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  1. #1
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    Default Spin off from whack PITAs: Borderline Personality Disorder?

    I don't mean to see this (misunderstood and maligned) Dx everywhere, but reading all the "family trouble" threads and a recent experience got me thinking about the accurate description of Borderline Personality Disorder and its treatment, not just "how do you cope with the (a-hole) who is BPD and good riddance."

    A long-time friend of mine was just given this Dx by her therapist and some ideas for working on it. I had the honor of being invited to one of her sessions so I learned a lot.

    The neutral description of BPD fits her to a T:

    Emotions are all "big"-- disproportionately so according to the rest of us.

    Those and loyalties change quickly, with the person saying "What? What's the big deal about the new one I ripped you?" afterward.

    A chaotic life with few long-term relationships because people get tired of it. In her case, that's true with men, employers, friends who don't have a thick skin.

    Surprising to me was the etiology. It seems to be not all her fault, but (according to the therapist) a "bad fit" between her intelligence and sensitivity and an alcoholic family that basically told its kids to shut the F up at every turn.

    As I understand it, the treatment du jour is "Dialectical Behavior Therapy." I don't quite get it, but it sounds like most of what it involves acknowledging an emotion (usually anger) and then making an effort to feel less of that anyway.

    That suggestion, of course, pissed off my friend. It does sound kind of invalidating to me. It also sounds hard to "talk yourself down off the roof" or even to want to.

    So I do understand that most people (including therapists) hate these BPD people and eventually bail on them. I'd bail on my friend except that she has asked me not to. We have been friends for a long time-- I'm listed as the "next of kin" on medical forms because she can't think of anyone else who has actually been around long enough and "on her side" enough to be trusted.

    So does any treatment for BPD actually work?
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  2. #2
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    DBT is currently the gold standard, and yes it works.

    The ideal treatment will have her go through each of the 4 modules twice, but it's not like a requirement. The modules are: interpersonal effectiveness, mindfulness, emotional regulation, and distress tolerance. Some of them may be easier than others, some may be more immediately relevant to her functioning that others, but they are interconnected and valuable.

    The reason DBT developed was because traditional CBT (cognitive behavioral therapy) was ineffective with BPD individuals. CBT can be very invalidating- it basically lays on the premise that distress comes from irrational beliefs.

    DBT says that the beliefs ARE rational based on the individual experiences of the client, HOWEVER they are maladaptive beliefs when looking at the bigger picture.

    The reason it is "dialectical" behavior therapy is because it acknowledges to polarities: accepting the person is doing the best they can, while also accepting that the person can do better. Dialectical basically relates to the possibility of two opposing truths being right at the same time while dialoging to discover a truth between, as well.

    DBT will only work, though, if she puts the work into it. It is hard at first. And feels really stupid. But as it slowly creeps into her and becomes a part of her thought process, she will notice changes. And she will probably like those changes.

    There are workbooks, exercises, and creative ways to modify them to suit an individual. Group therapy should be happening (2x a week is best), and that will be a place for her to share what works for her, and learn about different techniques others have done which will might work for her. It's also a place to learn the new skills and exercises, as well as discuss events that have happened that relate to the module themes.

    I have experience on both sides of the table with this therapy, and I'd be happy to talk via PM with you more if you'd like



  3. #3
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    I am not a psychologist, nor play one on TV (or the internet ), but had a long history with a true BPD. I say *had* because she ended up killing herself after completely alienating everyone, including the long-time friend who tried for a lifetime to help her/encourage her to get help and finally gave up when the BPD, firmly entreched in the victim role, refused to try any more approaches.

    My understanding is that they are almost impossible to treat because they feel justified in their actions/reactions, and get "pissed-off" when they are encouraged to modify them. They also tend to see things in extremely black and white terms, so when someone trying to help them pushes them into an uncomfortable place, that person becomes "all bad," and thus no longer worthy of being listened to. Besides that, they are masters of manipulation and transference, so they often end up doing a number on the people trying to help. I went into therapy for a year to sort myself out after being caught up in trying to be a friend to the BPD. It is admirable of you to stick by your friend; just watch that it doesn't have an effect on your own well-being.

    Good luck.



  4. #4
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    I have BPD. This is why I live alone and don't date. I'm very difficult to deal with so aside from work I am basically a hermit.

    I would like to go through the DBT by its not widely available.
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  5. #5
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    Pirateer I am sorry to hear that and hope you find a place near you to do this therapy if it helps. I have no experience with this disorder, but I have always loved your posts.



  6. #6
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    Someone very close to me has BPD. Like your friend, she was also raised in an unhealthy home environment that didn't mesh well with her intelligence and personality.

