

Overview of
The way of life outlined
in the 12-steps has
been adapted widely.
The effects of A.A.
family unit providing
improved quality of life
resulted in fellowships
people who did not
relate to the specifics of alcohol dependency started meeting together as
Narcotics Anonymous[3]; similar groups were formed for sufferers of cocaine
addiction, crystal meth addiction and many other behavioural problems.
Behavioural issues such as compulsion and/or addiction with sex, food, and
gambling were found to be solved for some people with the daily application of
the 12-steps in such fellowships as Sexual Compulsives Anonymous, Overeaters
Anonymous and Emotions Anonymous. Other groups addressing problems with

certain types of behaviours include Clutterers Anonymous, Debtors Anonymous

and Gamblers Anonymous. Over 50 fellowships composed of millions of recovery
members, all based in the same principles, are found around the world.
"After a while I began to wonder why I was not [happy] ... I decided to strive for
my own spiritual growth. I used the same principles [Bill] did to learn how to
change my attitudes. ... We began to learn that ...the partner of the alcoholic
also needed to live by a spiritual program."
"Lois's Story" in the Al-Anon "Big Book", a typical story of a sufferer finding
fulfillment through application of the 12 steps

The Twelve Steps

These are the original Twelve Steps as defined by Alcoholics Anonymous:
1. We admitted we were powerless over alcoholthat our lives had become
2. Came to believe that a Power greater than ourselves could restore us to
3. Made a decision to turn our will and our lives over to the care of God as we
understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact
nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make
amends to them all.
9. Made direct amends to such people wherever possible, except when to do
so would injure them or others.
10.Continued to take personal inventory and
when we were wrong promptly admitted
11.Sought through prayer and meditation to
improve our conscious contact with God
as we understood Him, praying only for
knowledge of His Will for us and the
power to carry that out.
12.Having had a spiritual awakening as the
result of these steps, we tried to carry
this message to alcoholics, and to
practice these principles in all our affairs.
Other twelve-step groups have adapted these
steps of Alcoholics Anonymous as guiding
principles for problems other than alcoholism;
in some cases the steps have been altered to emphasize particular principles
important to those fellowships.


The first such program was Alcoholics Anonymous (A.A.), which was begun in
1935 by Bill Wilson and Dr. Bob Smith, known to A.A. members as "Bill W." and
"Dr. Bob", in Akron, Ohio. They established the tradition within the "anonymous"
Twelve-step programs of using only first names. The Twelve Steps were originally
written by Wilson and represented Wilson's incorporation of the teachings of Rev.
Sam Shoemaker about the Oxford Group's life-changing program.
As Alcoholics Anonymous was growing in the 1930s and 1940s and definite
guiding principles began to emerge as the 12 traditions, a singleness of purpose
emerged as tradition five: "Each group has but one primary purpose to carry its
message to the alcoholic who still suffers." [9] Consequently, drug addicts who do
not suffer from the specifics of alcoholism involved in Alcoholics Anonymous
hoping for recovery technically are not welcome in 'closed' meetings for alcoholics
only[10]. The reason for such emphasis on alcoholism as the problem is to
overcome denial and distraction[11]. Thus the principles of Alcoholics Anonymous
have been used to form many numbers of other fellowships for those recovering
from various pathologies, each of which in term emphasizes recovery from the
specific malady which brought the sufferer into the fellowship.

Key Recovery Concepts

There are five key recovery concepts that, through her research,
Mary Ellen found to be essential to effective recovery work. They
Hope - People who experience mental health difficulties get well, stay well and
go on to meet their life dreams and goals.
Personal Responsibility - It's up to you, with the assistance of others, to take
action and do what needs to be done to keep yourself well.
Education - Learning all you can about what you are experiencing so you can
make good decisions about all aspects of you life.
Self Advocacy -Effectively reaching out to others so that you can get what it is
that you need, want and deserve to support your wellness and recovery.
Support - While working toward your wellness is up to you, receiving support
from others, and giving support to others will help you feel better and enhance
the quality of your life.

Recovery Steps
Relief of symptoms is
only the first step in
treating depression or
Wellness, or recovery,
is a return to a life that
Recovery happens when
getting in the way of
your life.

What is Recovery?
Substance Abuse and
Mental Health Services
Administration / Center
for Mental Health Services) defines recovery as:
Mental health recovery is a journey of healing and transformation enabling a
person with a mental health problem to live a meaningful life in a community of
his or her choice while striving to achieve his or her full potential.

Next Steps in Recovery

Depression and bipolar disorder are
illnesses that affect a persons
moods, thoughts, body, energy and
emotions. Both illnesses, especially
bipolar disorder, tend to follow a
cyclical course, meaning they have
ups and downs.
Treatment for these illnesses can
also have ups and downs. As much
as we may want it to, wellness often
does not happen overnight. It is
normal to wish you could feel better
faster or to worry that you will never
feel better. However, know that you can feel better, and that ultimately you are
in charge of your recovery. There are many things you can do to help yourself.
Relief of symptoms is only the first step in treating depression or bipolar disorder.
Wellness, or recovery, is a return to a life that you care about. Recovery happens
when your illness stops getting in the way of your life. You decide what recovery
means to you.


You have the right to recover according to your needs and goals. Talk to your
health care provider (HCP) about what you need from treatment to reach your
recovery. Your HCP can provide the
treatment(s) and/or medication(s) that
work best for you. Along the way, you
have a right to ask questions about the
treatments you are getting and choose
the treatments you want.
It can also be helpful to work with a
therapist, family member, friend and
peer supporters to help define your
recovery. Your definition of a meaning
life may change at different times in
life. At times, depression and bipolar
disorder might make it seem difficult to
set a goal for yourself.
Sometimes it might feel almost
impossible to think about the things
that you hope for or care about. But goal setting is an important part of
wellness, no matter where you are on your path to recovery. Work on what you
can when you can.

Setting Goals
Identifying life goals is the heart of the recovery process. When we see a future
for ourselves, we begin to become motivated to do all we can to reach that
future. Goals can be big or small, depending on where you are in your recovery

Ask yourself:

What motivates me?

What interests me?

What would I do more if I could?

What do I want?

What do I care about, or what did I care

about before my illness?

Where do I want my life to go?

What brings me joy?

What are my dreams and hopes?

It can help to start small and work up to larger

goals. You might want to begin by setting one small
goal for yourself at the beginning of each day. As
you move forward with your recovery, look at the
different areas of your life and think about your short and long term goals.

Short term goals might include:

Be out of bed by xx:00 am.
Finish one household chore.
Call a DBSA support group.

Long term goals might include:

Get training or experience for a job.
Change a living situation, e.g., find an apartment
Build a relationship with a friend or family member.
Remember break your goals down into small steps at first. Looking at a goal
such as 'move to a new city' can be difficult to visualize and plan all at once. Ask
yourself what you need to do first. What can you do now that will help you
eventually reach this goal? Not only will this help move you closer to your goal,
but it will also help give you a positive feeling of accomplishment.

What are some things I can do that might help me feel better?
Know the difference between your symptoms
and your true self. Your HCPs can help you
separate your true identity from your symptoms
by helping you see how your illness affects your
behaviour. Be open about behaviours you want
to change and set goals for making those
Educate your family and involve them in
treatment when possible. They can help you
spot symptoms, track behaviours and gain
perspective. They can also give encouraging
feedback and help you make a plan to cope with
any future crises.
Work on healthy lifestyle choices. Recovery is also about a healthy lifestyle,
which includes regular sleep, healthy eating, and the avoidance of alcohol, drugs,
and risky behaviour.
Find the treatment that works for you. Talk to your HCP about your
medications' effects on you, especially the side effects that bother
you. Remember to chart these effects so that you can discuss them fully with
your HCP. You might need to take a lower dosage, a higher dosage, or a
different medication. You might need to switch your medication time from
morning to evening or take medication on a full stomach. There are many
options for you and your HCP to try. Side effects can be reduced or eliminated.
It is very important to talk to your HCP first before you make any changes to
your medication or schedule.
Talk with your HCP first if you feel like changing your dosage or stopping your
medication. Explain what you want to change and why you think it will help you.


Treatments for Depression and Bipolar Disorder

Treatments that work can help you:
Reach your goals.
Build on the strengths you have and the things you
can do.
Plan your health care based on your needs.
Live your life without the interference of symptoms.
Treatments can include some or all of these elements:
therapy, medications, peer support, and overall lifestyle

Medications for Depression and Bipolar Disorder

Your HCP might prescribe one or more medications to treat your symptoms.
These may include:
Mood stabilizers: These medications help balance your highs and lows. Some
mood stabilizer medications are called anticonvulsants, because they are also
used to treat epilepsy.
Antidepressants: These medications help lift the symptoms of depression. There
are several different classes (types) of antidepressants.
Antipsychotics: These medications are primarily used to treat symptoms of
mania. Even if you are not hallucinating or having delusions, these medications
can help slow racing thoughts to a manageable speed.

Talk Therapy
There are many types of talk therapy that can help
you address issues in your life and learn new ways to
cope with your illness. Goal setting is an important
part of talk therapy. Talk therapy can also help you
Understand your illness
Overcome fears or insecurities
Cope with stress
Make sense of past traumatic experiences
Separate your true personality from the mood
swings caused by your illness
Identify triggers that may worsen your symptoms
Improve relationships with family and friends
Establish a stable, dependable routine
Develop a plan for coping with crises
Understand why things bother you and what you can do about them
End destructive habits such as drinking, using drugs, overspending or risky
Address symptoms like changes in eating or sleeping habits, anger,
anxiety, irritability or unpleasant feelings

Peer Support
Support from people who understand is another
important part of recovery. There are many ways to
get this support. DBSA offers a variety of ways to
interact with your peers, such as support groups,
discussion forums, and an interactive chat room.
Find a support group
DBSA's discussion board
Interactive chat room

A healthy lifestyle is always important. Even if
symptoms of depression or bipolar disorder make
things like physical activity, healthy eating or
regular sleep difficult, you can improve your
moods by improving your health. Take advantage
of the good days you have. On these days, do
something healthy for yourself. It might be as
simple as taking a short walk, eating a fresh
vegetable or fruit, or writing in a journal. A talk
about lifestyle changes should be a part of your
goal setting with your HCPs.
You have the power to change. You are the most
important part of your wellness plan. Your
treatment plan will be unique to you. It will follow
some basic principles and paths, but you and your
HCPs can adapt it to fit you. A healthy lifestyle
and support from people who have been there can
help you work with your HCP and find a way to
real and lasting wellness.

Family and Friends' Guide to Recovery From

Depression and Bipolar Disorder
When a friend or family member has an episode of depression or bipolar disorder (manic
depression), you might be unsure about what you can do to help. You might wonder how
you should treat the person. You may be hesitant to talk about the persons illness, or
feel guilty, angry, or confused. All of these things are normal.
There are ways you can help friends or family members throughout their recovery while
empowering them to make their own choices.


The Five Stages of Recovery

It can be helpful to view recovery as a process with five stages. People go
through these stages at different speeds.
Recovery from an illness like
depression or bipolar disorder, like the illness itself, has ups and downs. Friends
and family who are supportive and dependable can make a big difference in a
persons ability to cope within each of these stages.

1. Handling the Impact of the Illness

Being overwhelmed and confused by the illness.
An episode of mania or depression, especially one
that causes major problems with relationships,
money, employment or other areas of life, can be
devastating for everyone involved. A person who
needs to be hospitalized may leave the hospital
feeling confused, ashamed, overwhelmed, and
unsure about what to do next.

What friends and family can do:

Offer emotional support and understanding.
Offer to help them talk with or find health care
Keep brief notes of symptoms, treatment, progress, side effects and
setbacks in a journal or personal calendar.
Be patient and accepting.
Your loved ones illness is not your fault or theirs. It is a real illness that can be
successfully treated. Resist the urge to try to fix everything all at once. Be
supportive, but know that your loved one is ultimately responsible for his or her
own treatment and lifestyle choices.

2. Feeling Like Life is Limited

Believing life will never be the same.
At this stage, people take a hard look at the ways their
illness has affected their lives. They may not believe
their lives can ever change or improve. It is important
that friends, families, and health care providers instill
hope and rebuild a positive self-image.


What friends and family can do:

Believe in the persons ability to get well.

Tell them they have the ability to get well with time and patience. Instill
hope by focusing on their strengths.

Work to separate the symptoms of the illness from the persons true
personality. Help the person rebuild a positive self-image.

Recognize when your loved one is having symptoms and realize that
communication may be more difficult during these times. Know that
symptoms such as social withdrawal come from the illness and are
probably not a reaction to you.
Do your best not to rush, pressure, hover or nag.

A mood disorder affects a persons attitude and beliefs. Hopelessness, lack of

interest, anger, anxiety, and impatience can all be symptoms of the illness.
Treatment helps people recognize and work to correct these types of distorted
thoughts and feelings. Your support and acceptance are essential during this

3. Realizing and Believing Change is Possible

Questioning the disabling power of the illness and
believing life can be different.

Hope is a powerful motivator in recovery. Plans,

goals, and belief in a better future can motivate
people to work on day-to-day wellness. At this
stage people begin to believe that life can be
better and change is possible.
What friends and family can do:
Empower your loved on to participate in
wellness by taking small steps toward a
healthier lifestyle. This may include:
Sticking with the same sleep and wake
Consistently getting good nutrition
Doing some sort of physical activity or exercise
Avoiding alcohol and substances
Finding a DBSA support group
Keeping health care appointments and staying with treatment
Offer reassurance that the future can and will be different and better.
Remind them they have the power to change.
Help them identify things they want to change and things they want to

Symptoms of depression and bipolar disorder may cause a hopeless, whats the
point? attitude. This is also a symptom of the illness. With treatment, people
can and will improve. To help loved ones move forward in recovery, help them

identify negative things they are dissatisfied with and want to change, or positive
things they would like to do. Help them work toward achieving these things.

4. Commitment to Change
Exploring possibilities and challenging the disabling power of the illness.
Depression and bipolar disorder are powerful illnesses, but they
do not have to keep people from living fulfilling lives. At this
stage, people experience a change in attitude. They become
more aware of the possibilities in their lives and the choices
that are open to them. They work to avoid feeling held back or
defined by their illness. They actively work on the strategies
they have identified to keep themselves well. It is helpful to
focus on their strengths and the skills, resources and support
they need.

