Younger sister - is it BPD?

[Depression = 72% of members]

BACKGROUND

My younger sister (26 years of age) currently resides with me, in a one-bedroom apartment. Her partner of three years and I are her primary emotional support pillars / caregivers.

Since childhood, she exhibited a raging temper which would culminate in her biting herself, but we wrote it off as toddler / childhood tantrums.  As a child, I would have to constantly give in, but our relationship has generally been very loving and amiable, aside from her episodes of rage.

The slow but sure downward spiral started when she left high school. She has been exhibiting signs of anxiety and depression for a while, perhaps even as early as 2014, but we did not think of the possibility of depression back then, and chalked it up to difficulty in adjusting to life post-secondary school / entering a new, unfamiliar environment in college. It got to a point where normal everyday tasks caused her severe anxiety.

In early 2019, my sister was diagnosed with depression, social anxiety and mild borderline personality disorder. This diagnosis was later expanded to potentially include bipolar II.
She is presently on medication (Lithium and Valdoxan).

We are unsure if it's mere depression, or BPD. She doesn't "act out" in that she doesn't lash out / actively manipulates everyone around her, but she flies into a rage every Sunday night, due to anxiety about going to work the next day. She has exhibited inability to regulate her emotions, but doesn't blame others (channels all the guilt and blame inwardly instead, and frequently expresses that she just needs to "toughen up".) She has described the fear and pain as being "overwhelming" to bear.

PRESENT SITUATION

She has been undergoing therapy for about two years. However, her partner and I both feel that she isn't making progress with therapy, in that she has not opened up wholly / fully to her therapist. It is also of concern to us that her therapist has chosen to completely ignore the borderline personality disorder diagnosis, asserting that this diagnosis may be incorrect because my sister does not exhibit the classic signs of BPD (i.e.: does not typically act out, and does not exhibit manipulative behaviour).

While we do understand that this may be a possibility, and that diagnosing underlying mental conditions may not be an exact science, it is frustrating because her therapist is adopting a purely behavioural approach to my sister's diagnosis. Therapy sessions have focused mainly on CBT and mindfulness techniques, which my sister has attempted very half-heartedly. I am frustrated and angry, but I think we have no choice but to stick to this therapist, as it was an uphill battle getting my sister to even consider therapy in the first place.

My sister is a high-functioning individual, and is able to mask her depression / pain very well.I suspect that in therapy sessions, she has not been fully honest about her concerns / anxieties. She has expressed doubt that she "really has depression, and maybe she's just being a big baby about things".

Since accepting her new job role at a company about five months ago, she has had nightly breakdowns, and her partner / myself have taken turns listening to her / persuading her that her self-worth is not tied to her job. She truly believes that she is "useless", and that "things will only get worse". She has expressed that "she doesn't want to get better, she just wants things to end".

Things culminated this year in June , when she was self-mutilating with a clothes iron. This was not the first instance she has self-harmed - she normally takes to biting herself until she bleeds, or making shallow cuts with a razor blade. Her train of thought frequently spirals into suicide ideation, and she believes that due to her inability to cope with pressures of her newfound job, she will lose her job, and that dying will be the only solution.

The worst breakdowns are on Sunday nights, where she has constant melt-downs every weekend, and attempts to hurt herself by slapping / biting, and throws household objects at us. She will frequently express suicidal thoughts, express that she is in pain, and that she "needs help", but rejects all forms of advice or persuasion.  It has come to a point where we are all at our wit's end, we're both very burnt out, frustrated, and very emotionally exhausted. My parents are generally supportive, but they are also at a loss as to how best to support her. We have all read through BPD materials, and my parents are less accepting of the possibility that she has BPD.

WHAT I WISH TO FIND OUT

My questions are:

1) How can we be sure of the BPD diagnosis? How can we convince her that she has a problem, and that she is *not the problem*?