    She went through DBT after a failed suicide attempt. Spent several years on a few different SSRIs following, but now takes nothing and does great—family, good social life, happy, etc.

    That's not to say it's not a tough personality type to deal with, even after therapy, but it's possibly to live a very fulfilling life once you "learn" how to.



  7. #7
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    I worked at a state psych hospital for awhile and let me tell you, Borderlines were one on the most difficult populations to work with. I can honestly say that I have never seen any treatment plan for a borderline really work. It is really sad too. And when a person come in with a diagnosis of BPD most staff groan because they are so difficult.

    One patient I had did do well for awhile but backslid again after several months of stability. I believe this will be the pattern for the rest of her life. This particular patient really benefited from animals being worked into her treatment plan believe it or not. For her they were something she never got angry with. As for dealing with her...we had to just always be really calm. Even when she was throwing stuff at us screaming in our faces. One on one time with her helped a lot too. She really dealt with things better like that and would really open up. Her story was very sad but it always seemed to help her talk about it with people she trusted. She tried to kill herself more times than I can count, so that was also always tough. I actually really liked her after I got to know her and learn how to deal with her.

    Another patient I had nothing worked. However, she was not interested in any treatment offered to her what so ever. So, that of course had a lot to do with it. Can't help if they aren't willing.

    It is a very difficult disorder to deal with and it is frustrating for friends and family. Good for you for sticking with your friend. I know it is really difficult. A lot of therapists do bail and it is unfortunate. A good support system is really important and it sounds like she has that in you. I think that she can for sure make improvements but there is always going to be tough times with her. But, those time where she is doing well can be great and really rewarding for her and for you. Good luck!



  8. #8
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    Funny, we seem to collect them. Not really, but they certainly stand out. I've learned to run away once they are identified and hope they don't follow.



  9. #9
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    Thanks for all your replies. They are so helpful. Everything I read on the web for those around BPD was about "coping" with them, not helping them get better.... But as you all point out, support systems help! So WTF?

    Fortunately, my buddy is charismatic and can at least *make* friends easily. She always has at least someone who isn't currently on the Sh!t List.

    Quote Originally Posted by Pirateer View Post
    I have BPD. This is why I live alone and don't date. I'm very difficult to deal with so aside from work I am basically a hermit.

    I would like to go through the DBT by its not widely available.
    Yeah, and comparing my friend's way of going about life to mine, her history and mine (I had her F-ed up family Lite), and my ability to not be freaked out by over-the-top pissed when I could see why a more minor version was in order made me think:

    "Takes one to know one." Yikes!

    DBT doesn't sound like Rocket Science. But I'll bet it needs to come with some compassion. Otherwise it sounds like "Just change how you behave and feelings will follow (or not)." I'm sure it wasn't originally meant to sound so Duct Tape, right?

    So maybe people who want to improve *and* can see this as a form of self-care (leaving intact the idea that the rest of the world is a-hole). It might be hard, but do you think it's possible to do a Home Brew version.

    Quote Originally Posted by SFrost View Post
    I worked at a state psych hospital for awhile and let me tell you, Borderlines were one on the most difficult populations to work with. I can honestly say that I have never seen any treatment plan for a borderline really work. It is really sad too. And when a person come in with a diagnosis of BPD most staff groan because they are so difficult.

    One patient I had did do well for awhile but backslid again after several months of stability. I believe this will be the pattern for the rest of her life. This particular patient really benefited from animals being worked into her treatment plan believe it or not. For her they were something she never got angry with. As for dealing with her...we had to just always be really calm. Even when she was throwing stuff at us screaming in our faces. One on one time with her helped a lot too. She really dealt with things better like that and would really open up. Her story was very sad but it always seemed to help her talk about it with people she trusted. She tried to kill herself more times than I can count, so that was also always tough. I actually really liked her after I got to know her and learn how to deal with her.

    Another patient I had nothing worked. However, she was not interested in any treatment offered to her what so ever. So, that of course had a lot to do with it. Can't help if they aren't willing.

    It is a very difficult disorder to deal with and it is frustrating for friends and family. Good for you for sticking with your friend. I know it is really difficult. A lot of therapists do bail and it is unfortunate. A good support system is really important and it sounds like she has that in you. I think that she can for sure make improvements but there is always going to be tough times with her. But, those time where she is doing well can be great and really rewarding for her and for you. Good luck!
    Wow-- My buddy hasn't been suicidal at least in the 15 years I have known her. But there's plenty of other addictions.