What friends and family can do:

Help people identify:

Things they enjoy or feel passionate about

Ways they can bring those things into their lives
Things they are dissatisfied with and want to change
Ways they can change those things
Skills, strengths and ideas that can help them reach their goals.
Resources that can help build additional skills
Help them figure out what keeps them well.
Encourage and support their efforts.


The key is to take small steps. Many small steps will add up to big positive
changes. Find small ways for them to get involved in things they care about.
These can be activities they enjoy, or things they want to change, in their own
lives or in the world.

5. Actions for Change

Moving beyond the disabling power of the illness.

At this stage, people turn words into actions by

taking steps toward their goals. For some
people, this may mean seeking full-time, parttime or volunteer work, for others it may mean
changing a living situation or working in
mental health advocacy.
What friends and family can do:
Help your friends or family members to
use the strengths and skills they have.
Keep their expectations reachable and
realistic without holding them back.
Help them find additional resources and
supports to help them reach their goals
Continue to support them as they set new goals and focus on life beyond
their illness.
Help them identify and overcome negative or defeatist thinking.
Encourage them to take it easy on themselves and enjoy the journey.
People with depression or bipolar disorder have the power to create the lives they
want for themselves. When they look beyond their illness, the possibilities are

What you can say that helps:

You are not alone in this.
Im here for you.
I understand you have a
real illness and thats what
causes these thoughts and
You many not believe it
now, but the way youre
feeling will change.
I may not be able to
understand exactly how
you feel but I care about
you and want to help.
When you want to give up,
tell yourself you will hold of
for just one more day,
hour, minute - whatever
you can manage.
You are important to me.
Your life is important to
Tell me what I can do now
to help you.
I am here for you. We will
get through this together.

Avoid saying:
Its all in your head.
We all go through times like this.
Youll be fine. Stop worrying.
Look on the bright side.
You have so much to live for why do you want to die?
I cant do anything about your situation.
Just snap out of it.
Stop acting crazy.
Whats wrong with you?
Shouldnt you be better by now?


What to find out:

Contact information (including emergency numbers) for your loved ones doctor,
therapist, and psychiatrist, your local hospital, and trusted friends and family
members who can help in a crisis
Whether you have permission to discuss your love ones treatment with his or her
doctors, and if not, what you need to do to get that permission.
The treatments and medications your loved one is receiving, any special dosage
instructions and any needed changes in diet or activity.
The most likely warning signs of a worsening manic or depressive episode (words
and behaviours) and what you can do to help.
What kind of day-to-day help you can offer, such as doing housework or grocery
When talking with your love ones health care providers, be patient, polite and
assertive. Ask for clarification of things you do not understand. Write things
down that you need to remember.

Helping and getting help

As a friend or family
member you can provide the
best support when youre
taking care of yourself. It
helps to talk to people who
know how it feels to be in
your situation. Talk with
relatives, look for therapy of
your own, or find a support
DBSA support groups are
run by families and friends
affected by depression or
bipolar disorder. They are
meetings where people can learn more about these illnesses and how to live with
One father of a daughter with bipolar disorder says, DBSA support groups help
take a lot of stress out of your life. As a family member, you have to be as
prepared as possible, and accept that things will still happen that you arent
totally prepared for. DO all the research you can. Build a long list of dependable
resources and support people, so when a situation arises, you know where to
turn and how to take the next step. This really helped my family when we
needed it.


Sometimes depression and bipolar disorder have symptoms that can best be
helped by inpatient psychiatric treatment. Try to find out what treatment is
available to your loved one, and what steps you can take during a crisis before
the crisis occurs, if possible.

People may need to go to the hospital if they:

Threaten or try to take their lives

or hurt themselves or others
Believe things that arent true
Need special treatments such as
electroconvulsive therapy
Have problems with alcohol or
Have not eaten or slept for
several days
Are unable to care for themselves
or their families, e.g., getting out
of bed, bathing, dressing
therapy, medication and support
and still have a lot of trouble with
Need to make a significant switch
in treatment or medication under
the close supervision of their

Have any symptom of mania or depression that significantly interferes with

Voluntary hospitalization takes place when a person willingly signs forms agreeing
to be treated in the hospital. A person who signs in voluntarily may also ask to
leave. This request should be made in writing. The hospital must release people
who make requests within a period of time (two to seven days, depending on
state laws), unless they are a danger to themselves or others.
Most psychiatric hospital stays are from five to ten days. There are also longer
residential rehabilitation programs for alcohol or substance abuse, eating
disorders or other issues that require long-term treatment.
Involuntary hospitalization is a last resort when someones symptoms have
become so severe that they will not listen to others or accept help. You may need
to involve your loved ones doctor, the police or lawyers. It is better to talk with
your loved one before a crisis and determine the best treatment options together.
Work with your loved one in advance to write down ways to cope and what to do


if symptoms become severe. Having a plan can ease the stress on you and your
loved one, and ensure that the appropriate care is given.

How can I convince my loved one to check in voluntarily?

Explain that the person is not going to an institution, asylum or prison.
Hospitalization is treatment, not punishment.
Reassure your loved one that the hospital is a safe place where a person can
begin to get well. No one outside the family needs to be told about the
Tell your loved one that getting help does not mean someone has failed. A
mood disorder is an illness that needs treatment, like diabetes or heart
disease. Hospitalization is nothing to be ashamed of.
Call the hospital and find out more about admission, treatment and policies.
Help your loved one pack comfortable clothing and safe items that are
reminders of home.
Offer the person a chance to make choices (such as what to take to the
hospital, or who to go with), if this is desired.

How should I talk to a person in crisis?

Stay calm. Talk slowly and use reassuring tones.
Realize you may have trouble communicating with your loved one. Ask simple
questions. Repeat them if necessary, using the same words each time.
Dont take your loved ones actions or hurtful words personally.
Say, Im here. I care. I want to help. How can I help you?
Dont say, Snap out of it, Get over it, or Stop acting crazy.
Dont handle the crisis alone. Call family, friends, neighbors, people from your
place of worship or people from a local support group to help you.
Dont threaten to call 911 unless you intend to. When you call 911, police
and/or an ambulance are likely to come to your house. This may make your
loved one more upset, so use 911 only when you or someone else is in
immediate danger.

Crisis Planning:
Some people find it helpful to write down mania prevention and suicide
prevention plans, and give copies to trusted friends and relatives. These plans
should include:
A list of symptoms that might be signs the person is becoming manic or
Things you or others can do to help when you see these symptoms.
A list of helpful phone numbers, including health care providers, family
members, friends and a suicide crisis line such as 1-800-273-TALK.
A promise from your friend or family member that he or she will call you,
other trusted friends or relatives, one of his or her doctors, a crisis line or a
hospital when manic or depressive symptoms become severe.
Encouraging words such as My life is valuable and worthwhile, even if it
doesnt feel that way right now. Reality checks such as, I should not make
major life decisions when my thoughts are racing and Im feeling on top of
the world. I need to stop and take time to discuss these things with others

before going through with them. How can an advance directive or a medical
power of attorney help?
An advance directive and a medical power of attorney are written documents that
give others authority to act on a persons behalf when that person is ill. Your
loved one can specify what decisions should be made and when. It is best to
consult a qualified attorney to help with an advance directive or a medical power
of attorney. These documents work differently in different states.


Helping Others Throughout Their Lives

What can I do when my child is ill?
Patience and understanding are
especially important when a
child is ill. Children with bipolar
disorder often have different
symptoms than adults do, and
are more likely to switch
quickly from manic symptoms
to depressive symptoms. Make
sure you have a doctor who
understands mood disorders in
children, and is able to spend
time discussing your childs
treatment. Communicate to
your child that there is hope you and the doctors are
working on a solution that will help him or her feel better. Explain your childs
disorder to siblings on a level they can understand. Suggest ways they can help.
Seek family counseling if necessary. It is also helpful to network with other
parents whose children have a mood disorder.
With the assistance of your childs mental health care provider, help your child
learn relaxation techniques and use them at home. Teach positive coping
strategies to help him or her feel more prepared for stressful situations.
Encourage your child to self-express through art, music, writing, play, or any
other special gifts he or she has. Provide routine and structure in the home, and
freedom within limits. Above all, remember that mood disorders are not caused
by bad parenting, and do not blame yourself for your childs illness.
Children with mood disorders do better in a low-stress, quiet home environment,
and with a family communication style that is calm, low-volume, non-critical, and
focused on problem-solving rather than punishment or blaming. Stress reduction
at school through use of an Individual Educational Plan (IEP) is also very
important. Request an evaluation from your childs school counselor or
psychologist to get the process started.
If your child with a mood disorder is an adult, it is important to treat him or her
like an adult, even when he or she is not acting like one. As much as you may
want to, you may not be able to force your adult child to keep doctors
appointments or take medications. As with any other family member, keep
encouraging treatment and offering your support, but establish boundaries for
yourself too, such as not lending money if your adult child seems to be having
manic or hypo manic symptoms.

What can I do when an older relative is ill?

Mood disorders are not a normal part of aging. You may
face more challenges if an elderly relative is ill and lives far
away from you or in an assisted living facility. Stay
informed about the treatment your loved one is receiving.
Develop a relationship with his or her doctors and the staff
at the facility. Your relative may need special help
remembering to take medications. Make sure all of his or
her doctors communicate if he or she is being treated for
multiple illnesses. This is extremely important, since some
medications for mood disorders can interact with
medications for other illnesses and cause problems.
It may be helpful for you to spend additional time with
your elderly relative, or, if that is difficult, meet with other
relatives to see if you can take turns visiting or caring for your loved one.


Self Help Affirmations That Work

Memory Storage:
It used to be thought that information is planted in long term memory through
repetition. Today, we know that information transfers to long term memory
through association between new data and the already stored information.

Affirmations that Dont Work:

Ever promised yourself, Im going to do better, Im going to do better, Im not
going to eat so much junk food, Im going to eat healthier to find you ate even
more? Most try such affirmations hoping the repetition, earnestness, positive
words and thoughts will transform a habitual negative behaviour. Wrong! Truth
is, for the most part, just the opposite transpires. You often end up doing more of
what you dont want and less of what you do want. Affirmations done in this way
just may be a part of the problem, not a part of the solution.

On a conscious brain and body awareness

level, you made a promise that the
unconscious brain and body did not hear,
understand or agree to. Often times, the
repeated, the further into despair and
failure you can sink. Sometimes the only
result is increased guilt, hopelessness,
powerlessness and self doubt that further
sabotage your positive intention to change.
Detrimental early experiences, generational
coding, and environmental learning drive
the unconscious reactions and are not
affirmations, medicine, or treatments.
Learning new habits requires unlearning
existing ones. For several reasons, it is
easier to learn something new than to
unlearn something old. First, many factors
influence how information is stored in the
memory. The hippocampus part of the brain
records a lifetime of experiences and
thoughts. One thought connects to another. Information is retrieved by searching
through the network of interconnections to the place where it is stored. The more
frequently a path of retrieval is followed, the stronger the path becomes. It took
years to create the negative part in the first place, so how many repetitions
would it take to create a new one in its place? You could just try harder, but the
latest scientific research found it takes at least a 1000 repetitions before a habit
begins to change on the unconscious level. Most people are not motivated to
commit to such a long term process of repetitions, no matter how much they
desire the outcome.

Second, the unconscious does not hear or process negative words. Traditionally,
affirmations state what you dont want, plus what you do want. For example, you
may say, Im not going to eat ice cream every day, because I dont want to get
fat so Ill choose more fruits and vegetables. Your unconscious hears, Im going
to eat ice cream, Im going to get fat, Im going to choose more fruits and
vegetables. These messages are usually enhanced mentally with pictures of ice
cream and being fat instead of eating healthy vegetables and a healthy body.

Affirmations That Work!

Most spend far more time thinking what they dont want
than what they desire. Each time you think about a
problem in a particular habitual way, the mental circuits
or pathways get activated and strengthen with each
recall. Through time, mental ruts form that makes it
difficult to reorganize infor-mation, or see it from a
different perspective, much less choose a different
Reversal Conflict Tapping Technique uses a combination
of energy modalities including Touch for health, Eye
Movement Desensitization, and the Acupuncture
Meridian System. The goal is to 1) confuse and weaken
negative habits and neural pathways, and 2) replace
and strengthen new, positive patterns of connections
between the nerve cells, so increasing the odds are that
you will call up the new memory. Real change without
the struggle can be realized when the unconscious and
conscious brain and body are congruent. Given the right
tools, all parts are willing, ready and able to change.

Reversal Conflict Tapping Technique:

Goal: Confuse and delete old habits and install a new
1. Pinpoint your underlying negative emotion or state:
fear, stressed, anxious, depressed, failure, angry, overwhelmed, guilty, sad,
jealous, stuck, frustrated, hopeless, powerless
2. The key to choice and change is to make peace with your conflicting parts that
sabotage your intentions and affirmations. This requires self acceptance and love
for yourself just the way you are presently, even before things change, even if
things never change.
Say: In spite of this inner conflict, _______ (ie, fear, anxiety,depression,
apathy, anger, failure, conflict, etc.) I deeply and profoundly love, accept, and
respect myself.
3. Stimulate both brain hemispheres. Since your brain has 100 billion neurons,
each being a learning center capable of storing new information, activate this
potential by tapping.
Do: Tap lightly in a semi-circle on the area one inch above and around the ear.


4. Circular eye movements integrate both brain hemispheres to assist in deleting

the mental ruts and replacing them with new information.
Do: With your head still and facing straight, move your eyes in a large circle,
then begin looking down on the floor, move them to the right as if you are
outlining a large circle with your eye. Follow the imaginary circle up and down the
opposite side, and back to the floor where you started. Repeat the circles for 5-6
times in one direction, then change directions for 5-6 eye circles.
* Combine A, B, C to delete the old and enhance the new.
5. Exercise your mind to strengthen your desired outcome. Expedite change
through the visual field of your brain. Take advantage of your brains inability to
know the difference between the past, the present, and the future. Play the new,
more positive movie as if it already is in the present.
Do: Put a picture of the affirmation you desire on the movie screen of your mind.
See it clearly, with color, up close, and life size, the way you dream it to be. Play
that movie often.

How long will it take before the person feels better?

Some people are able to stabilize quickly after starting treatment; others take
longer and need to try several treatments, medications or medication
combinations before they feel better. Talk therapy can be helpful for managing
symptoms during this time.
If your friend or family member is
facing treatment challenges, the person
needs your support and patience more
than ever. Education can help you both
find out all the options that are
available and decide whether a second
opinion is needed. Help your loved one
to take medication as prescribed, and
dont assume the person isnt following
the treatment plan just because he or
she isnt feeling 100% better.

