Aug 25, 2011
An Account of 68 Years of My Experience With Bipolar Disorder:
A Personal-Clinical Study of A Chaos Narrative
by Ron Price
Original written in English.
The many manifestations of health problems like neurotic, personality, psychotic and non-psychotic mental disorders is now one of the leading causes of death globally.(1) Mental disorders also account for a significant percentage of the non-fatal burden of disease.
This is my personal story and experience of bipolar disorder(BPD). It is my life-narrative and my experience with a special focus on the idiosyncratic manifestations of BPD in my life. For this reason, among others, I have posted part or all of what I call my 'chaos-narrative' at a number of internet sites.
Severe mental tests are everywhere apparent, not only in the field of psychiatry and clinical psychology, disciplines whose role is to deal with these afflictions, but also across the wider culture in which we all live. These tests have been afflicting people across most cultures in the long history of humankind, but especially in the last century as the world’s population has gone from 1.5 billion in 1914 to 7.5 billion in 2014.
The onset of the Great War: 1914-1918 in some ways marked a new stage in the burgeoning problem of mental health and the tempests of our modern world. Disaster psychiatry now plays a vital role in the evolving structures for preparedness and response in the fields of disaster management. Science and experience now address the tragedies of mass catastrophe with new systems. The challenges are massive for integrating mental health contributions into the practical requirements for survival, aid, emergency management and ultimately recovery. The human face of disaster and the understanding of human strengths and resilience alongside the protection of, and care for, those suffering profound trauma and grief are central issues.
These tests, disasters and crises will continue in the decades ahead as the tempest afflicting society continues seemingly unabated. There are now available, though, a burgeoning range of resources in today’s print and electronic media to help people understand this complex field of mental health. My life-narrative, which I hope will be of help with respect to BPD, is but one small resource for readers. I have posted sections of this account at internet sites which contain a dialogue between people interested in particular mental health issues about which I have had some experience.
There are many internet sites today, some organized for and by mental health experts and others for the general public and especially for sufferers of mental-illness to provide information as well as opportunities to discuss issues and obtain help for what has become a very large range of specific disorders. If one goes to the google search engine and inserts the following words: mental health, depression, bipolar disorder, affective disorders, OCD, PTSD, anger management, indeed, any one of dozens of other disorders in this field, one discovers a host of sites of interest and of relevance to one’s special concerns.
According to one source, one-third of all people in western cultures will suffer from a disorder or emotional problem during their lifetime and they would benefit from therapy. In the last half century there has been a revolution in treatment programs and regimes which have found better and permanent cures for many, if not most, of the mentally afflicted, but there are millions more suffering from mental illness as well. In this world mental illness is truly a heavy burden to bear. I leave it to readers to do more googling for there is much to read for those who are interested in this subject.
Despite the plethora of treatment options for BPD, it remains suboptimal from the points of view of clinicians and patients alike. Whether measured by recovery time from manic or depressive episodes or preventive efficacy of maintenance treatments, BPD is characterized by sluggish responses, inadequate responses, poor compliance and recurrences in controlled clinical trials. Results of naturalistic studies additionally show pervasive, often chronic symptoms, multiple episode recurrences, very infrequent euthymic periods when measured over years and marked functional disability in many patients.(Euthymic means a normal, non-depressed, reasonably positive mood distinguished from euphoria) Thus, despite the explosion of options over the last quarter century when lithium dominated treatment, treatment resistance remains a central problem in BPD. Whether measured by symptom/syndrome/recurrence status or functional status, the majority of treated BPD patients have a less than satisfactory outcome. My life experience with BPD is a good example of this reality, although at the age of 67 I have come to see my present treatment regime as "as good as it gets."
I have joined over 100 of these sites and participate, as circumstances permit, in the discussions on mental health, bipolar disorder, depression and personality disorders among other topics in the field of psychiatry. What I have posted below is, as I say, also posted in whole or in part at many of these sites. I have posted this account here and at other locations in cyberspace because: (a)it is part of my own effort to de-stigmatize the field of mental illness and (b) it provides a useful longitudinal account of BPD for those who are interested.
My own somewhat lengthy account below will hopefully provide mental health sufferers, clients or consumers, as they are variously called these days, with: (i) a more adequate information base to make some comparisons and contrasts with their own situation, their own predicament, whatever it may be, (ii) some helpful general knowledge and understanding, (iii) some useful techniques in assisting them to cope with and sort out problems associated with their particular form of mental health problem or some other traumatized disorder that affects their body, their spirit, their soul and their everyday life and (iv) some detailed instructions on how to manage their lives more successfully despite the negative consequences of their BPD or whatever trauma or illness affects their lives.
For many readers the following post will be simply too long for their reading tastes and interests. In that case just file this document for future use, skim and scan it as suits your taste, go to the sections relevant to your interest or delete it now. Apologies, too, for the absence of an extensive body of footnotes which I have been unable to transfer to this document at BLO.(2)
(1) See a 17 page list of neurotic, personality and other nonpsychotic mental disorders on the internet; see also psychotic or affective mental health disorders. The internet has excellent overviews of all these mental health disabilities.
(2) I have had difficulties placing footnotes into this document and so readers will not find the full list of annotations that I originally placed here. I hope to remedy this problem in a future edition.
My 68 Year Chaos Narrative
A Longitudinal Context: October 1943 To October 2011
11th Edition, Draft #4
Ron Price of George Town Tasmania Australia
(180 Pages: Font 14—75,000 words)
Disclaimer: This on-line book is offered for informational purposes and as an aid to others. It is NOT a substitute for medical advice. Although I make every effort to offer only accurate information, I cannot guarantee that the information I make available here is always correct or current. This is my personal, idiosyncratic, story. Consequently, no one should rely upon any information contained herein, nor make any decisions or take any action based on such information. Consult your doctor before starting any diet or exercise program, taking any medication or, indeed, taking any action at all as a result of reading this work. I am not responsible for any action taken in reliance on the information contained herein and for any damages incurred, whether directly or indirectly, as a result of errors, omissions or discrepancies contained herein.
