Good afternoon DBT adventurers,
Welcome to part 2 of the introductory chapter of the DBT skills training manual. Once again I am trying to summarise...and once again I am finding it super difficult because it is ALL important. Oh well, here goes...

Understanding Emotion Dysregulation

Biosocial Theory: How Emotion Dysregulation Develops.
According to Linehan (2015), BPD is a severe mental disorder which results from serious emotion dysregulation. Linehan describes suicidal behaviour as being a response to unbearable emotional suffering (p. 5). I so very badly wish that more mental health professionals understood this. The stigma that continues to surround BPD is so crushing. I don't know how many times I have been told by mental health professionals that I am manipulative and attention seeking. I don't know how many times I have been told that I just need to grow up. How can we ever expect the broader community to understand BPD, when the mental health professionals hold such attitudes! I am so very VERY grateful for the wonderful people at SANE who truly "get" it.

The DBT Model of Emotions
According to Linehan (2015), emotions are brief, involuntary, full-system, patterned responses to internal and external stimuli (p. 6). Together, the following components make up an emotional response:

⦁ Emotional vulnerability to cues. The emotionally vulnerable individual is one who experiences a high level of negative emotions at baseline (i.e. when nothing at all is really going on), is super sensitive to emotional stimuli, experiences very intense responses to emotional stimuli, and takes a long time to return to baseline after being emotionally aroused.

⦁ Internal and external events that act as cues. Note that an event can only act as a cue if it is noticed. If you don't notice something, it won't elicit an emotion.

⦁ An appraisal and interpretation of the cue.

⦁ Response tendencies. These include neurochemical and physiological responses (i.e. things that happen in the brain and other parts of the body), experiential responses and action urges.

⦁ Nonverbal and verbal responses and actions.

⦁ The aftereffects of the initial emotion. This can include secondary emotions (e.g. feeling ashamed of having become so angry).

A core tenet of DBT is that by changing one component of this emotional system, you can change the entire system.

Emotion Dysregulation
According to Linehan (2015), emotion dysregulation is the inability, even when one's best efforts are applied, to change or regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal expressions under normative conditions (p. 6). My favourite bit of this statement is even when one's best efforts are applied. Guess what? That means you can threaten me, shame me, and hand out aversive consequences as much as you like, it isn't going to help me to become better at regulating my big feelings. I am always doing the best I can - even if my best sometimes looks extremely chaotic to those around me.

Biological Vulnerabilities
Some people are born more impulsive, more sensitive to emotion cues, and more likely to experience negative emotions than other people. This is why it is unhelpful to compare people. If two people go through exactly the same experience, it is unfair to say that because one coped well with it, the other person should be able to cope well too. We are all born with different strengths and weaknesses...and that's ok.

The Caregiving Environment
As well as a person's natural disposition that we are each born with, the social environment also contributes to the development of emotion dysregulation. Linehan (2015) suggests that the family environment can contribute to the development of emotion dysregulation in three ways:

⦁ The child's emotions may be invalidated, and parents may not role-model how to appropriately express emotions.

⦁ The way family members interact may reinforce emotional arousal. That is, a child may learn that they need to express very intense emotions in order to get their needs met.

⦁ The child's natural disposition and the caregivers' parenting style may be a poor match.

The Role of the Invalidating Environment
From an evolutionary perspective, the purpose of emotions is to convey information. If someone expresses an emotion and it is invalidated (e.g. ignored, not heard, or labelled as somehow "wrong"), then it makes sense that the person will express the emotion more strongly in order to be heard. If the other person doesn't "get" what the person expressing the emotion is trying to convey, they will tend to try and shut the person down with further invalidation (e.g. ignoring, telling the person they are over-reacting, telling the person they shouldn't be feeling that way or to stop feeling that way). This becomes a vicious cycle; the person trying to be heard escalates their expression of emotion in order to be heard, and the more it is escalated, the more the other person responds in an invalidating way to shut it down, which escalates it more etc. etc. etc.

This very much sums up my entire life, and yes, it was tricky reading this because it raises a whole lot of painful "if only's..." in my mind, which in turn make my tummy ache. I very much hold core beliefs of "no one hears me," "no one believes me," "I do not matter." Therefore, some of the most comforting words for me are "I hear you" and "I believe you." One of the things I find so super amazing here in Forum Land is the way in which I can use my calm voice to ask for support, and support appears. You have no idea how novel this experience is for me, and I'm not sure if I will ever grow tired of experiencing it here. I think I probably need to experience it about a bazillion times in order to negate the bazillion experiences I have had of not being heard.

Anyway, back to the story...
So...biological vulnerability (nature) and social environment (nurture) can interact in one of four ways:

⦁ Someone who is biologically predisposed towards developing emotion dysregulation and who also then experiences an invalidating environment, is at super high risk of developing emotion dysregulation.

⦁ Someone who is NOT biologically predisposed towards developing emotion dysregulation, but who experiences a particularly invalidating environment (e.g. where there is severe abuse or neglect), is also likely to develop emotion dysregulation.

⦁ In contrast, if someone was born biologically predisposed to emotion dysregulation but was raised in a very supportive and validating environment, then they are likely to become a well adjusted albeit sensitive adult. This demonstrates that biology (or innate nature) is certainly not destiny.

⦁ The ideal of course is to be born without the biological predisposition towards developing emotion dysregulation AND be fortunate enough to grow up in a nurturing and validating environment. Such a combination tends to lead people towards becoming emotionally healthy well-adjusted adults.

I recognise that I fall very much into the first of these categories. Being Aspie, I am naturally superly duperly sensitive. I can see that if my family dynamic hadn't been so complex and unhealthy, and if the icky abuse stuff hadn't happened, I would have become a successful albeit socially awkward and quirky adult. Again, the "if only's" are weighing heavily in my thoughts right now.

Reading this conceptualisation of how emotion dysregulation develops caused me to reflect again on the fact that people try to differentiate between BPD and complex PTSD. I am yet to find anyone who can explain to me how one would do a differential diagnosis between these two labels. People try to argue that not everyone with BPD has a history of trauma. This is quite correct. According to Linehan (p. 9) it is estimated that 60-75% of people with BPD have a history of childhood trauma. However, it is entirely possible for someone to be naturally superly duperly sensitive such that even a relatively healthy environment is experienced as invalidating, leading to emotion dysregulation. Equally, as described above, it is possible to be born with a naturally resilient disposition, but experience such severe invalidation (through abuse or neglect), that emotion dysregulation develops. The end result is the same. Therefore I genuinely have no idea how any clinician can ever label someone as having both BPD and complex PTSD. I am super open to anyone trying to explain this to me because right now I view this very much as an example of using two labels when one would be perfectly sufficient

Ok, well I think that is probably more than enough for today. All comments, thoughts, reflections and questions are warmly welcomed (not that I am going to guarantee I will have any answers for you ). The next installment will be about the consequences of emotion dysregulation. Stay tuned.