There is hope:
As a friend or family member of
someone who is coping with bipolar
disorder or depression, your support is
an important part of working toward
wellness. Dont give up hope. Treatment
for mood disorders does work, and the
majority of people with mood disorders
can return to stable and productive
lives. Keep working with your loved one
and his or her health care providers to
find treatments that work, and keep reminding your loved one that you are there
for support.

for more publications like this, about: coaching, family therapy, borderline personality
disorder, crisis counseling, empowerment, mental imagery, mind reading, communication,
influencing, manipulation, interpersonal relationships etc...


3. Narcissistic personality disorder

Personality disorders are conditions in which

people have traits that cause them to feel and
behave in socially distressing ways, limiting
their ability to function in relationships and in
other areas of their life, such as work or
Narcissistic personality disorder is one of
several types of personality disorders. It is a
mental disorder in which people have an
inflated sense of their own importance and a
deep need for admiration. Those with
narcissistic personality disorder believe that
they're superior to others and have little regard
for other people's feelings. But behind this
mask of ultra-confidence lies a fragile selfesteem, vulnerable to the slightest criticism.


Narcissistic personality disorder

Narcissistic personality disorder is characterized by dramatic, emotional behaviour,
which is in the same category as antisocial and borderline personality disorders.

Narcissistic personality disorder symptoms may include:

Believing that you're better than others

Fantasizing about power, success and attractiveness
Exaggerating your achievements or talents
Expecting constant praise and admiration
Believing that you're special and acting accordingly
Failing to recognize other people's emotions and feelings
Expecting others to go along with your ideas and plans
Taking advantage of others
Expressing disdain for those you feel are inferior
Being jealous of others
Believing that others are jealous of you
Trouble keeping healthy relationships
Setting unrealistic goals
Being easily hurt and rejected
Having a fragile self-esteem
Appearing as tough-minded or unemotional

Although some features of narcissistic personality disorder may seem like having
confidence or strong self-esteem, it's not the same. Narcissistic personality disorder
crosses the border of healthy confidence and self-esteem into thinking so highly of
yourself that you put yourself on a pedestal. In contrast, people who have healthy
confidence and self-esteem don't value themselves more than they value others.

When you have narcissistic personality disorder, you may come across as conceited,
boastful or pretentious. You often monopolize conversations. You may belittle or look
down on people you perceive as inferior. You may have a sense of entitlement. And
when you don't receive the special treatment to which you feel entitled, you may
become very impatient or angry. You may insist on having "the best" of everything
the best car, athletic club, medical care or social circles, for instance.
But underneath all this behaviour often lies a fragile self-esteem. You have trouble
handling anything that may be perceived as criticism. You may have a sense of
secret shame and humiliation. And in order to make yourself feel better, you may
react with rage or contempt and efforts to belittle the other person to make yourself
appear better.


Tests and diagnosis

Narcissistic personality disorder
is diagnosed based on signs and
symptoms, as well as a thorough
psychological evaluation that
Although there's no laboratory
test to diagnose narcissistic
personality disorder, you may
also have a physical exam to
make sure you don't have a
physical problem causing your
Some features of narcissistic
personality disorder are similar to
disorders. It's possible to be
diagnosed with more than one
personality disorder at the same
To be diagnosed with narcissistic
personality disorder, you must
meet criteria spelled out in the
Diagnostic and Statistical Manual
of Mental Disorders (DSM). This
manual is published by the
American Psychiatric Association and is used by mental health providers to diagnose
mental conditions and by insurance companies to reimburse for treatment.

Criteria for narcissistic personality disorder to be diagnosed include:

Having an exaggerated sense of self-importance

Being preoccupied with fantasies about success, power or beauty
Believing that you are special and can associate only with equally special
Requiring constant admiration
Having a sense of entitlement
Taking advantage of others
Having an inability to recognize needs and feelings of others
Being envious of others
Behaving in an arrogant or haughty manner

When to see a doctor

When you have narcissistic personality disorder, you may not want to think that
anything could be wrong doing so wouldn't fit with your self-image of power and
perfection. But by definition, a narcissistic personality disorder causes problems in
many areas of your life, such as relationships, work, school or your financial affairs.
You may be generally unhappy and confused by a mix of seemingly contradictory
emotions. Others may not enjoy being around you, and you may find your
relationships unfulfilling.
If you notice any of these problems in your life, consider reaching out to a trusted
doctor or mental health provider. Getting the right treatment can help make your life
more rewarding and enjoyable.

It's not known what causes narcissistic personality disorder. As with other mental
disorders, the cause is likely complex. The cause may be linked to a dysfunctional
childhood, such as excessive pampering, extremely high expectations, abuse or
neglect. It's also possible that genetics or psychobiology the connection between
the brain and behaviour and thinking plays a role in the development of narcissistic
personality disorder.

Because the cause of narcissistic personality disorder is unknown, there's no known
way to prevent the condition with any certainty. Getting treatment as soon as possible
for childhood mental health problems may help. Family therapy may help families
learn healthy ways to communicate or to cope with conflicts or emotional distress.
Parents with personality disorders may benefit from parenting classes and guidance
from therapists or social workers.

Risk factors
Narcissistic personality disorder is rare. It affects more
men than women. Narcissistic personality disorder often
begins in early adulthood. Although some adolescents
may seem to have traits of narcissism, this may simply
be typical of the age and doesn't mean they'll go on to
develop narcissistic personality disorder.
Although the cause of narcissistic personality disorder
isn't known, some researchers think that extreme
parenting behaviours, such as neglect or excessive
indulgent praise, may be partially responsible.

Risk factors for narcissistic personality disorder may include:

Parental disdain for fears and needs expressed during childhood

Lack of affection and praise during childhood
Neglect and emotional abuse in childhood
Unpredictable or unreliable care
giving from parents
Learning manipulative behaviours
from parents

Children who learn from their parents that

vulnerability is unacceptable may lose
their ability to empathize with others'
needs. They may also mask their
egotistical behaviour that's calculated to

Complications of narcissistic personality
disorder can include:

Substance abuse
Alcohol abuse
Suicidal thoughts or behaviour
Relationship difficulties
Problems at work or school

Preparing for your appointment

People with narcissistic personality disorder are most likely to seek treatment when
they develop symptoms of depression often because of perceived criticisms or
rejections. If you recognize that aspects of your personality are common to
narcissistic personality disorder or you're feeling overwhelmed by sadness, talk with
your doctor. Whatever your diagnosis, your symptoms signal a need for medical care.
When you call to make an appointment, your doctor may immediately refer you to a
mental health provider, such as a psychiatrist.
Use the information below to prepare for your first appointment and learn what to
expect from the mental health provider.

What you can do

Write down any symptoms you're experiencing and for how long. It will
help the mental health provider to know what kinds of events are likely to make
you feel angry or defeated.
Write down key personal information, including traumatic events in your
past and any current, major stressors.
Make a list of your medical information, including other physical or mental
health conditions with which you've been diagnosed. Also write down the
names of any medications or supplements you're taking.
Take a family member or friend along, if possible. Someone who has
known you for a long time may be able to ask questions or share information
with the mental health provider that you don't mention.
Write down questions to ask your mental health provider in advance so
that you can make the most of your appointment.


For narcissistic personality disorder, some basic questions to ask

your mental health provider include:

What exactly is narcissistic

personality disorder?
Could I have different mental
health conditions?
What is the goal of treatment in
my case?
What treatments are most likely to
be effective for me?
How much do you expect my
quality of life may improve with
How frequently will I need therapy
sessions and for how long?
Would family or group therapy be
helpful in my case?
Are there medications that can
I have these other health
conditions. How can I best
manage them together?
Are there any brochures or other
printed material that I can take home with me? What websites do you
recommend visiting?

In addition to the questions that you've prepared to ask your mental health provider,
don't hesitate to ask any additional questions that may come up during your

What to expect from your mental health provider

The mental health provider is likely to ask you a number of questions to gain an
understanding of your symptoms and how they're affecting your life. The mental
health provider may ask:

What are your symptoms?

When do these symptoms occur, and how long do they last?
How do you feel and act when others seem to criticize or reject you?
Do you have any close personal relationships? If not, how do you explain that
What are your accomplishments?
What do you plan to accomplish in the future?
How do you feel when someone needs your help?
How do you feel when someone expresses difficult feelings, such as fear or
sadness, to you?

How would you describe your childhood, including your relationship with your
How would you say your symptoms are affecting your life, including school,
work and personal relationships?
Have any of your close relatives been diagnosed with a mental health problem,
including a personality disorder?
Have you been treated for any other mental health problems? If yes, what
treatments were most effective?
Do you use alcohol or illegal drugs? How often?
Are you currently being treated for any other medical conditions?

Treatments and drugs

Narcissistic personality disorder treatment is centered around psychotherapy. There
are no medications specifically used to treat narcissistic personality disorder.
However, if you have symptoms of depression, anxiety or other conditions,
medications such as antidepressants or anti-anxiety medications may be helpful.
Types of therapy that may be helpful for narcissistic personality disorder include:

Cognitive behavioural therapy. In general, cognitive behavioural therapy

helps you identify unhealthy, negative beliefs and behaviours and replace them
with healthy, positive ones.

Family therapy. Family therapy typically brings the whole family together in
therapy sessions. You and your family explore conflicts, communication and
problem solving to help cope with relationship problems.

Group therapy. Group therapy, in which you meet with a group of people with
similar conditions, may be helpful by teaching you to relate better with others.
This may be a good way to learn about truly listening to others, learning about
their feelings and offering support.

Because personality traits can be difficult to change, therapy may take several years.
The short-term goal of psychotherapy for narcissistic personality disorder is to
address such issues as substance abuse, depression, low self-esteem or shame. The
long-term goal is to reshape your personality, at least to some degree, so that you
can change patterns of thinking that distort your self-image and create a realistic selfimage.
Psychotherapy can also help you learn to relate better with others so that your
relationships are more intimate, enjoyable and rewarding. It can help you understand
the causes of your emotions and what drives you to compete, to distrust others, and
perhaps to despise yourself and others.

Lifestyle and home remedies

Whether you decide to seek
treatment on your own or are
encouraged by loved ones or a
concerned employer, you may feel
defensive about treatment or think
it's unnecessary. The nature of
narcissistic personality disorder can
also leave you feeling that the
therapy or the therapist is not worth
your time and attention, and you
may be tempted to quit. Try to keep
an open mind, though, and to focus
on the rewards of treatment.

Also, it's important to:

Stick to your treatment
plan. Attend
therapy sessions and take
any medications as directed.
Remember that it can be
hard work and that you may
have occasional setbacks.

Learn about it. Educate

yourself about narcissistic
personality disorder so that
you can better understand
symptoms, risk factors and

substance abuse or other
problems. Your addictions,
depression, anxiety and
stress can feed off each
other, leading to a cycle of
unhealthy behaviour.
Learn relaxation and stress management. Try such stress-reduction
techniques as meditation, yoga or tai chi. These can be soothing and calming.
Stay focused on your goal. Recovery from narcissistic personality disorder
can take time. Keep motivated by keeping your recovery goals in mind and
reminding yourself that you can work to repair damaged relationships and
become happier with your life.


Narcissistic Relationships
Narcissistic Relationships bring with them
huge risks to the partner of the narcissist
because their behaviour is a manifestation of
an excessive ego and self absorption at the
cost of everyone around them. Over the years,
if this behaviour doesn't change, it generally
results in a codependent, emotionally draining
Narcissistic Relationships will require lots of
energy and work, because narcissists are in
constant need for outside support and
approval. Once these needs are fulfilled they
feel powerful, but many times this need will be
very hard to be satisfied and the self image
and the peace of the partner may be dramatically impacted.
Narcissistic Relationships test the mental limits of their partners patience, and
individuals in a relationship with a narcissist feel something is not 'quite right', feel a
lack of emotional connection and most eventually realize it's wise to seek answers to
the unsettling experience of their day to day contact with a narcissist.
However, it's important for you to
know that you do not have to be the
victim of narcissism forever. You don't
have to lose your confidence, self
image, hope and passion for life
because you are in a relationship with
a narcissist. You can learn the skills to
move beyond the downside effects of
your narcissistic relationship and
move on to a more normal

The first step is to recognise

the signs.
Narcissists have a grandiose sense of
self-importance, like they have a
special mission on this earth and they
often have a 'I am the emperor' type
of personality, and they expect all
others should behave as humble
servants of their wishes.
achievements and talents making everything in their power to gain everybody's
attention and recognition. Most of the times they are arrogant and self absorbed to
fulfill what they see as their special destiny.

Narcissists will indulge in fantasies of tremendous power, success or beauty, being

addicted to the attention and admiration that others manifest. You will find much
snobbery between them which they do not deny it but rather be proud of it.
They see themselves as unique masterpieces. Complicated rather than complex
personalities, they will find it difficult to empathize with other people.
They can't actually go out of the
margins of their own personality, not
understanding how people don't
think the same as they do. That's
why many times you may have the
feeling of talking to a blank
wall because no matter how deep
you explain your point of view, most
They often can't maintain long
relationships, because they lack
empathy and most times people around them give up on explaining themselves over
and over again.
Narcissists tend to transform their partners in beggars - you will beg for understanding
and some unconditional attention but most of the time you will celebrate only leftovers
from the feast in which the narcissist has indulged.
Narcissists expect and demand that the ones nearest and dearest to them, love,
admire, tolerate, and cater to their needs. They expect others to be at their immediate

Here are the seven most common signs of narcissism.

1. He or she displays a lack of empathy.
As you spend more time investing in a narcissist, you may notice that he / she seems
unable to put him / herself in someone else's place emotionally. This often leads to
callous and self serving behaviours. Sometimes dangerous behaviours.
2. A narcissistic personality will often show a willingness to exploit other
You may well see they have few qualms about stepping on other people if it benefits
him / her.
3. Idealized thinking is a prevalent theme.
A narcissistic might put others, including you, on a pedestal, only to completely
discard or describe you as worthless further down the track. He or she often
fantasizes about the perfect love, beauty, or power, and feels he / she has a right to it.


4. Having a grandiose sense of self worth is a very common pattern.

Your narcissist might exaggerate his or her accomplishments and expect to associate
with other 'high level' people. This most often leads to feelings of superiority, a
haughty attitude and / or excessive expectations.
5. A narcissistic personality often will exhibit an excessive sense of
He or she may feel as if preferential treatment ought to come her / his way as of right.
6. A narcissist will most often will crave admiration and praise to the point that
it becomes almost like a drug.
This drug has been termed 'narcissistic supply' and the narcissist most often goes to
excessive lengths to obtain it.
7. He or she often may be very jealous of the accomplishments of others,
They may even become angry at the successes of others who then take the focus
away from her or him.