1. Preamble and Introduction:
1.1 This medium-sized book was once very small, indeed, not much more than a long essay of about 2000 words. It started out as that very short essay ten years ago in 2001: (a) as a statement to obtain a disability pension in Australia and (b) as an appendix to my memoirs, a five volume 2600 page opus found in whole and in part at various places on the internet. Both this statement and that book of my memoirs could benefit from the assistance of one, Rob Cowley, affectionately known in publishing circles back in the seventies and early eighties as “the Boston slasher.” His editing was regarded by some as constructive and deeply sensitive. If he could amputate several dozen pages, several thousand words, of this exploration of my life experience of bipolar disorder(BPD) with minimal agony to my emotional equipment I’m sure readers would be the beneficiaries. But, alas, I think Bob is dead.
I did find an editor, a proof-reader and friend who did not slash and burn but left my soul quite intact as he waded through my labyrinthine passages, smoothed them all out and excised undesirable elements. But this editor is in the late evening of his life and, after editing several hundred pages of my writing, he has tired of any continued exercise in my literary fields and so I am left on my own. I have begun to assume the role that both Cowley and my friend exercised, but it is a difficult and relentless role and I, therefore, only take it up sporadically given the quantity of my writing which does require editing. Without my editor friend, who is now nearly 80 and leads a quiet non-editing life, I advise readers not to hold their breath waiting for me to do what is a necessary edit in this now lengthy work.
1.1.1 John Kenneth Galbraith, the famous economist and a fine writer, had some helpful comments for writers like myself. So, too, did Galbraith’s first editor Henry Luce, the founder of Time Magazine. Both Luce and Galbraith were aces at helping a writer like me to avoid excess. Galbraith saw this capacity to be succinct as a basic part of all good writing. Galbraith also emphasized the music and the rhythm of the words as well as the need to go through many drafts. I've always admired Galbraith, a man who helped me understand some of the mystery that is economics. He passed away while I was writing this book. I’ve followed his advice on the need to go through endless drafts. I’ve lost count of the number of changes, of additions and of deletions to this text. I know I have not avoided excess or repetition among other writing weaknesses that readers will find in the following pages. In some ways I have found that the more drafts I do, the more I have had to say. Excess is one of the qualities of my life, it seems to me, as I muse over seven decades of living, if I may begin the confessional aspect of this work in a minor key.
And so it is that I have Galbraith watching over my shoulder and his mentor, Henry Luce, as well. Galbraith spent his last years in a nursing home before he passed away in 2006 at the age of 98. Perhaps his spirit will live on in my writing as an expression of my appreciation for his work and for a man who lived and worked not far from where I grew up and studied in Ontario, in Canada. His spirit is needed here for there is much editing that is required in this far too-lengthy work; but I do not have the energy or enthusiasm or, perhaps, even the skill, to take on the task.
Spontaneity did not begin to come into this piece of exposition until, perhaps, one of the drafts of its fifth edition back in 2005. Galbraith says that artificiality enters a text along with spontaneity because of the process of writing many drafts. I think he is right; part of this artificiality is the same as that artificiality which one senses in life itself: at least that I sense. Galbraith also observed with considerable accuracy, in discussing the role of a columnist, that a literary man or woman is obliged by the nature of their trade to find significance three times a week in events, often, of absolutely no consequence. I trust that the nature of my work here, as I say a part of my memoir, what I have come to call my chaos narrative, will not result in my being obliged to find significance where there is none. I’m not optimistic though. Perhaps I should simply say “no comment” and accept the reality of the presence of the inevitable gassy emissions that are part of the world of memoirs.
1.2 This is a longitudinal, retrospective account going back to my conception in the last half of October 1943. The story continues up to October 2011. This statement, even at some 75,000 words, is still a work in progress, as they say these days, some 68 years. Neurobiological, neuropsychiatric and affective disorders like BPD are found in diverse forms as well as in a broad range of age of onset and in a specificity of symptoms. Little is still known about its pathogenesis, that is, the origin and development of the disease. What follows is one person’s story, one person’s life experience of BPD, an illness that silently and not-so-silently shaped my life. It is a focussed account on a part of my personal life-narrative with the many manifestations, the symptomology, of BPD as I experienced it. BPD shaped, but did not define all that has been my life. It was a medical affliction that made for a certain inconstancy in living, a certain impulsivity and much else. BPD is treatable but not curable. My story of that ‘much else’ to which I refer is found here.
1.3 I make reference to a strong genetic contribution to the aetiology of BPD, a genetic predisposition, a genetic susceptibility as a factor in the pathogenesis of BPD. No specific gene has yet been definitively linked to BPD, although some chromosome regions have been implicated by several studies. Thus, despite extensive research efforts, the underlying pathophysiology of BPD remains unknown. 1.3.1 A family history, what is sometimes referred to as a family pedigree, of affective disorder in a first-degree relative, in my case my mother(1904-1978) is relevant to this narrative. My mother had a mild case of what may very well have been BPD, at least I have come to think of her mood swings as falling into a significantly high place in what is sometimes called the BPD or affective spectrum during her 75 year life. Her mood-swing disability or affective disorder, though, was never given the formal medical diagnosis manic-depressive(MD), a term which developed from several concepts as early as the 1850s if not centuries before. The term MD was replaced in 1980 after my mother died in 1978 by the term BPD. In retrospect my mother exhibited symptoms which may be more accurately labelled: (a) explosive disorder disability, (b) neurotic disorder: anxiety state or (d) depressive disorder. I know nothing of the mental health of my mother’s parents or grandparents and so am unable to draw on what could be a useful knowledge base to explain the origins of my BPD.