    The bolded part is true of her, too. She takes great care of her dog, no matter what. I have never seen her mistreat him or any other animal. She seems to like them all in a generous way. It's like there's a completely different set of rules for the 4-leggeds and 2-leggeds!

    I deal with her as you would a 1,000 horse with an "issue." I don't take it personally. That lets me "stay in the ring" with them. When it gets tiring or out of hand, I "put a solid fence" between me and her-- just like you would the horse. But hopefully that only need to be temporary.

    I think people/horses have legitimate reasons to be angry (or scared or hurt or whatever) and I'm not going to get mad at an animal that doesn't know "proportion" in his actions. I assume the colt needs to be taught that. Maybe it's the same for people? I don't really know how our species is successfully taught to have the right emotion in the right size at the right time.

    Maybe we all get imperfect training and those who pass some threshold get labeled BPD..... Maybe the rest of us are just squeaking by somewhere under the radar hehehe.
    The armchair saddler
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  10. #10
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    Quote Originally Posted by mvp View Post
    I think people/horses have legitimate reasons to be angry (or scared or hurt or whatever) and I'm not going to get mad at an animal that doesn't know "proportion" in his actions. I assume the colt needs to be taught that. Maybe it's the same for people? I don't really know how our species is successfully taught to have the right emotion in the right size at the right time.
    Its very true.
    I found that once I accepted the diagnosis and became more educated I am much more in control of this disorder. I can prepare those closest to me for what they may encounter, and I know that when I am having a reaction (one way or the other) i need to not push it but instead just "quit". Rebecca sometimes needs "Rebecca Goes Away" time.
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  11. #11
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    Quote Originally Posted by Pirateer View Post
    Its very true.
    I found that once I accepted the diagnosis and became more educated I am much more in control of this disorder. I can prepare those closest to me for what they may encounter, and I know that when I am having a reaction (one way or the other) i need to not push it but instead just "quit". Rebecca sometimes needs "Rebecca Goes Away" time.
    Yeah, so more on the Yikes! point.

    I was telling my mom just yesterday: When I say something like, "My job feels pretty damned hard" you need to put a coefficient of 3 or so next to that. Same words as everyone else, but meant to describe a more intense version of it.

    She and I have a long history of me thinking she doesn't take things seriously and me bumming myself out in the process of trying to explain why she should. I don't go there anymore; it's too "expensive" to me.

    Thinking about it, my friend doesn't choose "alone time" so much as a different audience or distraction. I guess that works well enough as a temporary solution....but Pirateer what do you do to "get down off the roof" when you do get that alone time?

    Again, thanks for your insight and help on what seems to be an unusual problem. Look, if they'd just make a Made For TV movie about this.... if it would just become "fashionable" as Anorexia did in the 1980s and Cutting had its moment in the sun in the 1990s, we could all just figure it out.
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  12. #12
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    Quote Originally Posted by mvp View Post
    Thinking about it, my friend doesn't choose "alone time" so much as a different audience or distraction. I guess that works well enough as a temporary solution....but Pirateer what do you do to "get down off the roof" when you do get that alone time?
    For a while I really wasn't good about the roof thing. I walked out of job, lost relationships, quit being president of the State Horse Show Assoc, all because I was "mad". At one point I was sent to the Pysch ER and they took all my stuff and locked me up for hours which annoyed the shit out of me because I wasn't suicidal, I was just angry.

    Its HARD. While I can see when it is going to happen I can't really fix anything- all I can do is get myself out of situations I can do damage in.

    I work in a highly public area- but I live alone with my cats. I dont date. I dont hang out with friends. I rarely socialize at the barn when I rode. (A lot of that is also because I have aspergers syndrome).

    I used to try to be normal and failed miserably. I hope to someday have normal relationships but its extremely unlikely.

    Your friend is going to be like that until she finds another outlet. Not saying mine is a healthy way to cope but at least I haven't quit any jobs lately.
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  13. #13
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    Quote Originally Posted by mvp View Post

    Again, thanks for your insight and help on what seems to be an unusual problem. Look, if they'd just make a Made For TV movie about this.... if it would just become "fashionable" as Anorexia did in the 1980s and Cutting had its moment in the sun in the 1990s, we could all just figure it out.
    Cutting and BPD have a lot in common.

    Also, "Girl, Interrupted" is about a woman with BPD in the 60s. Now, it's a great movie, but I don't think it really captures what it's like to have BPD.