Narcissistic Relationships - You Must Protect Yourself!

This is your first priority if you have a narcissistic partner.
If you're in a narcissistic relationship it's
essential that you protect yourself, from
many areas that you will be under attack.
Some of these types of abuse are:
Emotional Abuse:
The verbally abusive and controlling
narcissist - the one who uses emotional
abuse as his weapon of choice. He tells
his victim who she can see, think and do.
Or in the case of Janet, whose husband
makes her recite every day, "I'm only
worth 29 cents - the price of a bullet," and
in doing so he erodes her self-worth to
nothing to keep her under his control.
Who else could possible want such a
worthless woman? With that belief formed,
she will never leave him for good,
although she makes many brief attempts
to do so. The brainwashing that continues daily is emotionally exhausting, draining,
and vastly unhealthy.

Verbal Abuse:
Verbal abuse is hurtful and usually attacks the nature and abilities of the partner.
Over time, the partner may begin to believe that there is something wrong with her /
her abilities. She may come to feel that she is the problem, rather than her partner.
Verbal abuse is often insidious. The partner's self-esteem gradually diminishes,
usually without her realizing it's happening. She may consciously or unconsciously try
to change her behaviour so as not to upset the abuser.
Sexual Abuse:
Normally a narcissist stays within the law,
but may break the rules of morality of a
society. Narcissist are careful about it
because, even if they do not feel guilty,
they want to avoid the shame of
The sexual relationship with the narcissist
is peculiar. Narcissists are exhibitionists
and sex is just one further means of being
admired to her or him. True intimacy
doesn't and you will frequently feel used.
The narcissist will demand that you
subdue yourself to their wishes.

Physical Abuse:
Narcissistic individuals do not tend to be
physically abusive although there are
some out there that are. Their worst
weapon is their mouth. With their mouth
they spit verbal negations and dispense
emotional abuse. Their vocal cords are
their method of attempting to control

Narcissistic Relationships Can Be Improved.

(But it will take detailed knowledge and considerable effort.)
Since narcissists cannot be changed, you need to reevaluate your needs and long
term goals for the relationship - it may be interesting for a while to be around such
type of people but in the long run it gets exhausting and anger and resentment will
overshadow any feelings of love and tenderness.
Don't give in to their never-ending demands, keep your independence from this type


of person - if in any way you depend on them, they will blackmail you to make you
give in to their desires.
Don't let yourself be infuriated by their lack of empathy or understanding - they are not
capable of it. Showing them their incapacity will do nothing - they will blame you for
everything that it doesn't work.
Narcissists will be attached to those that satisfy their needs but will never treat them
as partners but as followers. They have the need to lead and be in control constantly they do not need equals but disciples or pleasers. The worst thing that can happen is
when one narcissist meets someone with low self-esteem - it will be the perfect victim
and toy for them.
Finally, you need to decide when enough is enough. A relationship with a narcissist
can take you places where you do not want to be, can make you behave in ways you
do not recognize yourself . It can undermine your self esteem and will rob you of the
attention you need to give to yourself trying to meet all their needs.

Arm Yourself Now With Detailed

Detailed knowledge can help you so
you never are involved, ever again, in a
continuing toxic relationship.
I hope the brief information above has
helped you and that it prompts you to
go on now to get the detailed
information that will insure that your
relationship moves quickly in a more
positive direction.
I wish you every success and lasting

Experts Recommend:
All the experienced experts in preventing narcissistic abuse make two vital
1) If at all possible, walk away (leave) your narcissistic abuser.
2) If that's not possible due to constraints of your employment, wider family, children
or love, you must, repeat must, take advantage of the support and resources
available to learn how to deal with a narcissist, and in doing so discover how to
protect yourself from ongoing emotional, mental and sometimes physical harm.
Please take action TODAY to protect yourself!

How to Cope with a Narcissist?

Give up on your relationship with the narcissist and maintain a no contact policy.
If you choose to stay with him either give him a taste of his own medicine by reflecting
his misbehaviour or provide him with narcissistic supply (attention and adulation).


No one should feel responsible for the narcissist's predicament. To him, others hardly
exist so enmeshed he is in himself and in the resulting misery of this very selfpreoccupation. Others are objects on which he projects his wrath, rage, suppressed
and mutating aggression and, finally, ill disguised violence. How should his closest,
nearest and dearest cope with his eccentric vagaries?
The short answer is by abandoning him.
Alternatively, you can
try by threatening to
abandon him.
The threat to abandon
need not be explicit or
conditional ("If you don't
do something or if you do
it I will ditch you"). In
some cases it may be
sufficient to confront the
narcissist, to completely
ignore him, to insist on
boundaries and wishes, or
to shout back at him. The
narcissist takes these
autonomy to be harbinger
of impending separation
and reacts with anxiety.
The narcissist might be tamed by the very same weapons that he uses to subjugate
others. The spectre of being abandoned looms large over everything else. In the
narcissist's mind, every discordant note presages solitude and the resulting
confrontation with his self.
The narcissist is a person who is irreparably traumatized by the behaviour of the most
important people in his life: his parents, role models, or peers. By being capricious,
arbitrary, and sadistically judgmental, they moulded him into an adult, who fervently
and obsessively tries to recreate the trauma in order to, this time around, resolve it
(repetition complex).
Thus, on the one hand, the narcissist feels that his freedom depends upon reenacting these early experiences. On the other hand, he is terrified by this prospect.
Realizing that he is doomed to go through the same traumas over and over again, the
narcissist distances himself by using his aggression to alienate, to humiliate and in
general, to be emotionally absent.

This behaviour brings about the very consequence that the narcissist so fears abandonment. But, this way, at least, the narcissist is able to tell himself (and others)
that HE was the one who
fostered the separation,
that it was fully his choice
and that he was not
The truth is that, governed
by his internal demons,
the narcissist has no real
choice. The dismal future
of his relationships is
The narcissist is a binary
person: the carrot is the
stick in his case. If he gets
too close to someone
ultimate and inevitable
abandonment. He, thus,
distances himself, acts
cruelly and brings about
the very abandonment
that he feared in the first
In this paradox lies the key to coping with
the narcissist. If, for instance, he is
having a rage attack rage back. This
will provoke in him fears of being
abandoned and the resulting calm will be
so total that it might seem eerie.
Narcissists are known for these sudden
tectonic shifts in mood and in behaviour.
Mirror the narcissists actions and
repeat his words.
If he threatens threaten back and
credibly try to use the same language
and content. If he leaves the house
leave it as well, disappear on him. If he is
suspicious act suspicious. Be critical,
denigrating, humiliating, go down to his
level because that's the only way to
penetrate his thick defences. Faced with
his mirror image the narcissist always


This article appears in my book, "Malignant Self-love: Narcissism Revisited"

We must not forget that the narcissist behaves the way he does in order to engender
and encourage abandonment. When mirrored, the narcissist dreads imminent and
impending desertion, which is the inevitable result of his actions and words. This
prospect so terrifies him that it induces in him an incredible alteration of conduct.
He instantly succumbs and obsequiously tries to make amends, moving from one
(cold and bitter, cynical and misanthropic, cruel and sadistic) pole to another (warm,
even loving, fuzzy, engulfing, emotional, maudlin, and saccharine).
The other coping strategy is to give up on him.
Dump him and go about reconstructing your own life. Very few people deserve the
kind of investment that is an absolute prerequisite to life with a narcissist. To cope
with a narcissist is a full time, energy and emotion-draining job, which reduces people
around him to insecure
nervous wrecks. Who
No one, to my mind, not
even the most brilliant,
charming, breathtaking,
suave narcissist. The
glamour and trickery
underneath them a
monster lurks which
the lives of those
around it for the worse.
notoriously difficult to
change. Thus, trying to
doomed to failure. You
should either accept
them as they are or avoid them altogether. If one accepts the narcissist as he is one
should cater to his needs. His needs are part of what he is. Would you have ignored a
physical handicap? Would you not have assisted a quadriplegic? The narcissist is an
emotional cripple. He needs constant adulation. He cannot help it. So, if one chooses
to accept him it is a package deal, all his needs included.


1. THE PATHOLOGICAL LIAR is skilfully deceptive and very convincing. Avoids
accountability by diverting topics, dodging questions, and making up new lies, bluffs
or threats when questioned. His memory is self serving as he denies past statements.
Constant chaos and diverting from reality is their chosen environment.
Defence Strategy: Verify his words. Do not reveal anything about yourself - he'll use it
against you. Head for the door when things don't add up. Don't ask him questions you'll only be inviting more lies.
2. THE CONTRACT BREAKER agrees to anything then turns around and does the
opposite. Marriage, Legal, Custody agreements, normal social/personal protocol are
meaningless. This con artist will accuse you of being the contract breaker. Enjoys
orchestrating legal action and playing the role of the 'poor me' victim.
Defence Strategy: Expect him to disregard any agreement. Have Plan B in place.
Protect yourself financially and emotionally.
3. THE HIGH ROLLER Successfully plows and backstabs his way to the top. His
family a disposable prop in his success facade. Is charismatic, eloquent and
intelligent in his field, but often fakes abilities and credentials.
Needs to have iron-fisted control, relying on his manipulation
skills. Will ruthlessly support, exploit or target others in pursuit
of his ever-changing agenda. Mercilessly abuses the power of
his position. Uses treachery or terrorism to rule or govern.
Potential problem or failure situations are delegated to others. A
vindictive bully in the office with no social or personal
conscience. Often suspicious and paranoid. Others may
support him to further their own Mephistophelian objectives, but
this wheeler-dealer leaves them holding the bag. Disappears quickly when
consequences loom.
Defence Strategy: Keep your references and resume up to date. Don't get involved in
anything illegal. Document thoroughly to protect yourself. Thwarting them may
backlash with a cascade of retaliation. Be on the lookout and spot them running for
office and vote them out. Educate yourself about corporate bullies
4. THE SEXUAL NARCISSIST is often hypersexual (male or female). Pornography,
masturbation, incest are reported by his targets. Anything, anyone, young, old,
male/female, are there for his gratification. This predator takes what is available. Can
have a preference for 'sado-maso' sexuality. Often easily bored, he demands
increasingly deviant stimulation. However, another behaviour exists, the one who
withholds sex or emotional support.
Defence Strategy: Expect this type to try to degrade you. Get away from him. Expect
him to tell lies about your sexuality to evade exposure of his own.
5. THE BLAME-GAME NARCISSIST never accepts responsibility. Blames others for
his failures and circumstances. A master at projection.


Defence Strategy: Learn about projection. Don't take the bait when he blames you.
He made the mess, let him clean it up.
6. THE VIOLENT NARCISSIST is a wife-Beater, Murderer, Serial Killer, Stalker,
Terrorist. Has a 'chip-on-his-shoulder' attitude. He lashes out and destroys or uses
others (particularly women and children) as scapegoats for his aggression or
revenge. He has poor impulse control. Fearless and guiltless, he shows bad
judgement. He anticipates betrayal, humiliation
or punishment, imagines rejection and will
reject first to 'get it over with'. He will harass
and push to make you pay attention to him and
get a reaction. He will try to make you look out
of control. Can become dangerous and
unpredictable. Has no remorse or regard for
the rights of others.
Defence Strategy: Don't antagonize or tip your
hand you're leaving. Ask for help from the
police and shelters.
people against each other. Keeps his allies
and targets separated. Is verbally skilful at
twisting words and actions. Is charismatic and
usually gets his way. Often undermines our
support network and discourages us from
seeing our family and friends. Money is often
his objective. Other people's money is even
better. He is ruthless, demanding and cruel. This control-freak bully wants you
pregnant, isolated and financially dependent on him. Appears pitiful, confused and in
need of help. We rush in to help him with our finances, assets, and talents. We may
be used as his proxy interacting with others on his behalf as he sets us up to take the
fall or enjoys the performance he is directing.
Defence Strategy: Know the 'nature of the beast'. Facing his failure and
consequences will be his best lesson. Be suspicious of his motives, and avoid
involvement. Don't bail him out.
8. THE SUBSTANCE ABUSER Alcohol, drugs, you name it, this N does it. We see
his over-indulgence in food, exercise or sex and his need for instant gratification. Will
want you to do likewise.
Defence Strategy: Don't sink to his level. Say No.
9. OUR "SOUL MATE" is cunning and knows who to select and who to avoid. He will
come on strong, sweep us off our feet. He seems to have the same values, interests,
goals, philosophies, tastes, habits. He admires our intellect, ambition, honesty and
sincerity. He wants to marry us quickly. He fakes integrity, appears helpful,
comforting, generous in his 'idealization' of us phase. It never lasts. Eventually Jekyll
turns into Hyde. His discarded victims suffer emotional and financial devastation. He
will very much enjoy the double-dipping attention he gets by cheating. We end the
relationship and salvage what we can, or we are discarded quickly as he attaches to

a "new perfect soul mate". He is an opportunistic parasite. Our "Knight in Shining

Armour" has become our nightmare. Our healing is lengthy.
Defence Strategy: Seek therapy. Learn about this disorder. Know the red flags of their
behaviour, and "If he seems too good to be true..." Hide the hurt you feel. Never let
him see it. Be watchful for the internet predator.
10. THE QUIET NARCISSIST is socially withdrawn, often dirty, unkempt. Odd
thinking is observed. Used as a disguise to appear pitiful to obtain whatever he can.
11. THE SADIST is now the fully-unmasked malignant narcissist. His objective is
watching us dangle as he inflicts emotional, financial, physical and verbal cruelty. His
enjoyment is all too obvious. He'll be back for more. His pleasure is in getting away
with taking other people's assets. His target: women, children, the elderly, anyone
Defence Strategy: Accept the Jekyll/Hyde reality. Make a "No Contact' rule. Avoid him
altogether. End any avenue of vulnerability. Don't allow thoughts of his past 'good
guy' image to lessen the reality of his disorder.
12. THE RAGER flies off the handle for little or no
provocation. Has a severely disproportionate
overreaction. Childish tantrums. His rage can be
intimidating. He wants control, attention and
compliance. In our hurt and confusion we struggle
to make things right. Any reaction is his payoff. He
seeks both good or bad attention. Even our fear,
crying, yelling, screaming, name calling, hatred are
his objectives. If he can get attention by cruelty he
will do so.
Defence Strategy: Manage your responses. Be fully
independent. Don't take the bait of his verbal
abuse. Expect emotional hurt. Violence is possible.
13. THE BRAINWASHER is very charismatic. He is
able to manipulate others to obtain status, control,
compliance, money, attention. Often found in
religion and politics. He masterfully targets the naive, vulnerable, uneducated or
mentally weak.
Defence Strategy. Learn about brainwashing techniques. Listen to your gut instinct.
Avoid them.
14. THE RISK-TAKING THRILL-SEEKER never learns from his past follies and bad
judgment. Poor impulse control is a hallmark.
Defence Strategy: Don't get involved. Use your own good judgement. Say No.
15. THE PARANOID NARCISSIST is suspicious of everything usually for no reason.
Terrified of exposure and may be dangerous if threatened. Suddenly ends
relationships if he anticipates exposure or abandonment.