1.3.2 Definition: Bipolar disorder (BPD) or manic-depressive disorder (also referred to as bipolar affective disorder or manic depression (MD)) is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood and one or more depressive episodes. The elevated moods are clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time. There is a defect in the transmission of sense impressions to the brain, a flaw in communication. (See: Monica Ramirez Basco, The Bipolar Workbook: Tools for Controlling Your Mood Swings, 2006. p. viii).
These episodes are usually separated by periods of "normal" mood, but in some individuals, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. BPD has now been subdivided into: bipolar I, bipolar II, cyclothymia, and some other types based on the nature and severity of mood episodes experienced. The range of types and experiences is often described as the bipolar spectrum. –See Bipolar Disorder, Wikipedia, the free encyclopaedia.
1.4 My father also suffered from what seems to me now, in retrospect, a mild case of what today is sometimes called intermittent explosive disorder(I.E.D.) or impulse control disorder(I.C.D.), as opposed to planned acts of violence or a simple temper. Given the rarity of I.C.D., it seems to me that my father had only a mild I.C.D. Other names for I.E.D. include: rage attacks, anger attacks and episodic dyscontrol. People with I.E.D. experience anger which is grossly disproportionate to the provocation or the precipitating psychosocial stressor. My father may have been exposed to this type of behaviour as a child and so his I.E.D. may have been learned rather than organic and brain-centred. There are also complications associated with the diagnosis of I.E.D. and they include job or financial loss. My father lost much money on the stock market in his late middle age, his late 50s and early 60s. My father was also genuinely upset, regretful, remorseful, bewildered or embarrassed by his impulsive and aggressive behavior. In my father’s late 60s, and perhaps at earlier stages in his life, his disorder also exhibited, or so it seems to me now in retrospect, co-morbidity perhaps due to his genuine sense of remorse, but I don’t know for sure. I know nothing, either, of the mental health of his parents or grandparents all born in the 19th century. My conclusions regarding my father’s emotional disability are largely tentative. Perhaps he just had a bad temper.
1.4.1 About half of all patients with BPD have one parent who also has some form of mood disorder. There is then, or so it seems to me, a clinical significance in my mother’s and father’s mood disorders in the explanation of the origins and diagnosis of my own BPD. The high heritability of BPD has been well-documented through familial incidence, twin and adoption studies. There is an unquestionable justification for the inclusion of my family in the understanding of my BPD. No specific gene has yet been identified as the one bipolar gene. It appears likely that BPD is caused by the presence of multiple genes conferring susceptibility to BPD when combined with psychosocial stressors.
1.4.2 Advanced paternal age is a risk factor for BPD in the offspring. Since my father was 55 when I was born, the hypothesis that advancing paternal age “increases the risk for de novo mutations in susceptibility genes for neurodevelopmental disorders” has some relevance to my having BPD.”( Psychiatric News, November 7, 2008, V.43 No. 21, p. 18.) The offspring of men 55 years and older, that same article went on to say, were 1.37 times more likely to be diagnosed as having BPD than the offspring of men aged 20 to 24 years. The maternal age effect was less pronounced. For early-onset cases, that is BPD onset under the age of 20, and that was the case with me, the effect of paternal age was much stronger; whereas no statistically significant maternal age effect was found.
1.5 For an elaboration of the subject of the genetic connection of BPD and in utero BPD see: David Healy’s Mania: A Short History of BPD Johns Hopkins, 2008. A short history of BPD is also available on the internet. Genes may also contribute to the age of onset of BPD and this is analysed now in the context of a phenomenon called genetic anticipation. Anticipation refers to the phenomenon of an illness occurring in successive generations at earlier ages of onset and/or increasing severity. In a recent study using registry data of BPD subjects, age at onset of the first illness episode was examined over two successive generations. Subjects born from 1900 through 1939(my mother) and from 1940 through 1959(myself) were studied. The median age at onset of the first episode of BPD was lower by 4.5 years in subjects born during or after 1940. It was not until my mother was in at least her twenties that her first episode of BPD occurred, although this is somewhat of a guesstimation.
1.5.1 BPD and affective disorders of various kinds run in the family. I am unable to trace my BPD back several generations. But, if I knew more about the many generations that preceded me in my birth family episodes of hearing voices, delusions, hyper-religiosity, and periods of not being able to eat or sleep—I have little doubt would be found. These episodes, these types of experiences were remarkably similar across generations and between individuals. With modern psychiatry and chemotherapy treatments are now available. This is the story of my BPD and my treatments.
1.6 The goal of what is sometimes called ‘personalized medicine’ is to utilize a person's genetic makeup for appropriate disease diagnosis and treatment, an idea conceptualized initially in the recent years of the Human Genome Project. The current conceptualisation of MD/BPD can be traced back, as I indicated briefly above, to the 1850s, although its history can be traced as far back as ancient history in Turkey. Both terms, MD and psychosis, were coined in 1875 by Jules Falret, a French psychiatrist and he recognized its genetic link. German psychiatrist Emil Kraepelin (1856–1926), the founder of modern psychopharmacology, also made a major contribution to the early understanding of MD/BPD, only one of the many disorders in the general mood disorder category, but a cyclical mood disorder associated with a circularity between D and euphoria.
1.7 About 37,000 years ago Neanderthals arguably intermingled with modern humans and thus a new gene entered the human genome, the DRD4 7R gene. This gene arguably originated from Neanderthals. This gene is associated with risk-taking, sensation-seeking and novelty-seeking, and correlated with openness to new experiences, intolerance to monotony, and exploratory behavior, features of Neanderthal behaviour. About 10% of the population have the activated DRD4 7R gene. So goes yet another theory on the genetic predisposition to BPD.