2) How can we cope better, and help her better, as her support pillars? How should we react each time she expresses her feelings of being overwhelmed / wanting to kill herself, yet rebuffs all attempts at gently coaxing her out? I know we're approaching this all wrong, by smothering her when we really should be trying to help her to get well, but we're so afraid that if we leave her alone to her own devices, she might really just try to take the plunge and kill herself.

3) It was a terrible time trying to get her to go for psychotherapy in the first place, and she may decide to stick with her present therapist. Is there any way to make this work, in some way or another? Ideally, I would like to persuade her to try another therapist, as this one hasn't been able to yield any improvements in the past 2 years. 

OTHER THOUGHTS

Caring for my sister and her needs is taking a severe toll on all our lives. I am emotionally burnt out, and growing very numb to her woes, which frightens me. I don't want it to descend to a point where I actively resent her, and I'm trying very very hard to stay emotionally healthy as well. Her partner and I both have demanding day-jobs, which makes it both physically and mentally tiring, to try to be that grounding presence for her all the time.

I frankly would not blame her partner, should he decide to leave. I could never leave my younger sister and cut contact, I love her very much, but it is so, so difficult.

[klcki]

BACKGROUND

My younger sister (26 years of age) currently resides with me, in a one-bedroom apartment. Her partner of three years and I are her primary emotional support pillars / caregivers.

Since childhood, she exhibited a raging temper which would culminate in her biting herself, but we wrote it off as toddler / childhood tantrums.  As a child, I would have to constantly give in, but our relationship has generally been very loving and amiable, aside from her episodes of rage.

The slow but sure downward spiral started when she left high school. She has been exhibiting signs of anxiety and depression for a while, perhaps even as early as 2014, but we did not think of the possibility of depression back then, and chalked it up to difficulty in adjusting to life post-secondary school / entering a new, unfamiliar environment in college. It got to a point where normal everyday tasks caused her severe anxiety.

In early 2019, my sister was diagnosed with depression, social anxiety and mild borderline personality disorder. This diagnosis was later expanded to potentially include bipolar II.
She is presently on medication (Lithium and Valdoxan).

We are unsure if it's mere depression, or BPD. She doesn't "act out" in that she doesn't lash out / actively manipulates everyone around her, but she flies into a rage every Sunday night, due to anxiety about going to work the next day. She has exhibited inability to regulate her emotions, but doesn't blame others (channels all the guilt and blame inwardly instead, and frequently expresses that she just needs to "toughen up".) She has described the fear and pain as being "overwhelming" to bear.

PRESENT SITUATION

She has been undergoing therapy for about two years. However, her partner and I both feel that she isn't making progress with therapy, in that she has not opened up wholly / fully to her therapist. It is also of concern to us that her therapist has chosen to completely ignore the borderline personality disorder diagnosis, asserting that this diagnosis may be incorrect because my sister does not exhibit the classic signs of BPD (i.e.: does not typically act out, and does not exhibit manipulative behaviour).

While we do understand that this may be a possibility, and that diagnosing underlying mental conditions may not be an exact science, it is frustrating because her therapist is adopting a purely behavioural approach to my sister's diagnosis. Therapy sessions have focused mainly on CBT and mindfulness techniques, which my sister has attempted very half-heartedly. I am frustrated and angry, but I think we have no choice but to stick to this therapist, as it was an uphill battle getting my sister to even consider therapy in the first place.

My sister is a high-functioning individual, and is able to mask her depression / pain very well.I suspect that in therapy sessions, she has not been fully honest about her concerns / anxieties. She has expressed doubt that she "really has depression, and maybe she's just being a big baby about things".

Since accepting her new job role at a company about five months ago, she has had nightly breakdowns, and her partner / myself have taken turns listening to her / persuading her that her self-worth is not tied to her job. She truly believes that she is "useless", and that "things will only get worse". She has expressed that "she doesn't want to get better, she just wants things to end".

Things culminated this year in June , when she was self-mutilating with a clothes iron. This was not the first instance she has self-harmed - she normally takes to biting herself until she bleeds, or making shallow cuts with a razor blade. Her train of thought frequently spirals into suicide ideation, and she believes that due to her inability to cope with pressures of her newfound job, she will lose her job, and that dying will be the only solution.