Defence Strategy: Give him no reason to be suspicious of you. Let some things slide.
Protect yourself if you anticipate violence.
16. THE IMAGE MAKER will flaunt his 'toys', his children, his wife, his credentials and
accomplishments. Admiration, attention, even glances from others, our envy or our
fear are his objective. He is never satisfied. We see his arrogance and haughty strut
as he demands centre stage. He will alter his mask at will to appear pitiful, inept,
solicitous, concerned, or haughty and superior. Appears the the perfect father,
husband, friend - to those outside his home.
Defence Strategy: Ignore his childlike behaviours. Know his payoff is getting attention,
deceiving or abusing others. Provide him with 'supply' to avert problems.
17. THE EMOTIONAL VACUUM is the cruellest blow of all. We learn his lack of
empathy. He has deceived us by his cunning ability to mimic human emotions. We
are left numbed by the realization. It is incomprehensible and painful. We now
remember times we saw his cold vacant eyes and when he showed odd reactions.
Those closest to him become objectified and expendable.
Defence Strategy: Face the reality. They can deceive trained professionals.
18. THE SAINTLY NARCISSIST proclaims high moral standing. Accuses others of
immorality. "Hang 'em high" he says about the murderer on the 6:00 news. This
hypocrite lies, cheats, schemes, corrupts, abuses, deceives, controls, manipulates
and torments while portraying himself of high morals.
Defence Strategy: Learn the red flags of behaviour. Be suspicious of people claiming
high morals. Can be spotted at a church near you.
19. THE CALLING-CARD NARCISSIST forewarns his targets. Early in the
relationship he may 'slip up' revealing his nature saying "You need to protect yourself
around me" or "Watch out, you never know what I'm up to." We laugh along with him
and misinterpret his words. Years later, coping with the devastation left behind, his
victims recall the chilling warning.
Defence Strategy: Know the red flags and be suspicious of the intentions of others.
20. THE PENITENT NARCISSIST says "I've behaved horribly, I'll change, I love you,
I'll go for therapy." Appears to 'come clean' admitting past abuse and asking
forgiveness. Claims we are at fault and need to change too. The sincerity of his words
and actions appear convincing. We learn his words are verbal hooks. He knows our
vulnerabilities and what buttons to push. We question our judgement about his
disorder. We can disregard "Fool me once..." We hope for change and minimize past
abuse. With a successful retargeting attempt, this N will enjoy his second reign of
terror even more if we allow him back in our lives.
Defence Strategy: Expect this. Self-impose a "No Contact" rule. Focus on the reality
of his disorder. Journal past abusive behaviour to remind yourself. Join our support


for more publications like this, about: coaching, family therapy, borderline personality
disorder, crisis counseling, empowerment, mental imagery, mind reading, communication,
influencing, manipulation, interpersonal relationships etc...


4. Borderline Personality Disorder





Borderline Personality Disorder Treatment

by John M. Grohol, Psy.D. - June 22, 2007
Table of Contents


Borderline personality disorder is a disturbance of certain brain functions that
causes four types of behavioural disturbances:

poorly regulated and excessive emotional responses;

harmful impulsive actions;
distorted perceptions and impaired reasoning; and
markedly disturbed relationships.

The symptoms of borderline personaliy

disorder were first described in the medical
literature over 3000 years ago. The disorder
has gained increasing visibility over the past
three decades. The full spectrum of symptoms
of bordelrine personality disorder typically first
appears in the teenage years and early
twenties. Although
significant behavioural disturbances may
develop readily diagnosable borderline disorder
as they get older, it is very difficult to make
the diagnosis in children.
After its onset, the disorder becomes chronic.
Remissions, relapses, and overall significant
improvement with treatment is the most
common course of the illness. Borderline
disorder appears to be caused by the
interaction of biological, usually genetic, and
environmental risk factors, such as poor
parental nurturing, and early and sustained emotional, physical or sexual abuse.
Physical disorders, such as migraine headaches, and other mental disorders, such
as depression, anxiety, panic and substance abuse disorders, occur much more
often in people with borderline disorder than they do in the general population.

Borderline Personality Disorder is experienced in individuals in many different

ways. Often, people with this disorder will find it more difficult to distinguish
between reality from their own misperceptions of the world and their surrounding
environment. While this may seem like a type of delusion disorder to
some, it is actually related to their emotions overwhelming regular
cognitive functioning.
People with this disorder often see others in black-and-white terms.
Depending upon the circumstances and situation, for instance, a therapist can be
seen as being very helpful and caring toward the client. But if some sort of
difficulty arises in the therapy, or in the patients life, the person might then
begin characterizing the therapist as bad and not caring about the client at all.
Clinicians should always be aware of this all-or-nothing liability most often
found in individuals with this disorder and be careful not to validate it.
Therapists and doctors should learn to be like a rock when dealing with a
person who has this disorder. That is, the doctor should offer his or her stability
to contrast the clients liability of emotion and thinking. Many professionals are
turned-off by working with people with this disorder, because it draws on many
negative feelings from the clinician. These occur because of the clients constant
demands on a clinician, the constant suicidal gestures, thoughts, and behaviours,
and the possibility of self-mutiliating behaviour. These are sometimes very
difficult items for a therapist to understand and work with.
Psychotherapy is nearly always the treatment of choice for this disorder;
medications may be used to help stabilize mood swings. Controversy surrounds
overmedicating people with this disorder.

Like with all personality disorders, psychotherapy
is the treatment of choice in helping people
overcome this problem. While medications can
usually help some symptoms of the disorder, they
cannot help the patient learn new coping skills,
emotion regulation, or any of the other important
changes in a persons life.
An initially important aspect of psychotherapy is
usually contracting with the person to ensure that
they do not commit suicide. Suicidality should be carefully assessed and
monitored throughout the entire course of treatment. If suicidal feelings
are severe, medication and hospitalization should be seriously considered.
The most successful and effective psychotherapeutic approach to date has been
Marsha Linehans Dialectical Behaviour Therapy. Research conducted on
this treatment have shown it to be more effective than most other
psychotherapeutic and medical approaches to helping a person to better cope
with this disorder. It seeks to teach the client how to learn to better take control
of their lives, their emotions, and themselves through self-knowledge, emotion
regulation, and cognitive restructuring. It is a comprehensive approach that is
most often conducted within a group setting. Because the skill set learned is new


and complex, it is not an appropriate therapy for those who may have difficulty
learning new concepts.
Like all personality disorders, borderline personality disorder is intrinsically
difficult to treat. Personality disorders, by definition, are long-standing ways of
coping with the world, social and personal relationships, handling stress and
emotions, etc. that often do not work, especially when a person is under
increased stress or performance demands in their lives. Treatment, therefore, is
also likely to be somewhat lengthy in duration, typically lasting at least a year for
Other psychological treatments which
have been used, to lesser effectiveness, to
treat this disorder include those which
focus on social learning theory and conflict
resolution. These types of solutionfocused therapies, though, often neglect
the core problem of people who suffer
from this disorder difficulty in
expressing appropriate emotions (and
emotional attachments) to significant
people in their lives due to faulty
Providing a structured therapeutic setting
is important no matter which therapy type
is undertaken. Because people with this
disorder often try and test the limits of
the therapist or professional when in treatment, proper and well-defined
boundaries of your relationship with the client need to be carefully explained at
the onset of therapy. Clinicians need to be especially aware of their own feelings
toward the patient, when the client may display behaviour which is deemed
inappropriate. Individuals with borderline personality disorder are often unfairly
discriminated against within the broad
range of mental health professionals
because they are seen as troublemakers. While they may indeed need
more care than many other patients, their
behaviour is caused by their disorder.
Phillip W. Long, M.D. also notes that:
The therapeutic alliance should form
within the patients real experiences with
the therapist and with the treatment. The
therapist must be able to tolerate
repeated episodes of primitive rage,
distrust, and fear. Uncovering is to be
avoided in favor of bolstering of ego defences, in order to eventually allow the
patient to be less anxious about potential fragmentation and loss. The goals of
therapy should be in terms of life gains toward independent functioning, and not
complete restructuring of the personality.

Hospitalization is often a concern with people
who suffer from borderline personality disorder
because they so often visit hospital emergency
rooms and are sometimes seen on inpatient
units because of severe depression.
People with this disorder often present in crisis
at their local community mental health center,
to their therapist, or at the hospital emergency
room. While an emergency room is an
immediate source of crisis intervention for the
patient, it is a costly treatment and regular
visits to the E.R. should be discouraged.
Instead, patients should be encouraged to find
additional social support within their community (including self-help support
groups), contact a crisis hotline, or contact their therapist or treating physician
Emergency room personnel should be careful not to treat the person with
borderline personality disorder in blind conjunction with another set of therapists
or doctors who are treating the patient for the same problem at another facility.
Every attempt should be made to contact the clients attending physician or
primary therapist as soon as possible, even before the administration of
medication which may be contraindicated by the primary treatment provider.
Crisis management of the immediate problem is usually the key component to
effective treatment of this disorder when it presents in a hospital emergency
room, with discharge to the patients usual care provider.
Inpatient treatment often takes the form of medication in conjunction with
psychotherapy sessions in groups or individually. This is an appropriate treatment
option if the person is experiencing extreme difficulties in living and daily
functioning. It is, however, relatively rare to be hospitalized in the U.S. for this
disorder. Long-term care of the person suffering from borderline personality
disorder within a hospital setting is nearly never appropriate. The typical inpatient
stay for someone with borderline personality disorder in the U.S. is about 3 to 4
weeks, depending upon the persons insurance. Since this treatment is so
expensive, it is getting more difficult to obtain. Results of such treatment are also
mixed. While it is an excellent way of helping stabilize the client, it is usually too
short a time to attain significant changes within the individuals personality
Good inpatient care facilities for this disorder should be highly structured
environments which seek to expand the individuals independence. Phillip W.
Long, M.D., adds that the goals of such a treatment modality, include decreasing
acting out, clearly identifying and working with inappropriate behaviours and
feelings, accepting with the patient the magnitude of the therapeutic task,
fostering more effective interpersonal relationships, and working with both real
and transference relationships within the hospital.


Partial hospitalization or a day treatment program is often all thats needed for
people who suffer from borderline personality disorder. This allows the individual
to gain support and structure from a safe environment for a short time, or during
the day, and returning home in the evening. In times of increased stress or
difficulty coping with specific situations, this type of treatment is more
appropriate and more healthy for most people than full inpatient hospitalization.

Phillip W. Long, M.D. has noted:
Medications play three very important roles in the
treatment of most patients with borderline disorder.
They are effective in reducing the four major groups
of symptoms of the disorder. They thereby enhance
the rate and quality of improvement derived from
psychotherapy. Finally, medications are effective in
treating other emotional disorders that frequently
are associated with borderline disorder, for example,
depression, anxiety/panic attacks, and ADHD, and
physical disorders such as migraine headaches.
During brief reactive psychoses, low doses of
antipsychotic drugs may be useful, but they are
usually not essential adjuncts to the treatment
regimen, since such episodes are most often self-limiting and of short duration.
It is, however, clear that low doses of high potency neuroleptics (e.g.,
haloperidol) may be helpful for disorganized thinking and some psychotic
symptoms. Depression in some cases is amenable
to neuroleptics. Neuroleptics are particularly
mentioned above, and for patients who show anger
which must be controlled. Dosages should
generally be low and the medication should never
Antidepressant and anti-anxiety agents may be
appropriate during particular times in the patients
treatment, as appropriate. For example, if a client
presents with severe suicidal ideation and intent,
the clinician may want to seriously consider the
prescription of an appropriate antidepressant
medication to help combat the ideation. Medication
of this type should be avoided for long-term use,
though, since most anxiety and depression is
directly related to short-term, situational factors
that will quickly come and go in the individuals life.

Treatment for Depression Co-occurring with Borderline Disorder

If you think you have the symptoms of either type of depression, immediately
alert your psychiatrist. If appropriate, the treatment for depression frequently
involves the addition of an antidepressant, an increase in dosage if one is already
being used, and/or the use of behavioural techniques.
There are no controlled studies on the relative
antidepressants for the treatment for depression
disorder. However, studies of these disorders in
disorder, and experience, suggest that the following
may have merit:

effectiveness of different
in people with borderline
people without borderline
initial treatment strategies

Treatment for Depression in Bipolar Disorder-Depressed

Bupropion (Wellbutrin)
Lamotrigine (Lamictal)
SSRIs such as fluoxetine (Prozac) or sertraline (Zoloft) if bupropion

and lamotrigine are ineffective

Treatment for Depression in Major Depressive Disorder

SSRIs such as fluoxetine or sertraline
Bupropion and lamotrigine if SSRIs are ineffective

Note: It is important in the treatment for depression to recognize that some

antidepressants may cause an episode of mania or hypomania in patients with
depression who have never experienced such episodes in the past.
focused on treatment for depression may
also prove useful to help identify thought
patterns and behaviours that operate as
risk factors for mood disorders, and to
* Bipolar I and II, and major depressive
disorders occur more commonly in
patients with borderline disorder than
they do in the general population. Bipolar
II disorder is the most common type of
borderline disorder. People with bipolar II
disorder do not experience manic
episodes as do those with bipolar I
episodes of depression. Depressions
associated with bipolar disorder appear to
be related to depressions referred to as
atypical depression and seasonal affective disorder (SAD).


Self-help methods for the treatment of this disorder are often overlooked by the
medical profession because very few professionals are involved in them.
Encouraging the individual with borderline personality disorder to gain additional
social support, however, is an important aspect of treatment. Many support
groups exist within communities throughout the world which are devoted to
helping individuals with this disorder share their commons experiences and
Patients can be encouraged to try out new coping skills and emotion regulation
with people they meet within support groups. They can be an important part of
expanding the individuals skill set and develop new, healthier social

Education and Support

During the past decade, an increasing number of educational and support groups
have been formed for patients with borderline disorder, and for their families.
Many of these have been the result of the efforts of lay advocacy groups
dedicated to increasing knowledge about, and reducing the stigma associated
with borderline disorder.