1.8 All manifestations of BPD share uncertain etiologies, with often opaque, obscure, relationships between genes and environment. Some medical experts and theorists in the field of such studies posit latent changes in the expression of specific genes initially primed at the developmental stage of life. Some studies and some experts emphasize that certain environmental agents disturb gene regulation in a long-term manner, beginning at early developmental stages in the lifespan perhaps even in utero. There may be, in fact, pervasive developmental disorders that involve a triad of deficits in social skills, communication and language. For the underlying neurobiology of these symptoms, disturbances in neuronal development and synaptic plasticity have been discussed, but I don’t want to comment on this area of complexity, this puzzling area and the aetiology of BPD.
1.8.1 These disturbances, these perturbations, as they are sometimes called, might not have pathological results until significantly later in life. In retrospect, as I look back from these middle years(65-75) of late adulthood, the years 60 to 80 as some developmental psychologists call these years of the lifespan, these perturbations and pathological results were clearly manifested at the age of 18. I could easily theorize an earlier onset on the basis of behavioural perturbations manifested in early childhood and into adolescence and I do such theorizing later in this account(see sections 2.7.1 and 2.7.2 below). The change from psychodynamic models of psychiatry to neurobiological models that dominate the discipline today has been a critical determinant in both my story and its treatment by the psychiatric profession.
1.9 I received three diagnoses between 1963 and 1980 from psychiatrists, friends, family, GPs and concerned others. The diagnosis that was made in 1980, namely, BPD, is a diagnosis that is standardized according The Diagnostic and Statistical Manual of Mental Disorders (DSMMD-III: 1980 and DSM-IV: 1994) which provides diagnostic criteria for mental disorders. I use the term BPD not MD throughout this document and I use that acronym. In the DSM-IV MD is a 5 axis/level system of diagnosis that is used.
1.9.1 In my case, axis/level 1 is for clinical disorders that are mood disorders. Axis 3 in this system is for what they refer to as acute medical concerns that relate to BPD; axis-4 is for psycho-social and environmental problems that contribute to BPD and axis-5 is an overall caregiver’s assessment of my functioning on a scale 1 to 100. Most of the successful diagnoses and treatment of my BPD have come from psychopharmacology and its roots in physiological assumptions. In the last decade, say, 2001 to 2011, talking cures and behaviour modification techniques like cognitive behaviour therapy with their roots, their emphasis on assumptions in the domain of intrapsychic experience have also been successful as adjuncts to medications or separate from them.
1.9.2 In my case, my caregiver, namely my wife, evaluated me at 61-70 on the numeric scale. This place on the scale reads as follows: “this adult has some mild symptoms as well as some difficulty in social and occupational functioning. Generally, though, he functions pretty well. He also has some meaningful interpersonal relationships." The bar is set quite high by government departments in order for my wife to get a Caregiver’s Allowance and so it is that she and I have not seriously considered applying for such an allowance. My symptoms are not sufficiently extreme for her to qualify as my Caregiver. Readers wanting access to this diagnostic tool can easily find it on the internet. I have appended it to this statement in appendix 2.
1.9.3 With the introduction of psychoactive drugs in the 1950s, and sharply accelerating in the 1980s, the focus in psychiatry shifted from talk therapies like Freudian psychology, to the brain. Psychiatrists began to refer to themselves as psycho-pharmacologists, and they had less and less interest in exploring the life stories of their patients. Their main concern was to eliminate or reduce symptoms by treating sufferers with drugs that would alter brain function. An early advocate of this biological model of mental illness, Leon Eisenberg, a professor at Johns Hopkins and then Harvard Medical School, in his later years became an outspoken critic of what he saw as the indiscriminate use of psychoactive drugs, driven largely by the machinations of the pharmaceutical industry. I mention this here because the subject of psychiatry and the various treatments for mental illness has become highly controversial and complex. For some of the claims and some of the defence from critics of medical and therapeutic advances in psychiatry go to this link: http://www.nybooks.com/articles/archives/2011/aug/18/illusions-psychiatry-exchange/
1.10 The literature now available to those wanting to explore the subject, the field of BPD, is massive both on the internet and off and much of it should be considered by readers wanting to become more familiar with BPD. My story is only one of thousands, if not 100s of thousands, now available. Readers wanting what to me is the best resource to help them deal with BPD should go to Sarah Freeman, The Bipolar Toolkit, 2009. It is far better than this personal, idiosyncratic and non-systematic account.
1.10.1 A good example of one of the most recent findings is from psychologists at the Universities of Manchester and Lancaster in a study published in April 2011. These psychologists say their findings are important because they mean talking therapies, like cognitive behavioural therapy (CBT), could prove effective treatments for BPD. Mood swings of people with BPD, these findings indicate, can be predicted by the current thoughts and behaviour of BPD sufferers. People with BPD are prone to extreme mood swings that take them from great emotional highs to the pits of depression; the cause of these mood swings is often put down to the patients' genes and biology rather than their own thoughts and actions.
For this latest study – published in the American Psychological Association journal Psychological Assessment – the researchers followed 50 people with BPD for a month. The team found that the patients' thinking and behaviour predicted their future mood swings even when their medical history had been accounted for.
"Individuals who believed extreme things about their moods – for example that their moods were completely out of their own control or that they had to keep active all the time to prevent becoming a failure – developed more mood problems in a month's time," said study lead Dr Warren Mansell, in Manchester's School of Psychological Sciences.
"In contrast, people with BPD who could let their moods pass as a normal reaction to stress or knew they could manage their mood, fared well a month later. These findings are encouraging for talking therapies – such as CBT – that aim to help patients to talk about their moods and change their thinking about them."