The worst breakdowns are on Sunday nights, where she has constant melt-downs every weekend, and attempts to hurt herself by slapping / biting, and throws household objects at us. She will frequently express suicidal thoughts, express that she is in pain, and that she "needs help", but rejects all forms of advice or persuasion.  It has come to a point where we are all at our wit's end, we're both very burnt out, frustrated, and very emotionally exhausted. My parents are generally supportive, but they are also at a loss as to how best to support her. We have all read through BPD materials, and my parents are less accepting of the possibility that she has BPD.

WHAT I WISH TO FIND OUT

My questions are:

1) How can we be sure of the BPD diagnosis? How can we convince her that she has a problem, and that she is *not the problem*?

2) How can we cope better, and help her better, as her support pillars? How should we react each time she expresses her feelings of being overwhelmed / wanting to kill herself, yet rebuffs all attempts at gently coaxing her out? I know we're approaching this all wrong, by smothering her when we really should be trying to help her to get well, but we're so afraid that if we leave her alone to her own devices, she might really just try to take the plunge and kill herself.

3) It was a terrible time trying to get her to go for psychotherapy in the first place, and she may decide to stick with her present therapist. Is there any way to make this work, in some way or another? Ideally, I would like to persuade her to try another therapist, as this one hasn't been able to yield any improvements in the past 2 years. 

OTHER THOUGHTS

Caring for my sister and her needs is taking a severe toll on all our lives. I am emotionally burnt out, and growing very numb to her woes, which frightens me. I don't want it to descend to a point where I actively resent her, and I'm trying very very hard to stay emotionally healthy as well. Her partner and I both have demanding day-jobs, which makes it both physically and mentally tiring, to try to be that grounding presence for her all the time.

I frankly would not blame her partner, should he decide to leave. I could never leave my younger sister and cut contact, I love her very much, but it is so, so difficult.

[missing NC]

Given that there are 256 possible variations of BPD based on five out of nine symptoms, I'd say your sister's therapist may be coming from a rather narrow view. The reason that Marsha Linehan developed Dialectical Behavior Therapy (DBT) was that she found individuals with BPD responded unfavorably to CBT.  Even without the label of BPD, it's evident that your sister is in tremendous pain and has trouble regulating her emotions. So the Distress Tolerance portion of DBT may be very helpful regardless of her diagnosis.   If she is not ready to see a new therapist, might she be open to an initial exposure to DBT through a workbook?  Dr. Daniel Fox has a very compassionate approach on his Youtube channel.  I have an acquaintance with "quiet" BPD who said she finds his workbook useful. 

This sounds extraordinarily stressful for the whole family. I've suggested the Family Connections skills training through NEAPBP in various other treads though I myself have not taken it.  I was on a Zoom meeting this weekend with the mother of a daughter with BPD who is finishing up the 12 week program and indicated she is finding it quite helpful.  See https://www.borderlinepersonalitydisorder.org/family-connections/ 

I took a condensed version of family skills training through BPD Global, which was quite substantive.  One of the instructors talked about her own experience in dealing with being held hostage by her daughter's suicide threats and how she finally addressed those episodes.  Whether or not you do the skills training, connecting with her may be quite useful to you. 

Given that your sister's most acute issues are on a predictable schedule is there any chance of getting her to engage in strenuous exercise such as running stair and/or immersing her face in cold water or using an ice pack across her eyes and bridge of her nose on a Sunday evening?   Both techniques serve to counter the fight or flight response, the running because it signals to the brain that she has outrun the danger and is now safe, triggering a parasympathetic response and the cold across her face by triggering the mammalian dive reflex.  Perhaps either or both activity could be positioned as part of some fun family activity or game.  (This is probably not a realistic approach, but my son and I actually had fun tracking our heart rates on my Apple watch before and after immersing our faces in ice water.  The reduction was really impressive.)     