Patient and Family Educational Programs

A growing number of educational programs are being conducted for people with
borderline disorder and their families. These are often co-sponsored by
community organizations working with the assistance of consumer and family
organizations such as the National Education Alliance for Borderline Personality
Disorder (NEA-BPD), the Treatment and Research Advancements National
Association for Personality Disorder (TARA), and the National Alliance on Mental
Illness (NAMI).
opportunities for family members of people with
borderline disorder has been the introduction of
family educational and training programs.

Family Connections
Connections (FC), is available in multiple
locations throughout the US, and at several
locations in Canada, Europe and the UK. It
operates under the auspices of NEA-BPD with
research funding from the National Institute of
Mental Health. Experienced family members colead the 12-week manualized series of sessions
for other families. These sessions provide
participants with the most current information
and research about borderline disorder, teach

DBT and family coping skills, and provide an opportunity to develop a support
Research documents a reduction in family member depression, burden, and grief
and an increase in coping skills. No registration fee is required, but in some
locations a donation to cover costs of the course materials is suggested.

The National Alliance on Mental Illness (NAMI) has recently designated borderline
disorder as a priority population. In doing so, NAMI has now extended its
popular 12 week Family Education Program to include this disorder. The course is
taught by trained NAMI volunteers in every state in the country. It provides a
broad range of information essential to those caring for loved ones with
borderline and other serious mental disorders.

Family Training Workshop

TARA sponsors an eight session DBT family training workshop in New York City
and other cities across the country. The main goals of the program are similar to
that provided by NEA-BPD. Each training cycle is limited to sixteen members, and
a registration fee is required.

Support Groups
In some communities, groups of people with borderline disorder and family
members meet on a regular basis, without a therapist or trained and skilled
group leader, to help one another. Such support groups typically do not charge
members a fee and can be very beneficial for the reasons cited above for
therapist-assisted group therapy.

There are two types of support groups:

groups for the person with borderline disorder
groups for their family members

Although it may be helpful, participation in such groups should be approached

with caution by the person with borderline disorder or family members.
Considerable harm can be done if one or more individuals in the group act in an
angry, manipulative, malicious, or otherwise inappropriate and destructive way
toward another group member or the group as a whole. Without a skilled leader
or facilitator present to step in to handle the situation promptly and properly, a
member of the group, and even the group itself, may be exposed to significant
Prior to joining a support group, it is wise to seek recommendations about groups
in your community from your nearest NAMI Chapter, or from mental health
professionals working with patients with borderline disorder. In addition, it may
be helpful to request information from members of such groups before joining.


Symptoms of Borderline Personality Disorder

by John M. Grohol, Psy.D. - June 22, 2007

The main feature of borderline personality disorder (BPD) is a pervasive pattern

of instability in interpersonal relationships, self-image and emotions. People with
borderline personality disorder are also usually very impulsive.
This disorder occurs in most by early adulthood. The instable pattern of
interacting with others has persisted for years and is usually closely related to the
persons self-image and early social interactions. The pattern is present in a
variety of settings (e.g., not just at work or home) and often is accompanied by a
similar liability (fluctuating back and forth, sometimes in a quick manner) in a
persons emotions and feelings. Relationships and the persons emotion may
often be characterized as being shallow.

A person with this disorder will also often exhibit impulsive

behaviours and have a majority of the following symptoms:

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 (e.g.,
spending, sex, substance abuse, reckless driving, binge eating)
Recurrent suicidal behaviour, gestures, or threats, or self-mutilating
Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours and
only rarely more than a few days)
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights)
Transient, stress-related paranoid ideation or severe dissociative

Details about Borderline Personality Disorder Symptoms

Frantic efforts to avoid real or imagined abandonment.

The perception of impending separation or rejection, or the loss of external
structure, can lead to profound changes in self-image, emotion, thinking and
behaviour. Someone with borderline personality disorder will be very sensitive to
things happening around them in their environment. They experience intense
abandonment fears and inappropriate anger, even when faced with a realistic
separation or when there are unavoidable changes in plans. For instance,
becoming very angry with someone for being a few minutes late or having to
cancel a lunch date. People with borderline personality disorder may believ that
this abandonment implies that they are bad. These abandonment fears are
related to an intolerance of being alone and a need to have other people with
them. Their frantic efforts to avoid abandonment may include impulsive actions
such as self-mutilating or suicidal behaviours.

Unstable and intense relationships.

People with borderline personality disorder may idealize potential caregivers or
lovers at the first or second meeting, demand to spend a lot of time together,
and share the most intimate details early in a relationship. However, they may
switch quickly from idealizing other people to devaluing them, feeling that the
other person does not care enough, does not give enough, is not there enough.
These individuals can empathize with and nurture other people, but only with the
expectation that the other person will be there in return to meet their own
needs on demand. These individuals are prone to sudden and dramatic shifts in
their view of others, who may alternately be seen as beneficient supports or as
cruelly punitive. Such shifts other reflect disillusionment with a caregiver whose
nurturing qualities had been idealized or whose rejection or abandonment is


Identity disturbance.
There are sudden and dramatic shifts in self-image, characterized by shifting
goals, values and vocational aspirations. There may be suddent changes in
opinions and plans about career, sexual identity, values and types of friends.
These individuals may suddenly change from the role of a needy supplicant for
help to a righteous avenger of past mistreatment. Although they usually have a
self-image that is based on being bad or evil, individuals with borderline
personality disorder may at times have feelings that they do not exist at all. Such
experiences usually occur in situations in which the individual feels a lack of a
meaningful relationship, nurturing and support. These individuals may show
worse performance in unstructured work or school situations.

Display self-damaging impulsivity

Individuals with Borderline Personality Disorder display impulsivity in at least two
areas that are potentially self-damaging. They may gamble, spend money
irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive

Display recurrent suicidal behaviour

Individuals with Borderline Personality Disorder
may also sometimes display recurrent suicidal
behaviour, gestures, or threats, or selfmutilating behaviour. Completed suicide occurs
in 8%-10% of such individuals, and selfmutilative acts (e.g., cutting or burning) and
suicide threats and attempts are very common.
Recurrent suicidality is often the reason that
these individuals present for help. These selfdestructive acts are usually precipitated by threats of separation or
rejection or by expectations that they assume increased responsibility. Selfmutilation may occur during dissociative experiences and often brings relief by
reaffirming the ability to feel or by expiating the individuals sense of being evil.

Display affective instability

Individuals with Borderline Personality Disorder may display affective instability
that is due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few
days). The basic dysphoric mood of those with Borderline Personality Disorder is
often disrupted by periods of anger, panic, or despair and is rarely relieved by
periods of well-being or satisfaction.
These episodes may reflect the individuals extreme reactivity troubled by chronic
feelings of emptiness
intense anger or have
difficulty controlling their
anger (Criterion 8). They
may display extreme
outbursts. The anger is
often elicited when a
caregiver or lover is seen
withholding, uncaring, or
expressions of anger are often followed by shame and guilt and contribute to the
feeling they have of being evil. During periods of extreme stress, transient
paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur
(Criterion 9), but these are generally of insufficient severity or duration to
warrant an additional diagnosis. These episodes occur most frequently in
response to a real or imagined abandonment. Symptoms tend to be transient,
lasting minutes or hours.
The real or perceived return of the caregivers nurturance may result in a
remission of symptoms.

Associated Features and Disorders

Individuals with Borderline Personality Disorder may have a pattern of
undermining themselves at the moment a goal is about to be realized (e.g.,
dropping out of school just before graduation; regressing severely after a
discussion of how well therapy is going; destroying a good relationship just when
it is clear that the relationship could last). Some individuals develop psychoticlike symptoms (e.g., hallucinations, body-image distortions, ideas of reference,
and hypnagogic phenomena) during times of stress. Individuals with this disorder
may feel more secure


with transitional objects (i.e., a pet or inanimate possession) than in

interpersonal relationships. Premature death from suicide may occur in
individuals with this disorder, especially in those with co-occurring Mood
Disorders or Substance-Related Disorders. Physical handicaps may result from
self-inflicted abuse behaviours or failed suicide attempts. Recurrent job losses,
interrupted education, and broken marriages are common. Physical and sexual
abuse, neglect, hostile conflict, and early parental loss or separation are more
common in the childhood histories of those with Borderline Personality Disorder.
Common co-occurring Axis I disorders include Mood Disorders, Substance-Related
Disorders, Eating Disorders (notably Bulimia), Posttramatic Stress Disorder, and
Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder also
frequently co-occurs with the other Personality Disorders.

Specific Culture, Age, and Gender Features

The pattern of behaviour seen in Borderline Personality Disorder has been
identified in many settings around the world. Adolescents and young adults with
identity problems (especially when accompanied by substance abuse) may
transiently display behaviours that misleadingly give the impression of Borderline
Personality Disorder. Such situations are characterized by emotional instability,
"existential" dilemmas, uncertainty, anxiety-provoking choices, conflicts about
sexual orientation, and competing social pressures to decide on careers.
Borderline Personality Disorder is diagnosed predominantly (about 75%) in

The prevalence of Borderline Personality Disorder is estimated to be about 2% of
the general population, about 10% among individuals seen in outpatient mental
health clinics, and about 20% among psychiatric inpatients. In ranges from 30%
to 60% among clinical populations with Personality Disorders.

There is considerable variability in the course of Borderline Personality Disorder.
The most common pattern is one of chronic instability in early adulthood, with
episodes of serious affective and impulsive dyscontrol and high levels of use of
health and mental health resources. The impairment from the disorder and the
risk of suicide are greatest in the young-adult years and gradually wane with
advancing age. During their 30s and 40s, the majority of individuals with this
disorder attain greater stability in their relationships and vocational functioning.

Familial Pattern
Borderline Personality Disorder
degree biological relatives of
population. There is also an
Disorders, Antisocial Personality

is about five times more common among firstthose with the disorder than in the general
increased familial risk for Substance-Related
Disorder, and Mood Disorders.

Differential Diagnosis
Borderline Personality Disorder often co-occurs with Mood Disorders, and when
criteria for both are met, both may be diagnosed. Because the cross-sectional
presentation of Borderline Personality Disorder can be mimicked by an episode of
Mood Disorder, the clinician should avoid giving an additional diagnosis of
Borderline Personality Disorder based only on cross-sectional presentation
without having documented that the pattern of behaviour has an early onset and
a long-standing course.

Other Personality Disorders may be confused with Borderline Personality Disorder
because they have certain features in common. It is, therefore, important to
distinguish among these disorders based on differences in their characteristic
features. However, if an individual has personality features that meet criteria for
one or more Personality Disorders in addition to Borderline Personality Disorder,
all can be diagnosed. Although Histrionic Personality Disorder can also be
characterized by attention seeking, manipulative behaviour, and rapidly shifting
emotions, Borderline Personality Disorder is distinguished by self-destructiveness,
angry disruptions in close
relationships, and chronic feelings of deep emptiness and loneliness. Paranoid
ideas or illusions may be present in both Borderline Personality Disorder and
Schizotypal Personality Disorder, but these symptoms are more transient,
interpersonally reactive, and responsive to external structuring in Borderline
Personality Disorder.
Although Paranoid Personality Disorder and Narcissistic Personality Disorder may
also be characterized by an angry reaction to minor
stimuli, the relative stability of self-image as well as
the relative lack of self-destructiveness, impulsivity,
and abandonment concerns distinguish these disorders
from Borderline Personality Disorder. Although
Personality Disorder are both characterized by
manipulative behaviour, individuals with Antisocial
Personality Disorder are manipulative to gain profit,
power, or some other material gratification, whereas
the goal in Borderline Personality Disorder is directed
more toward gaining the concern of caretakers. Both
Dependent Personality Disorder and Borderline Personality Disorder are
characterized by fear of abandonment, however, the individual with Borderline
Personality Disorder reacts to abandonment with feelings of emotional emptiness,
rage, and demands, whereas the individual with Dependent Personality Disorder
reacts with increasing appeasement and submissiveness and urgently seeks a
replacement relationship to provide caregiving and support. Borderline
Personality Disorder can further be distinguished from Dependent Personality
Disorder by the typical pattern of unstable and intense relationships.
Borderline Personality Disorder must be distinguished from Personality Change
Due to a General Medical Condition, in which the traits emerge due to the direct


effects of a general medical condition on the central nervous system. It must also
be distinguished from symptoms that may develop in association with chronic
substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).
Borderline Personality Disorder should be distinguished from Identity
Problem...which is reserved for identity concerns related to a developmental
phase (e.g., adolescence) and does not qualify as a mental disorder."

Frequently Asked Questions about Borderline

by John M. Grohol, Psy.D. - June 22, 2007

What is Borderline Personality Disorder (BPD)?

The main feature of borderline personality
disorder (BPD) is a long pattern of instability in
their relationships with others, and in their own
self-image and emotions. People with borderline
personality disorder are also usually very
impulsive. The instable pattern of interacting with
others has persisted for years and is usually
closely related to the persons self-image and
early social interactions. The pattern is present in
a variety of settings (e.g., not just at work or
home) and often is accompanied by a similar
lability (fluctuating back and forth, sometimes in a quick manner) in a persons
emotions and feelings. Relationships and the persons emotion may often be
characterized as being shallow. The disorder occurs in most by early adulthood.

How common is Borderline Personality Disorder?

It is not very common, and is estimated to be found in 1 to 2% of the general
U.S. population at any give time. It is more common amongst people seeking
treatment for another mental disorder.

How does Borderline Personality Disorder cause problems?

Like any mental health issue, borderline
personality disorder causes problems in a
persons social and life functioning by interfering
with the persons ability to reliably maintain
these relationships or their everyday living.
People with this disorder often cause a great
amount of stress or conflict in relationships with
others, especially significant others or those
who are very close to the person. This can often
lead to divorce, physical, sexual or emotional
abuse, additional emotional problems (such as
an eating disorder or depression), losing ones job, estrangement from ones
family, and more.

What is the course of Borderline Personality Disorder?