A new form of CBT, known as TEAMS (Think Effectively About Mood Swings), is being developed by Dr Mansell and colleagues, at The University of Manchester. It aims to improve on previous therapies by focusing on current problems, like depression, anxiety and irritability, and helping patients to set goals for their life as a whole.
The aim of this new approach is to encourage patients to accept and manage a range of normal emotions – like joy, anger and fear – and a controlled trial is about to start following a successful case series of the TEAMS approach. The researchers will use the TEAMS approach to follow up their current findings with a larger study that identifies who relapses and who heads towards recovery in the long term.
In addition, MRP (The Mind Resonance Process) totally unrelated to CBT claims to permanently and completely deletes the negative thoughts, emotions (and negative memories responsible for the former) and helps to restore resilience, self-esteem, self-confidence, and much more. Clients who have failed CBT, EFT, EMDR, psychotherapy, NLP, hypnosis, etc. often achieve significant and permanent life changing success with MRP empowerment coaching.
We all have a life history "movie" which is always playing in the background and acting as a "set point" to which we always are drawn (down) back to. We all carry our history in this cript or movie form and are simply not able to transcend it easily. Hence the need for all the talk and all the medications.
1.11 BPD is not medically curable, as I point out elsewhere in this account, but it is possible through psychiatry, medicine, some types of talk therapy like the one indicated above, and nutritional supplements or adjuncts, to achieve varying degrees or periods of long-term stability. BPD needs to be managed like many other chronic diseases, with combination therapies and long-term treatment in order to achieve sustained success. I feel I have achieved this stability and this success by degrees since the 1960s. This is not to say that I have never had any more episodes since those 1960s, that I have not become hypomanic(i.e. mild mania) again nor exhibited other symptoms of BPD. I have had five, and arguably as many as seven, decades of experience of BPD symptoms and some of these symptoms are still in my day-to-day life. This lengthy 75,000 word statement is an account of my experience in achieving varying degrees of stability at various periods of my life.
1.11.1 I should emphasize at the outset of this statement that some research shows that some forms of psychotherapy or talk therapy are an effective substitute for or accompaniment with medication. Medication plus a structured psychotherapy has been compared to medication plus a less structured psychotherapy or medication alone. Building on earlier studies over the last 5 years, a variety of psychotherapy techniques have been evaluated, including family-focused treatment (FFT), cognitive therapy (CT), group psychoeducation, and interpersonal and social rhythm therapy (IPSRT). For all approaches, the addition of the structured psychotherapy added additional benefit, as measured by a variety of outcome variables, including longer survival time before relapse, fewer relapses, greater reductions in symptom rating scales, enhanced compliance, fewer days in mood episodes, improved social functioning, and fewer and shorter hospitalizations.
At the age of 67 and generally happy with my medication regime, I do not seriously entertain these psychotherapeutic approaches after more than 30 years of dependence(1980-2011) on mood stabilizers and anti-depressant medications. I may seriously consider engaging in talk therapy in the years ahead. Time will tell. I have taken medication in some form for more than 40 years, as far back as June 1968. Although I acknowledge the research showing that health food and nutritional supplements like fish oil, for example and/or vitamins and minerals and/or amino acid(s) are of some value for BPD, and although I in fact take these supplements, I am still not prepared now after all these years to ‘go-it-alone’ without the medication. Both my GP and my psychiatrist concur with this decision. Symptom reduction is one of the main aims of any talk therapy or psychotherapy in general, and can be regarded as the benchmark against which the success of behavioural and cognitive therapies is to be measured. Elucidation of the neural correlates of symptom reduction is a primary goal of any investigation into the biological mechanisms of psychotherapy. But, as I say, I don't go down this road and haven't since going onto lithium in 1980.
1.11.2 I could go to see a counsellor, psychologist or a clinical psychologist for some talk therapy, perhaps CBT. My psychiatrist is a specialist in pharmacology and in treating BPD. Psychiatrists are more trained in pharmacology than psychologists. Some critics of psychiatry and psychiatrists go so far as to say pharmacology is their "weapon" against mental illness. I do not see my shrink, my psychiatrist, as using chemotherapy as a weapon in his arsenal. I have not seen my psychiatrist since November 2008 because my needs are chemical and I have been taking the same 2 meds for four years(2007-2011). If I want to tweak my meds I can visit him or just work out a different package with my wife. I did discuss my memory and OCD issues with him several years ago, but he felt these were not serious enough problems with which I should be concerned. Often my regular doctor, my GP, nails my problems and takes away any need I have to see my psychiatrist.
1.11.3 In the DSM-4(1994), and it will be in the DSM-5(2013), much easier to get a diagnosis of BPD. Allen Frances, a critic of both the DSM-4 and the DSM-5, says that this ease, this extension, this widening of the definition and criteria for diagnosis, has created an incredible opportunity for drug companies. "Drug companies got indications for treating BPD," Frances says. "Not just with mood stabilizers, but also with the newer antipsychotic drugs. And they began very intensive ubiquitous advertising campaigns. The rates of BPD have doubled since the early 1990s. Many people have now had too much antipsychotic and mood stabilizing medicines. And these aren't safe drugs." "If diagnosis can lead to over-diagnosis and overtreatment, that will happen. Doctors need to be very, very cautious in making changes that may open the door for a flood of fad diagnoses." As far as Frances is concerned, the new DSM-5 is proposing too many diagnoses that are written in too broad a way, meaning that ultimately a huge number of new people will be categorized as mentally ill. But there are others, many, who do not agree with Frances. They see this new definition of BPD as an enabling process so that those who would not otherwise get treated will.