    BPD is a lot more widely studied than you may think. The new DSM (5th edition) isn't even out yet, but there are already talks of the 6th edition being drastically revised to create a "trauma" category that would include BPD, among other already existing disorders. It won't change the illness, but it will change how we think about the etiology and how to treat it. My alternate thesis (that I didn't pursue) was a proposal to examine the literature about PTSD and BPD, with the intention of demonstrating a correlation of PTSD (often viewed as the result of an acute trauma situation, or longer-term trauma in adulthood), and BPD (becoming viewed as the result of ongoing, insidious trauma of childhood, such as being verbally abuse or other icky but often un-reportable relationship dynamics in the home).

    Your friend may want to consider talking to a psychiatrist (not PCP!) about an appropriate mood stabilizer during treatment. I know I kind of hit a plateau because we had scraped off enough crap to really hit the "good stuff", but my anxiety level was too high to go there even in counseling. Being on the mood stabilizer for... 2 months? maybe 3? Really helped me break through that and get the nitty gritty.

    If you really want to educate yourself, get the BPD book by Marsha Linehan (she developed it).

    You really can't "help her get better". I mean, you can't erase her past. But you can probably encourage her whenever possible to use her skills, to think thoughtfully and critically about which of the new things she's learning she is most likely to use, and in what circumstances. Another way people view this disorder is that these people, as kids, for whatever reason failed to learn appropriate self-soothing from adults among other things (not placing blame on the kid, though!). Maybe she can view this as a educational opportunity as well.

    You can also help her by insisting on healthy boundaries. You are not there to be abused, you are not there to baby sit her, but you are certainly there for her when she can demonstrate some sort of restraint and/or efforts to follow through on her treatment plan.



  14. #14
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    Quote Originally Posted by Pirateer View Post
    For a while I really wasn't good about the roof thing. I walked out of job, lost relationships, quit being president of the State Horse Show Assoc, all because I was "mad". At one point I was sent to the Pysch ER and they took all my stuff and locked me up for hours which annoyed the shit out of me because I wasn't suicidal, I was just angry. ...

    Your friend is going to be like that until she finds another outlet. Not saying mine is a healthy way to cope but at least I haven't quit any jobs lately.
    In the very angry/not suicidal situation I see a failure of communication and a conflict of interest more than "fault" on either side!

    I think the current triage for Psych ER is "Look, bottom line, is the person going to die in the immediate future?" It's not built to do a whole lot more. So maybe the very angry person can't explain the difference, or does so and have his or her actions carry more weight than words. But the triaging doc perhaps also isn't interested in finding that difference but asking the cruder life/death question only.

    And if you aren't quitting jobs or "being let go" (as the slowly backing away employers do with my friend) then you are doing better than she!

    I hope you can see some accomplishment in that even if you think your life looks NQR. As with everyone who needs to change, I think my friend needs to hit a "rock bottom." But she tolerates so much chaos that it's hard to convince her that losing jobs every other year (among other things) is bad enough to warrant change.

    What has worked in the past is to say something like "Look, even if you are right-- the bank who made a $2 mistake and then was rude in correcting it-- does not deserve your business. Doesn't it cost *you* in the end to move your accounts around all the time?" She can hear the "Living well is the best revenge" kind of argument.
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  15. #15
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    Quote Originally Posted by Jaideux View Post
    BPD is a lot more widely studied than you may think. The new DSM (5th edition) isn't even out yet, but there are already talks of the 6th edition being drastically revised to create a "trauma" category that would include BPD, among other already existing disorders. It won't change the illness, but it will change how we think about the etiology and how to treat it. My alternate thesis (that I didn't pursue) was a proposal to examine the literature about PTSD and BPD, with the intention of demonstrating a correlation of PTSD (often viewed as the result of an acute trauma situation, or longer-term trauma in adulthood), and BPD (becoming viewed as the result of ongoing, insidious trauma of childhood, such as being verbally abuse or other icky but often un-reportable relationship dynamics in the home).
    My old therapist suggest that my BPD is basically a result of unreported sexual abuse. (And suggested my fairly recent acceptance is due to finally talking to police about it and said d-bag ending up in jail for a long, long, long, long, long time...)
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  16. #16
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    Pirateer--I commend you for being so aware and kind to people that you have dine what you can to make yourself better.

    I had no clue what these people were like, until some "friend" wormed into my life. My recommendation is to get far, far away. Generally they don't have the self awareness and caring of anyone else's thoughts as Pirateer. They are completely focused on themselves and master manipulators, and as the diagnoses said, leave a trail of broken people behind them. They can f**k you up.