There is considerable variability in the course of Borderline Personality Disorder.
The most common pattern is one of chronic instability in early adulthood, with
episodes of serious loss of emotion and impulsive control, as well as high levels of
use of health and mental health resources. The impairment from the disorder and
the risk of suicide are greatest in the young-adult years and gradually wane with
advancing age. During their 30s and 40s, the majority of individuals with this
disorder attain greater stability in their relationships and job functioning.

Is Borderline Personality Disorder inherited?

Borderline Personality Disorder is about five times more
common among first-degree biological relatives of those
with the disorder than in the general population. There is
also an increased familial risk for Substance-Related
Disorders (e.g., drug abuse), Antisocial Personality
Disorder, and Mood Disorders, like depression or bipolar
Where can I go to learn more about Borderline
Personality Disorder?
Psych Central has a reviewed list of resources you can
consult for further information about Borderline
Personality Disorder. We also recommend the following
two books to understand more about this disorder:

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care
about Has Borderline Personality Disorder by Paul T. Mason and Randi

The Stop Walking on Eggshells Workbook: Practical Strategies for Living

With Someone Who Has Borderline Personality Disorder by Randi Kreger
and James Paul Shirley

For Loved Ones

People with borderline disorder have marked difficulties with relationships,
especially with the people who are closest to them, such as families, partners and
moodiness, and unreasonable, impulsive, and
which often appear
unprovoked, can result in considerable harm to
these important relationships. Attempts to
engage in a discussion to work out reasonable
solutions to problems frequently turn into
highly emotional battles.
This usually results in responses from family,
partners and friends that include anxiety and frustration, attempts to placate, and


angry retorts when the limits of normal patience have been exceeded. Therefore,
most loved ones of individuals with borderline disorder are quite relieved to learn
that effective treatment is available for the disorder, and that there are ways they
can help as well.
Two significant advances in the area of borderline disorder have been the recent
research on the effectiveness of different educational and therapeutic experiences
for families, and the development of consumer and family organizations focused
on the disorder.

Guidelines for Families, Partners and Friends

If you are a family member, partner or friend of someone with borderline
disorder, you probably have developed feelings of anger and resentment towards
them that conflict with your feelings of empathy and desire to help. The following
are ten specific actions that you can take that will help the person with borderline
disorder gain better control over her or his life, and help you in the process.

1. Learn About the Disorder

It is essential to understand that
person with
disorder is suffering from an
illness that is as real as
diabetes, heart disease, or
hypertension. For most people,
physical symptoms are easier to
accept as indications of a
disease than are behavioural
symptoms. However, there is no
reason to assume that a
complex organ such as the brain
is less susceptible to diseases
that affect behaviour than are
other bodily organs that result in
physical symptoms. Recently
studies demonstrate abnormal brain structure and function in patients with
borderline disorder, thus confirming this conclusion.
It is also helpful to realize that persons with borderline disorder did not acquire
the disorder through any actions of their own, nor do they enjoy having the
disorder. Imagine what it must be like to feel that you are frequently at the
mercy of forces within you, over which you seem to have little control, and that
cause you extreme emotional pain and significant life problems.
Therefore, a critical first step in the process of helping them and you is to learn
as much as you can about the symptoms and nature of borderline disorder, and
the specific situational causes of acute episodes in the member of your family
with the disorder.

2. Seek Professional Help

Facilitate the process of obtaining optimal help. It may be necessary that you do
the initial work necessary to set up the first appointment. It may also be helpful if
you agree to go also. Some people with borderline disorder initially refuse to seek
professional help. Provide them with a copy of my book and suggest they read
the first two chapters. This may help them understand their
potential problems well enough to agree to an initial
appointment with a psychiatrist.
Other people with borderline disorder are steadfast in their
refusal of help. This, of course, is a major problem. Dr. Perry
Hoffman, the founding president of the National Education
Alliance for Borderline Personality Disorder (NEA-BPD) offers
this advice: The best way of approaching this problem from
my perspective is for one to accept that you cannot get
someone into treatment. Timing is important as to when
someone might be open to hearing the idea. But the bottom line is to free
families of feeling guilty, and to understand that they are not so powerful to
effect that goal. Along that line, relatives need to get help and support for
themselves as they watch their loved one in the throes of the illness.

3. Support the Treatment Program

Once in treatment, encourage and support your loved one
with borderline disorder to regularly attend therapy sessions,
to take medicine as prescribed, to eat, exercise, and rest
appropriately, and to engage in wholesome recreational
activities. If alcohol or other drugs are a problem, strongly
support their efforts to abstain completely from these
substances, and encourage regular attendance in treatment
programs or self-help groups, such as Alcoholics Anonymous.
Remember, there is little hope of improvement of the
symptoms of borderline disorder if alcohol and drugs are
abused. It is very important that you remain persistent in
your efforts to do everything possible to help reduce the risk
of this behaviour, and not enable it.

4. Respond Consistently to Problematic Behaviours

Develop a clear understanding (it may even be written) of the realistic
consequences of recurring, problematic,
destructive behaviours such as episodes of
alcohol and drug abuse, physically selfdamaging acts, and excessive spending and
gambling. Also, agree beforehand on how
best to respond to threats and acts of selfharm.
These and other problematic behaviours are
often triggered by stressful events that need
to be identified, and a clear plan developed
for handling these events and situations more appropriately and effectively in the


future. Such a plan is best developed with the help of the patients primary
Experience has shown that responding positively to appropriate behaviours is also
very important in encouraging change to new and more successful ways of
handling stressful situations. Doing so also reduces the incidence of inappropriate
behaviours that then cause additional problems. Issuing spontaneous ultimatums
should be avoided.

5. Attempt to Remain Calm

Reacting desperately or angrily when there is a flare
up of symptoms will often add to the existing problem.
Remain calm. Acknowledge that it must be difficult to
experience the expressed feelings, even if they seem
out of proportion to the situation. This does not mean
that you agree with these feelings, or that you think
that the actions resulting from them are justified.
However, it is reassuring if you listen to their feelings,
the pain they are experiencing, and the difficulty they
are having in dealing with this pain. Remember that
you do not have to defend yourself if verbally
attacked, or develop solutions to their problems. If
they express thoughts of self-harm, remind them of the plan for dealing with this
problem that has been worked out with their therapist.
Allow and encourage the person with borderline disorder to attempt to bring their
response levels in line with the situation at hand. This may require that you give
them a little time alone to collect themselves. Then it may be possible to more
calmly and reasonably discuss the relevant issues.
In addition, do not be hesitant to express your feelings freely and openly, but
with moderation. Recent research suggests that caring involvement with your
loved one with borderline disorder is associated with better outcomes than a cool,
disinterested approach. Stay involved.

6. Remain Positive and Optimistic

It is important to remain optimistic about the ultimate results of treatment,
especially when the patient has a setback. The usual course of borderline disorder
with optimal treatment is one of increasing periods of time when symptoms are
absent or minimal, interrupted by episodes when the symptoms flare up. Over
time, the specific causes of relapses can be identified, anticipated, then steps
taken to develop alternative, more adaptive and effective responses. Occasional
family meetings with the therapist may help clarify the causes of relapses and
identify new ways of preventing them.
7. Participate in Educational Experiences About Borderline Disorder
It is very important that you learn as much as possible about borderline disorder
and your role in the treatment process. Your participation in educational
opportunities may benefit both you and your loved one with the disorder. When
conducted by skilled and experienced people, such structured and informative
experiences may involve both patients and family.

8. Join a Borderline Disorder Consumer and Family Support Organization

For information on such consumer organizations, contact the National Alliance on
Mental Illness (NAMI) or the National Education Alliance for Borderline Personality
Disorder (NEA-BPD). If such an organization exists in or near your community,
seriously consider joining it. You will then have available to you a large amount of
new information about borderline disorder, what you can do to help the member
of your family with the disorder and yourself, and compassionate and
understanding support in your efforts. If there is not a group in your area,
consider starting one with other family members you have met. Also consider
joining one of these national consumer organizations for borderline disorder.

9. Remember:
the Person with Borderline Disorder Must Take Charge
Remember that it is primarily
the responsibility of the person
with borderline disorder to take
charge of her or his behaviour
and life. Although difficult at
times, it is important for you to
provide the opportunity for
your family member with
borderline disorder to take
reasonable risks in order to try
new behaviours. It is also
important that you help her or
him to be accountable for the
Excessive dependency on family and friends is not helpful in the long run. Beware
of the tendency of people with borderline disorder to act at the extremes. For
example, the proper alternative to excessive dependency is not immediate, total
independency. The more appropriate responses are to remain engaged and to
gradually help move to a more balanced, mature relationship level of mutual

10. Take Care of Yourself

If you take the time to meet your own needs, when your help is needed most,
you will be best able to provide it. Remember that you cannot save your loved
one with borderline disorder on your own.
If you are the parent, there is a natural tendency to focus much of your attention
on the person with borderline disorder. However, make certain that you are not
neglecting your other sons and daughters who may appear to be doing well. They
have need of your time and attention too, even as they grow into adulthood. You
will learn from educational experiences the extent of this potential problem and
how best to deal with it.


who cannot be bought;
whose word is their bond;
who put character above wealth;
who possess opinions and a will;
who are larger than their vocations;
who do not hesitate to take chances;
who will not lose their individuality in a crowd;
who will be as honest in small things as in great things;
who will make no compromise with wrong;
whose ambitions are not confined to their own selfish
who will not say they do it" because everybody else does
who are true to their friends through good report and evil
in adversity as well as in prosperity;
who do not believe that shrewdness, cunning, and
hardheadedness are the best qualities for winning
who are not ashamed or afraid to stand for the truth
when it is unpopular;
who can say "no" with emphasis, although all the rest of
the world says "yes." - Charles Swindoll.

The following "test" may help you to evaluate the possibility
that you or a loved one has borderline disorder. It is simply
a check list of the nine criteria of borderline disorder as
defined by the American Psychiatric Association in their
diagnostic manual, DSM-IV-TR. However, it is reworded so
that you may readily apply the criteria to your situation.
Please note that you should not use the results of the test to
arrive at any fixed conclusion, but rather to provide you with
an estimation of the possibility that this disorder, or its
traits, may exist.
How to Use the Borderline Disorder Test
First, read carefully about the symptoms of borderline disorder provided on this
website, or as they are described in more detail in my book, Borderline
Personality Disorder Demystified.
Next, print this page and place a check mark next to those symptoms or
behaviours listed below that you believe accurately describe your condition. If
you are in doubt, leave the item blank.

The Borderline Disorder Test


1) My emotions change very quickly, and I experience intense episodes of sadness,

irritability, and anxiety or panic attacks.


2) My level of anger is often inappropriate, intense and difficult to control.


3) I suffer from chronic feelings of emptiness and boredom.


4) I engage in two or more self-damaging acts such as excessive spending, unsafe

and inappropriate sexual conduct, substance abuse, reckless driving, and binge


5) Now, or in the past, when upset, I have engaged in recurrent suicidal behaviours,
gestures, threats, or self-injurious behaviour such as cutting, burning or hitting


6) I have a significant and persistently unstable image or sense of my self, or of who

I am or what I truly believe in.


7) I have very suspicious ideas, and am even paranoid (falsely believe that others are
plotting to cause me harm) at times; or I experience episodes under stress when I
feel that I, other people or the situation is somewhat unreal.



8) I engage in frantic efforts to avoid real or imagined abandonment by people who

are close to me.
9) My relationships are very intense, unstable, and alternate between the extremes of
over idealizing and undervaluing people who are important to me.









Score of five or greater:

If you have checked five or more items on the
above list, you may have borderline disorder.
In order to determine if this is the case, you
will require an evaluation by a psychiatrist or
mental health care clinician who is well trained
and experienced in borderline disorder.

Score of one to four:

If you have checked one to four items on the
above checklist, you may have borderline
disorder traits. Depending on the level of
severity of your symptoms or behaviours, and
the amount of disruption that they cause you,
your family, friends and others, you may
require an evaluation by a psychiatrist or
mental health care clinician who is well trained
and experienced in borderline disorder.
It is important to realize that you do not have to meet five or more criteria of
borderline disorder for these symptoms to significantly disrupt your life. You may
still benefit greatly from appropriate treatment.

Guidelines for the Selection of a Psychiatrist and

Other Clinicians
Once you have located the names of one or more clinicians, you may wish to
contact them to determine if they provide the services you are looking for.
The following is a list of issues that you may wish to clarify in order to determine
if you have a reasonably suitable fit given your individual needs:
Primary Clinician: Ideally, in most cases, you are looking for a psychiatrist with
experience in borderline disorder who can serve as your primary clinician, that is,
perform your initial clinical evaluation and the other tasks of someone assuming
this role in your care. If such a person is not available in your community, you
should ask other potential providers of care about their level of experience in the
area of borderline disorder.
Types of Treatment: Determine what forms of treatment they typically use for
their patients with the disorder, especially medications and psychotherapies. Most
psychiatrists and other clinicians do not typically provide the full range of
treatments that we now know are useful for treating the disorder. In other words,
you may need several people working with you, for example, one to prescribe
medications, another to provide therapy, and possibly a third for group therapy
work. Therefore, you will need to ask how your special needs will be met by each
clinician. If you will be seeing just one person, be especially cautious if they
recommend only one form of treatment for all patients with borderline disorder,
for example either medications or psychotherapy, or one specific type of
psychotherapy. As noted elsewhere on this site, borderline disorder affects people

in many different ways. Therefore, in most cases, effective treatment plans are
more complex than can be accomplished by a single type of treatment.
Immediate Help: You should establish how the provider handles those times
when you may need immediate help, for example who will respond to your
telephone calls and under what
circumstances. Also, should you require
brief hospitalization, what hospital will
be utilized, and who will direct your
care when you are in the hospital.
Communication: If you will have more
than one clinician working with you, it
is important to establish the degree to
which they will work with you and with
your family or partner, and with each
other. It is important that the team
communicate openly. Under most
circumstances, it is essential that those
people who are very important in your
life are included in your treatment. The types and frequency of involvement
required are best discussed prior to the onset of treatment.
Finding the Right Fit: Ultimately, you are looking for clinicians who appear to
be good fits for you and your special needs. To some degree this is a subjective
quality, and cannot be easily defined further, but patients often sense when they
have found the right professionals with whom to work.
Credentials: It is very appropriate to ask about the potential providers specific
credentials: in what mental health specialty do they have their degree; are they
certified properly, for example., for psychiatrists, by the American Board of
Psychiatry and Neurology; are they licensed to practice in their specific clinical
area; and what degree of training and experience do they have with borderline
Payment Information: Finally, you should obtain their fee schedule and method
of payment for different services, for example medication checks, and individual
and group psychotherapy sessions. Many clinicians accept insurance with copayments, while some require self payment.
At the outset of care, remember that your doctor may not be able to determine
precisely the most effective treatments for you. Therefore, it seems to me most
reasonable to find a psychiatrist, and other clinicians when necessary, who know
the relevant medical literature, that have open minds regarding different
diagnostic possibilities and treatment approaches, and who communicate well
with you and your family. Given our current level of knowledge about borderline
disorder, it is likely that such professionals will give you the best help available,
now and in the future.