1.11.4 There is a world of language associated with an attempt like this to describe a lifetime of BPD. I only try to define some of the terms. For me the words short term apply to: today, this week and this month; medium term applies to a period of two months to a year and the two words long term applies to all the time after one year in my personal medical history, retrospectively or prospectively. I try, as far as it is logically possible to use the term mental health or mental distress and not mental illness. This has been a recent emphasis in mental health discussions and in the literature. Apologies at the outset of this statement for the occasional use of complex language. The field of mental health is replete with complex terminology. It is helpful for those with different types of mental health problems to become as familiar as they can with this language. I try for the most part to use simple language—but I do not always achieve this aim.
18.104.22.168 A good example of the language difficulties is the following part of this paragraph discussing the neurobiological bases of behavioural differences. The language used by specialists is often way over one’s head, both the head of the sufferer from BPD and the heads of others wanting to understand the disability. (See Erik Kandel, “A Biology of Mental Disorder,” Newsweek, June 27, 2009; and C. Langan & C McDonald, “Neurobiological Trait Abnormalities in BPD,” Molecular Psychiatry, Vol. 14, pp. 833–846, published online on 19 May 2009)
These two sources provide many excellent examples of this language complexity. The abstract of this article with this complex language is as follows: “Dissecting trait neurobiological abnormalities in BPD from those characterizing episodes of mood disturbance will help elucidate the aetiopathogenesis of the illness. This selective review highlights the immunological, neuroendocrinological, molecular biological and neuroimaging abnormalities characteristic of BPD, with a focus on those likely to reflect trait abnormalities by virtue of their presence in euthymic/normal patients or in unaffected relatives of patients at high genetic liability for illness. Trait neurobiological abnormalities of BPD include heightened pro-inflammatory function and hypothalamic–pituitary–adrenal axis dysfunction.”
22.214.171.124 This problem of language is dealt with at the following link: http://www.healthyplace.com/blogs/breakingbipolar/2010/06/are-bipolars-crazy-i-am/
I like the word 'crazy' which the author of the above blog emphasizes and uses in her daily life with others. But the word, 'crazy' like 'mentally ill' or even 'mental health problems/issues', has its downside. In some ways, the problem raised is one of language. There is a world of language associated with attempts to describe one's experience with BPD over the short term or over a lifetime. There is the problem of the use of complex language. The field of mental health is replete with complex terminology. It is helpful for those with different types of mental health problems to become as familiar as they can with this language. I try for the most part to use simple language—but I do not always achieve this aim. Language is a problem not only with respect to mental illness but also with respect to many other complex problems in society. KISS, keep it simple stupid, does not solve all problems. Whom the gods would destroy they first make simple and then simpler and then simplest. I will leave this problem here.
126.96.36.199 The term "Mental Illness" encompasses a wide range of conditions that have to do with the way the mind operates.
Some of these conditions are caused by physical dysfunctions of the
brain. Some are caused by various forms of emotional and psychological trauma. Some are primarily cognitive in nature.
Some are primarily emotional in nature.
11.5 BPD presents particular challenges with regard to assessing response to therapy. Criteria for determining remission and recovery have been suggested for mood disorders, but the clinical usefulness of these terms in BPD is elusive. Formal psychological rating scales may be impractical in a routine medical practice setting. As an alternative, clinicians might probe for information about particular "signal events," such as sleep disturbances, that may herald mood fluctuations. The ultimate goal of bipolar management should be complete and sustained remission, whenever possible, although most patients will not achieve this status for any significant length of time.
11.5.1 Overaggressive management might entail pushing medication doses to intolerable levels. Individual treatment goals should always take into account patient acceptance of side effect burden, allowing for trade-offs between treatment effect and quality of life. Noncompliance with therapy, notoriously common among patients suffering from BPD, can stem from drug side effects, treatment ineffectiveness, or even treatment success if the patient misses the manic symptoms. Despite effective treatment, relapse is common. Realistic treatment goals should strive for sustained symptom abatement while maximizing patient quality of life from visit to visit.
1.12 My wife, Chris, has suffered from different disorders all of our married life as well as in the years before our marriage in 1975. Her story is long with invasive surgery for two mastectomies and a hysterectomy as well as post-natal depression following two pregnancies and major psycho-social-family problems. I have not included her story here in any detail except in a tangential sense when it seems relevant to my own experience of BPD. The references in this account to the three major families in my life: my consanguineal family(birth), my two affinal families(marriages) and their many extensions(children and cousins, aunts and uncles, etc.), my work experience and my values are emphasised in this account, but only briefly and only en passant. My religion, the Baha’i Faith, which provides the major base for my values, beliefs and attitudes, is also important--but I do not focus on this Faith here, except in an indirect way. However important this religion has been to me in the past and in the present I do not refer to it except, as I say, en passant in my elaboration of my experience of BPD.
1.13 The new diagnostic term, BPD, is now found in the Diagnostic and Statistical Manual of Mental Disorders-IV published by the American Psychiatric Association in 1994. DSM-III had 300 disorders twice as many as in the DSM-II. DSM-V is due for publication in 2013. The DSM is considered the bible by specialists and by the various professions and other interest groups. It is considered by many as a core/basic information source, a major scientific instrument in the field of mental health. In the DSM-IV the term maniac was deleted and the one-size-fits-all classification system for MD and BPD was more finely tuned by the 4th edition published in 1994. The exact discourse that has come to have jurisdiction in this labelling process, the circumstances that have come to result in a person given some mental illness label are due to: (a) norms and expectations as well as (b) medical, psychological, physiological and (c) most recently, neurochemical and electrical brain activity as seen in brain imaging.
1.14 This account also provides a statement of my most recent experiences with BPD in the last four years, 2007-2011. Some prospective analysis of my illness is also included with the view to assessing: potential short term, medium term and long-term strategies, appropriate lifestyle choices and activities in which to engage in the years ahead in these middle years(65-75) of late adulthood(60-80) and old age(80++), if I last that long. For the most part, though, this account, this statement I have written here in some 75,000 words, is an outline, a description, of this partially genetically predisposing family-based illness and of my experience with it throughout my life.