  17. #17
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    Quote Originally Posted by Jaideux View Post
    BPD is a lot more widely studied than you may think. The new DSM (5th edition) isn't even out yet, but there are already talks of the 6th edition being drastically revised to create a "trauma" category that would include BPD, among other already existing disorders. It won't change the illness, but it will change how we think about the etiology and how to treat it. My alternate thesis (that I didn't pursue) was a proposal to examine the literature about PTSD and BPD, with the intention of demonstrating a correlation of PTSD (often viewed as the result of an acute trauma situation, or longer-term trauma in adulthood), and BPD (becoming viewed as the result of ongoing, insidious trauma of childhood, such as being verbally abuse or other icky but often un-reportable relationship dynamics in the home).

    Your friend may want to consider talking to a psychiatrist (not PCP!) about an appropriate mood stabilizer during treatment. I know I kind of hit a plateau because we had scraped off enough crap to really hit the "good stuff", but my anxiety level was too high to go there even in counseling. Being on the mood stabilizer for... 2 months? maybe 3? Really helped me break through that and get the nitty gritty.

    If you really want to educate yourself, get the BPD book by Marsha Linehan (she developed it).

    You really can't "help her get better". I mean, you can't erase her past. But you can probably encourage her whenever possible to use her skills, to think thoughtfully and critically about which of the new things she's learning she is most likely to use, and in what circumstances. Another way people view this disorder is that these people, as kids, for whatever reason failed to learn appropriate self-soothing from adults among other things (not placing blame on the kid, though!). Maybe she can view this as a educational opportunity as well.

    You can also help her by insisting on healthy boundaries. You are not there to be abused, you are not there to baby sit her, but you are certainly there for her when she can demonstrate some sort of restraint and/or efforts to follow through on her treatment plan.
    Also a really great post, like your first. Thanks!

    Listening to her describe what it was like growing up in her house (and knowing mine was parallel), I can see how the "bad fit" in her family was either a prolonged but subtle trauma or lacked that "self-soothing" training.

    As you would predict, my friend is a long way from wanting psychiatric help. Just having her not fire this therapist is a start!

    I also hear you on "my job" as establishing boundaries. It feels like the key is to distinguish between "OK, if you come at me with both hind feet, I'm going to get behind a fence. No questions, no hesitation, no apology. But I'll be back when it's safe. And I left for my well-being, not as a personal affront to you." When we have had this kind of conversation, I think she only believes me because I do, in fact, show back up again. I don't (dare) frame this as "And I'm teaching you something."

    I'd like to ask you stuff about how the looking at the past at some point as part of this treatment does fit in. But we can do that PM if you like. I think I assumed that "therapy" included this, and that DBT sounded like "duct tape" because it didn't sound like it did more than address present behavior and really the worst of it. The Marsha Linehan stuff (which my friend's T told us about) always speaks to the most extreme emotions to be controlled. I don't have a clue what long-term "recovery" would look like. You just hear about the first part looks like.
    Last edited by mvp; Jan. 1, 2011 at 06:36 AM.
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  18. #18
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    Hit me in a PM anytime



  19. #19
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    Quote Originally Posted by Jaideux View Post
    Hit me in a PM anytime
    Thanks Jaideux-- I'll do that.

    Oh, and the good news I forgot to mention:

    My friend's T said "When BPD people *do* recover they are great-- they have lots of empathy. They become the especially talented therapist, teacher, friend, oncologist with great bed-side manner that we all need and admire."

    Kinda cool, huh?
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  20. #20
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    Quote Originally Posted by Pirateer View Post
    For a while I really wasn't good about the roof thing. I walked out of job, lost relationships, quit being president of the State Horse Show Assoc, all because I was "mad". At one point I was sent to the Pysch ER and they took all my stuff and locked me up for hours which annoyed the shit out of me because I wasn't suicidal, I was just angry.

    Its HARD. While I can see when it is going to happen I can't really fix anything- all I can do is get myself out of situations I can do damage in.

    I work in a highly public area- but I live alone with my cats. I dont date. I dont hang out with friends. I rarely socialize at the barn when I rode. (A lot of that is also because I have aspergers syndrome).

    I used to try to be normal and failed miserably. I hope to someday have normal relationships but its extremely unlikely.

    Your friend is going to be like that until she finds another outlet. Not saying mine is a healthy way to cope but at least I haven't quit any jobs lately.
    Are we talking about BPD and Asperger Syndrome as a co-morbidity, or the other way around?

    I think there seems to be some muddling of the issues here and those two, if going by standard definitions, need different approaches to work with them.

    If AS is on board, much of that BPD diagnosis may be skewed by the AS, to the point the BPD diagnosis, although perfectly possible, may be suspect and definitely complicates the situation.
    We can't expecting a color blind person to just start seeing all color hues by providing them with treatment and coping skills.
    Does't work quite like that, I don't think.



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