The Diagnosis and Treatment for Depression

Co-Occurring with Borderline Disorder
by Robert O. Friedel, MD

More than 80 percent of people with borderline disorder suffer from episodes of
major depression. Treatment for depression is vital in these individuals. There are
two categories of major depressive episodes, those associated with bipolar I and
II disorder-depressed*, and those referred to as major depressive disorder.
Therefore, if you have borderline disorder, it is important that you know and
recognize the symptoms of these disorders. If they occur, you should alert your
physician so that you may receive prompt treatment for depression.

Symptoms of a Major Depressive Episode:

persistently depressed or irritable mood

diminished interest or pleasure in activities
significant decrease or increase in appetite, or weight loss
or weight gain
increased or decreased sleep
decreased mental and physical activity, or increase in such activity as
demonstrated by excessive worrying and agitated behaviour
fatigue, or loss of energy
feelings of worthlessness or excessive or inappropriate guilt
diminished ability to think or concentrate, or indecisiveness
recurrent thoughts of death and dying, recurrent suicidal thoughts with a
specific plan, or a suicide attempt
Understand the differences in symptoms of Borderline
Depressive Disorder, and learn about the various plans
for treatment for depression.
In order to initiate the proper treatment for depression, it is
necessary to determine if you are experiencing a decrease in
mood associated with borderline disorder, or if you have
developed a bipolar II disorder- depressed or major depressive

Depressed Mood in Borderline Disorder

In borderline disorder alone, depressed mood often occurs as follows:
sad, depressed, and lonely feelings are frequently triggered by some life
event and are often associated with strong feelings of emptiness,
loneliness and fears of abandonment.
symptoms readily improve if the situation causing them improves
sleep, appetite and energy disturbances (if present) are usually related to
an identifiable life stress and stop when the stress is managed successfully.
acute suicidal thoughts and self-injurious behaviour are usually the direct
result of a personal problem (for example, an argument with a parent,
boyfriend, spouse, or boss)

Bipolar II Disorder-Depressed*
In bipolar disorder-depressed, the symptoms
of a major depressive episode listed above
are often characterized by:
increased appetite or weight gain
increased sleep and napping
marked decrease in mental and
physical activity
marked fatigue and loss of energy

Major Depressive Disorder

In major depressive disorder, the symptoms
of a major depressive episode listed above
are often characterized by:
decreased appetite or weight loss
decreased sleep with early morning
increased mental and physical activity
worrying and agitated behaviour

Patients with Borderline Disorder
by Robert O. Friedel, MD

Two-thirds of people with borderline disorder seriously abuse alcohol, street

drugs, and/or prescribed drugs. This is a major factor resulting in poor outcome
of people with borderline disorder. Alcohol and drugs are abused by people with
borderline disorder to temporarily relieve the severe emotional pain that they
experience, especially when under stress. Predictably, this relief is short lived.
Even worse, the use of these substances markedly increases many of the
symptoms of borderline disorder making substance abuse treatment all the more
It is possible that some of the genetic alterations that are risk factors in
borderline disorder may also be among the group of genes that predispose people
to alcoholism and drug abuse.

DSM-IV-TR Criteria for Substance Use Disorders:

There are two types of substance use disorders, substance dependence and
substance abuse. Substance abuse treatment is important in both types of
substance use disorders.


Substance Dependence
A pattern of substance use that leads to significant impairment or distress in
three (or more) of the following ways:

tolerance, as defined by either

o a need for markedly increased amounts of the substance to achieve
the desired effect, or
o a markedly diminished effect with continued used of the same
amount of the substance
withdrawal symptoms characteristic for the substance, or increased use to
relieve or avoid withdrawal symptoms
the substance is taken in larger amounts or over a longer period than
a persistent desire or unsuccessful efforts to cut down or control substance
much time is spent in activities to obtain the substance, use the substance,
or recover from its effects
important social, occupational, or recreational activities are given up or
the substance use is continued despite it causing a persistent or recurrent
physical or psychological problem (e.g., current cocaine use despite
recognition of cocaine-induced depression)

Suicidality in Borderline Disorder
by Robert O. Friedel, MD

In a recent study, approximately 75 percent of women with borderline disorder

engaged in self-injurious behaviours such as cutting, burning and small drug
overdoses. Cutting is by far the most common act of this type. About 9 percent of
people with the disorder commit suicide. The most frequent means is by drug
overdose. Both types of behaviour may occur in the same individual. Cutting
behaviours double the risk of suicide in people with borderline disorder.

Self-Injurious Behaviours
In addition to cutting and burning themselves, and taking small drug overdoses,
people with borderline disorder hit themselves, pull out their hair, scratch their
skin to the point they open wounds, and injure themselves in other ways. Most
people with the disorder who injure themselves report that they do so mainly to
decrease the intense emotional pain they experience. Remarkably, they also
often report that the first time they engaged in cutting and other self injurious
behaviours, the idea just came to them. Finally, they report that these acts
usually do result in brief emotional relief.
It is important that family and other loved ones understand that this is the main
motive of self injurious behaviours, not primarily to manipulate the situation or
the people around them, though this is often a secondary motive.


Risk Factors for Suicidality

There are a number of factors that increase the risk that a person with borderline
disorder will commit suicide. Although nothing can be done to reverse some of
these factors, others are highly treatable, and
deserve immediate attention.

co-occurring disorders
antisocial personality disorder (higher in
major depression
substance abuse*
personality characteristics
impulsive aggression
poor emotional control
history and severity of childhood sexual abuse
age over 30 years
number of prior self-injurious behaviours and suicide attempts
no prior treatment, or extensive and unsuccessful treatment history

Prevalence Across the Life Cycle:

Self-injurious behaviours do not appear to
decrease or burn out with increasing age in
people with borderline disorder, as do other
aggressive and impulsive behaviours

Behaviours and Suicidality
General Treatment Interventions for
Injurious Behaviours and Suicidality:

careful evaluation
determine the level of intent and risk of
self-injurious behaviours and suicide overt and unstated
directly involve the patient and family in
the process
treat at the least restrictive level of care
for the shortest period of time indicated
aggressively treat all co-occurring disorders
modify the treatment to accommodate the significant increase in severity
of borderline disorder symptoms
highly structure the environment
identify and promptly address precipitating events
assure involvement and coordination of the entire treatment team,
including the family
continue to balance risk vs. reward


Specific Treatment Interventions: Medications


reduce or eliminate co-occurring disorders, such as major depressive

episodes, substance abuse, ADHD and anxiety disorders
reduce core symptoms of borderline disorder: e.g., emotional dysregulation;
aggressive-impulsivity; and cognitive-perceptual impairment

Specific Treatment Interventions: Psychotherapy

supportive therapy)


reduce self-injurious behaviours and



* Note: If you have borderline

disorder and have a tendency to
abuse alcohol or drugs, it is
essential that you obtain help to
abstain completely from doing so.

Substance Abuse
A pattern of substance use that leads
to significant impairment or distress
in one (or more) of the following
a failure to fulfill major role
obligations at work, school, or
recurrent substance use in situations in which it is physically hazardous
recurrent substance-related legal problems
continued substance use despite having persistent or recurrent social or
interpersonal problems caused or worsened by the effects of the substance


Consequences of Abuse of Alcohol and

Street Drugs in Borderline Disorder
dramatic worsening of the symptoms of borderline disorder
marked decrease in the effectiveness of medications and psychotherapy.
addiction to and sustained craving for these substances.

Substance Abuse Treatment Interventions

For all of these reasons, for substance
abuse treatment purposes, I strongly
advise my patients with borderline
disorder to not use alcohol, to not take any
street drugs, and to take prescribed
medications only as ordered by their
In addition, I encourage those patients
who have a substance-use disorder to
engage fully in a substance abuse
treatment program and attend support
groups (Alcoholics Anonymous or Narcotics
Anonymous). I also suggest to some of
them that they may benefit from a trial on
a medication appropriate for their specific
drug dependency, as this may help reduce
craving and use.
Substance use disorders are major
predictors of poor short- and long-term
outcome of borderline disorder.
There is little or no hope of gaining control over the symptoms of borderline
disorder while alcohol and other drugs are being used, no matter how appropriate
the substance abuse treatment program is otherwise.
Substance abuse treatment is essential if this problem co-occurs with borderline

Anxiety and Panic Attack Symptoms

Co-Occurring with Borderline Disorder
by Robert O. Friedel, MD

Have you or a loved one been diagnosed with borderline disorder and are
suffering from anxiety and panic attack symptoms? Read the following
article and learn more about these symptoms and how they are treated.
Anxiety and panic attack symptoms are common in people with borderline
disorder. Anxiety disorders occur in almost 90% of people with the disorder. If
you have borderline disorder, you may experience heightened levels of anxiety
and panic attack symptoms, especially at times of stress. For example, this may
occur when you feel you are personally criticized and rejected, or during periods
of separation from people who are very important to you. Moderate to severe
anxiety may also lead to physical symptoms, such as migraine headaches,
abdominal pain and irritable bowel syndrome.

Panic Attacks
A panic attack is an acute and severe form of anxiety that occurs in about 50% of
people with borderline disorder. Panic attacks are characterized by a discrete
period of intense fear in which four or more of the following symptoms develop
abruptly and reach a peak within 10 minutes:

increased heart rate
trembling or shaking
sensations of shortness of breath or
feeling of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, lightheaded, or
feelings of unreality or being detached
from oneself
fear of losing control or going crazy
fear of dying
numbness or tingling sensations
chills or hot flushes

Symptoms can appear unexpectedly and

suddenly, for no apparent reason, and
disappear either rapidly or slowly. People who suffer from anxiety and panic
attack symptoms may also be fearful of placing themselves in circumstances from
which escape may be difficult or embarrassing such as elevators, shopping malls
and movie theatres. This is referred to as agoraphobia.


Treatment of Anxiety and Panic Attack Symptoms in Borderline

Effective treatment of disabling anxiety and panic attack symptoms in people with
borderline disorder should be initiated promptly when these disorders occur. Such
treatment usually consists of the use of medications and behavioural techniques.
The use of medications to treat anxiety and panic attack symptoms in patients
with borderline disorder must proceed with care. This is so because these
disorders are commonly treated with benzodiazepines (Xanax, Klonopin, Valium,
etc.), that have been found to be harmful in most patients with borderline
disorder because they increase impulsivity and have addictive potential.
Therefore, in borderline disorder, other classes of medications are often required,
such as a temporary increase in the neuroleptic, atypical antipsychotic or
antidepressant medication being used to treat the disorder. Initiating the use of
an antipsychotic agent or an antidepressant may prove effective for moderate to
severe anxiety and panic attack symptoms if one is not already prescribed.
In addition, a course of cognitive behavioural therapy, or of biofeedback,
specifically tailored to target anxiety and panic attack symptoms are often
considered as part of the long-term treatment of these problems.

The Symptoms and Treatment of Attention

Deficit Hyperactivity Disorder in Patients
with Borderline Disorder
by Robert O. Friedel, MD

Attention deficit hyperactivity disorder (ADHD) occurs in about 25% of people
with borderline disorder; 5 times more often than it does in the general
population. The symptoms of ADHD include decreased attention and
concentration, easy distractibility, difficulty in the completion of tasks, and poor
management of time and the space area that you use. These symptoms of ADHD
result in significantly impaired school, work and social performance, and are
described in detail below.
ADHD is estimated to occur in about 5% of school age children. It is more
common in boys than in girls. There are subtypes associated with hyperactivity
and normal activity levels. The hyperactive subtype is much more common in
boys, while the inattentive subtype (the subtype with normal activity levels) is
somewhat more evenly distributed among boys and girls. The symptoms of ADHD
are now known to persist into adulthood in many people, and to require
continued treatment. There is often a strong family history of ADHD.

Identifying the symptoms of ADHD in patients with

Borderline Disorder is critical for their treatment plan.
Symptoms of ADHD

fails to give close attention to details or

makes careless mistakes in school
work, work, or other activities
has difficulty sustaining attention in
tasks or play activities
does not follow through on instructions
and fails to finish school work, chores,
or duties in the workplace (not due to
oppositional behaviour or failure to
understand instructions)
has difficulty organizing tasks and
avoids, dislikes, or is reluctant to
engage in tasks that require sustained
mental effort (such as schoolwork or
loses things necessary for tasks or
assignment, pencils, books, or tools)
is easily distracted by extraneous
is often forgetful in daily activities


fidgets with hands or feet or squirms in seat

leaves seat in classroom or in other situations in which remaining seated is
runs about or climbs excessively in situations in which it is inappropriate (in
adolescents or adults, may be limited to subjective feelings of restlessness)
has difficulty playing or engaging in leisure activities quietly
is often on the go or often acts as if driven by a motor
talks excessively


blurts out answers before questions have been completed

has difficulty awaiting turn
interrupts or intrudes on others (e.g., butts into conversations or games)


Treatment of ADHD in Patients with Borderline Disorder

It is not uncommon for
children, teenagers and adults
with borderline disorder who
have some symptoms of
ADHD to be misdiagnosed
with ADHD, and then receive
customary treatment with
disorder treated with these
medications typically do not
do well, and may even do
worse than without these
If borderline disorder and
often do worse when treated
for ADHD if they first receive
symptoms of ADHD. Under
these circumstances, they
may then demonstrate an
increase in emotionality and
experience and anecdotal reports in the scientific literature suggest that this
problem can be effectively managed in one of two ways.
When the symptoms of ADHD are mild, behavioural treatments alone may be
effective, thereby avoiding the risk of increasing the symptoms of borderline
disorder with a stimulant.
However, if medications are required to bring the symptoms of ADHD under
optimal control, it appears to be helpful to initiate treatment with a low dose of a
neuroleptic or antipsychotic agent for the symptoms of borderline disorder. Doing
so then appears to permit the use of a stimulant to produce a beneficial effect on
the symptoms of ADHD with a minimal risk of worsening the core symptoms of
borderline disorder.
*Adapted from DSM-IV-TR. American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington,
DC, American Psychiatric Association, 2000.

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