1.14.1 I would, though, discourage others from blaming their parents for their genetic contribution to the disorders. I would also discourage them from blaming other family members for their contributions in the form of psycho-social stress and conflict and failure to understand. Rather than wasting time and energy in finger-pointing or bemoaning the fact that one has BPD, I would encourage sufferers to learn how to best use available treatment programs, or modalities as they are sometimes called in the literature, to minimize their symptoms and to find success and satisfaction in their lives despite their disorder.
1.15 Some of the personal context for this illness over the lifespan in my private and public life, in the relationships with my consanguineal family(family of birth) and in my two affinal families(families by marriage), in my employment life(1961-2005) and now in my retirement(2000-2011) are discussed in this document. I include in the description and analysis of my BPD some of what seems to me my major and relevant life events, not as triggers in my experience of BPD but as accompanying factors: (a) personal circumstances as they relate to my values, beliefs and attitudes--what some might call my religion as defined in the broad of senses; (b) family circumstances; for example, my parents’ life, my wife’s illnesses, the life-experiences of my three children as well as significant others in my lifespan like my father and mother and my first wife; (c) employment circumstances involving as they did: (i) psycho-social stress, (ii) movement from place to place and (iii) my sense of identity and meaning; (d) aspects of day-to-day life and their wider socio-historical setting and (e) details on other aspects of my medical condition to help provide a wider context for this BPD in the last two years.
1.15.1 I could explore section (d) above in some detail, but to be brief, let me simply add here that: processes of social inequality, poverty, human exploitation, besides many other ideological processes, install emptiness, disempowerment and lack of meaning in life. This is a frightening discovery because if we assume that this constitutes illness, the treatment for psychopathology should be a lot more complex than what have been traditionally used in clinical psychology and in psychiatry. It should give priority to political and community processes which help to make it possible and preserve mental health in addition to any neurobiological processes.
1.16 This lengthy account will hopefully provide mental health sufferers, clients or consumers, as they are now variously called these days, with: (i) a more adequate information base to make some comparisons and contrasts with their own situation, their own predicament, whatever it may be, (ii) some helpful general knowledge and understanding, (iii) some useful techniques in assisting them to cope with and sort out problems associated with their particular form of mental health problem or some other traumatized disorder that affects their body, their spirit, their soul and their everyday life and (iv) some detailed instructions on how to manage their lives more successfully despite the negative consequences of their BPD or whatever trauma or illness affects their lives. I am registered at over 100 mental health sites and contribute in ways that seem appropriate. But I do not assume the role of coach or mentor on the internet as some doctors, specialists and people who have experienced various forms of mental illness do at many sites on the world-wide-web.
1.17 I like to think that what has become over the last few years this book of 180 pages has advice that could be used by many people with BPD as well as others without BPD. Keeping detailed records, for example, written or mnemonic, ingrained in memory and/or with signs for immediate recall when required--of one’s feelings and relationships and, in the process, taking responsibility for maintaining and improving them, might help BPD sufferers and others deal with their problems and have more successful lives. As for the meaning of successful, I prefer Thoreau's evocative lines: "If the day and the night are such that you greet them with joy and life emits a fragrance like flowers and sweet-scented herbs; if life is more elastic, more starry and more immortal in the process--that is your success." Even ‘Abdu’l-Bahá’s ‘oft repeated phrase: “Be Happy!” is a simple enough aphorism and yardstick for measuring your daily life, your sense of well-being and the extent to which you are well-oriented and well-positioned to assume the responsibilities that are the result of your interests and commitments. Of course, in using such definitions of ‘success’ like this, one must recognize that millions of people without mental health issues don’t have success defined in these terms. Finally, success and happiness are highly idiosyncratic terms and how each person sees them, defines them and experiences them are their own--even if there are many common threads from person to person.
1.18 There are two kinds of lists that BPD sufferers need to keep in mind in going about their daily lives in dealing with this disorder. So wrote one writer and, liking what he wrote, I include his ideas here. The first list is what you could call risk-factors that increase the chances of BPD sufferers becoming ill and/or having their symptoms dominate their daily life and produce ill-effects for themselves and others in their environment. Such socio-environmental factors as: family distress, psycho-social stress, drinking alcohol or using drugs, sleep deprivation or missing medication are in this category. A second list of what could be called protective factors help to protect people with BPD from becoming ill. They include: keeping charts of one’s moods, going to bed and getting up at the same time every day, staying on one’s programs/regimes of medication and psychotherapy and avoiding psycho-social stressors that one knows will precipitate negative symptoms of BPD.
1.19 My note-taking and list-making are works-in-progress so to speak, and have been for years. How they are implemented varies from year to year and decade to decade. Now, at the age of 66, I keep: (a) a medical file in 5 sections in a separate briefcase. Readers can see the outline of this file in Appendix 7; (b) this 75,000 word and 180 page book updated to outline my life-experience of BPD; and (c) a written autobiography in 5 volumes which I update, as well as 1000s of prose-poems. I continue to write poetry each week. All of this helps me monitor my experience of BPD both directly and indirectly. I have used many charts, made many plans and tried to implement various safety-nets over my lifetime. Freeman’s description of the ones BPD sufferers can use is the best I’ve seen.
1.20 I like to think that this account is crammed full of useful information for patients with BPD and other illnesses, for their family members, for therapists, for friends, lovers, employers and anyone else interested in BPD. The insights I share were not acquired by reading the voluminous literature on BPD, although I have taken a serious intellectual interest in the subject in the last decade since I retired from FT employment in 1999. My insights come, in the main, from reflecting on 68 years of life since my conception in October 1943.