In any case, I have no doubt you will receive plenty of input on the board from participants with far more wisdom and practical experience than I. 

[JNChell]

Ugh. This sounds extremely stressful. The meltdowns sound like one thing, but lashing out at you and her partner are another thing. As stated above, there are currently 256 comorbid diagnosis that fit with BPD. I’m not a therapist so I can’t say for sure, but a lot of the behaviors that you describe line up with what I’ve read here. You also stated that she has been seeing her current therapist for a couple of years. If BPD is part of the problem, it can take 7-8 years to successfully treat. That’s a ballpark. If she is BPD, staying in for two years is a huge accomplishment on it’s own. I’ve also read that the success rate without outside support is pretty much impossible. Do you know what type of therapy she is currently receiving?

Have you tried tried talking to her therapist? Privacy acts are in place, but maybe your sister signed a document that would allow you some insight. I imagine that trying to switch therapists right now would be too overwhelming for her and she would just drop out of the idea.

Don’t be scared off by behavioral approaches. A lot of therapists are cause and affect based in their approach. Just an idea. You know your sister and the situation best. Would you be up for talking with her therapist if the opportunity was there?

[missing NC]

JNChell is right that progress with individuals with BPD is extremely slow. I would add that because BPD has only been recognized fairly recently and treatment of personality disorders is not covered by insurance (it is coded as something else such as depression or bipolar for billing) many or perhaps most therapists are really not well informed about the disorder. 

In terms of your sister seemingly not opening up about her true worries and concerns, I would also add that many individuals with BPD have alexithymia, which is an inability to identify emotions. They just know they feel bad but are unable to unravel  why. 

Jenny Lawson, a blogger and author who struggles with depression, anxiety and self-harm has shared that when she gets the urge to self-harm, she holds ice cubes in her hands as long as she can. The pain stimulates endorphin release and grounds her. But unlike cutting or burning, the ice cubes don't hurt her. 

Sorry for jumping around among topics - but I thought I'd also mention exercise. The newer research on stress responses and anxiety identifies the critical role of the mitochondria (the powerhouses of our cells) and clearly demonstrates the protective effect of exercising somewhat vigorously every day for those, like your sister, who have an overwhelming stress response. The minor and controlled consistent stressor of exercise effectively "trains" the mitochondria to deal better with stress.  Because she may be unwilling to exercise for her own sake, it can be positioned as a way of supporting you in improving your health. 

At one of the information sessions I attended through BPD Global, two sisters spoke of their concern for their highly suicidal sister and their parents' struggle to understand BPD and deal with the overwhelming stress. The coordinator offered to the sisters to reach out to their parents, which I found extremely kind.  She too had traveled that path with her daughter and really understands what it's like.  I hope you are able to connect with some of those resources.

My sister is more in the other camp of outwardly raging and harming others.  But I remember when it first became obvious that something was terribly wrong.  I spent most of the night on the phone with her and calling the police and everyone else I could think of to save her from her impending threatened suicide and then her assurance to me as she hung up that she was going to do it anyway.  The stress is unspeakable (on both ends of the behavioral spectrum).  I empathize with what you are going through and wish you and your family some relief moving forward. 

[Naughty Nibbler]

Hi klcki:
If you are hanging around in the background, jump in and resume posting.  I have a few thoughts to share, if you are still interested in interacting in a conversation about your sister.

They say the definition of insanity is doing the same thing over and over again and expecting a different result.  So I have to wonder about the Sunday night habit/meltdown. There are lots of tools to try, when someone actively makes an effort to manage anxiety. 

What has she tried on Sunday nights?  Any activity/actions to "improve the moment", manage the stress, break the habit?

A therapist can introduce mindfulness tools, but the patient has to want to use them.  Whether it's DBT, CBT or mindfulness training by itself, a person has to participate and practice the skills.  There is no magic.

[JNChell]

Great insight here, but let’s get this back to you klcki and how you’re feeling. We hope that you’re feeling better. Any new stuff?