1.20.1 I have benefited from what you might call the collective wisdom of others about what it means to live with BPD and other conditions. This wisdom comes from the reflections of other writers, from specialists, indeed a range of commentators. Finding solutions to my BPD problems and telling about what works for me taps into my creative resources and it also requires investigating my own trial and error efforts to create a personally satisfying life in order to separate what works from what doesn’t work. Finding solutions and what works in one’s own life is a form of artistry that can result in highly individual and unique solutions and outcomes. I like to think that this book taps into both my own wisdom and experience and the collective wisdom of others looking for a better quality of life by writing about what has been helpful for them as sufferers with BPD or some other condition or, indeed, as a loved one or family member.
The medical psychiatric perspective believes in the centrality of genetic and biological approaches to mental ill-health over psychosocial ones and, at least in my case, this perspective informs this account. To put this idea another way, this account is based on the psychiatric perspective of the centrality of genetic and biological approach to mental health.
1.21 There are other psychiatric disorders often confused or associated with BPD and sufferers with BPD need to be aware of these other disorders in their diagnostic dialogue with their doctor and as they go about negotiating their lives. Differential diagnoses, as they are sometimes called, include: ADHD, schizophrenia, obsessive-compulsive personality disorder; recurrent major depressive disorder, schizo-affective disorder, post-traumatic stress disorder, narcissistic personality disorder, borderline personality disorder, antisocial personality disorder, avoidance disorder and cyclothymic personality disorder. I have many of the features of any one of these disorders except schizophrenia at one time or another in the last seven decades. I was officially diagnosed by a psychiatrist in 1968 as having schizo-affective disorder. All of the other disorders I can partly, indeed, significantly, identify with when I read the list of symptoms associated with each of them. I would not list these disorders here if I did not exhibit or have not exhibited many of their symptoms in my lifetime.
1.21.1 In one study of 60 patients with BPD, 23 (38%) fulfilled the diagnostic criteria for at least one personality disorder. Those personality disorders most commonly were: narcissistic, borderline, antisocial, avoidance disorder and obsessive-compulsive. In my case the obsessive-compulsive personality disorder(OCPD) and post-traumatic stress disorder(PTSD) have been the most dominant and especially after the age of 60. The presence of these disorders sometimes make BPD symptoms more intense and more difficult to treat and they appear to increase the risk of suicide, but not in my case. I will deal with suicidal ideation later in this account of my chaos narrative. This account is about BPD and by a person with BPD and it only ventures into these several other psychiatric illnesses and personality disorders to a limited extent and only from time to time when it seems relevant. I will deal with these personality disorders in my life briefly in the next several sections before continuing this account of BPD.
1.21.2 A personality disorder is an enduring pattern of inner experience and behavior that: (a) deviates markedly from the expectation of the individual's culture, (b) is chronic, pervasive and inflexible, (c) affects two or more of the following areas: thoughts, emotions, interpersonal functioning and impulse control. To be considered a personality disorder the behaviour should also have an onset in adolescence or early adulthood, that is the years 20 to 40, be stable over time and lead to distress or impairment. Because these disorders are chronic and pervasive, they can lead to serious impairments in daily life and functioning.
1.21.3 In a list of ten basic symptoms of obsessive-compulsive personality disorder(OCPD), I possessed six symptoms rated at 5 or above on a 10 point scale in January 2010. I will not list these symptoms of OCPD here since this narrative and analysis is a focus on BPD, but readers can easily google them if they are interested. Wikipedia is an informative source for information on OCPD. The pattern of behaviours for my OCPD has been highly diverse rather than stable over the years as far back as my childhood and has become more dominant, as I say, in my late adulthood, the years after the age of sixty on a new medication regime of an anti-depressant and a mood stabilizer which I will discuss in more detail later in this story. People with OCD are ridden with anxiety. This overstates my level of anxiety. By contrast, people with OCPD tend to derive pleasure from their obsessions or compulsions. This is the case with me.
188.8.131.52 The primary symptoms of OCPD are: (i) a preoccupation with details, rules, lists, order, organization, and schedules; (ii) showing a perfectionism that interferes with the completion of a task, (iii) excessive focus on being productive with time and (iv) excessively devoted to work and productivity to the exclusion of leisure activities and friendships. People with OCPD, when anxious or excited, may tic, grimace, or make noises, similar to the symptoms of Tourette syndrome or do impulsive, and unpredictable things. Children are sometimes born with a genetic predisposition to OCPD, but may never develop the full traits. Windows of vulnerability to stress exist across human cortical development and this has: (a) a critical role in determining the brain's capacity to respond to stress, and (b) has been implicated in the pathogenesis of psychiatric illness. The neonatal and infant period, specifically the period less than 130 days, and the late adolescent periods represent critical windows of stress pathway development.
Looking back to my early childhood there is some evidence that I had OCPD. The literature suggests that much depends on the context in which such children are raised. Since anxiety, trust and everyday routines of social interaction are so closely bound up with one another, it is easy to understand how the rituals of day-to-day life become a type of coping mechanism.
1.21.4 I was diagnosed with a mild schizoaffective disorder in the autumn of 1968. After six months(6/68-11/68) in four different psychiatric wards and hospitals I was eventually released. I have also been taking the anti-depressants luvox(fluvoxamine-2001) and then effexor(venlafaxine-2007) for depression. The side-effects from these anti-depressants which I have manifested in the years 2001 to 2011 are: sleepiness, fatigue and weight gain. Less common side-effects that have been manifest in my day to day life include: gas, difficult or laboured breathing, some loss of touch with reality, neck pain, vertigo, diarrhoea, heartburn, abnormal dreams, unusual tiredness and social withdrawal symptoms.
184.108.40.206 The luvox and effexor have helped decrease the intensity of the depressions which I had been experiencing late at night for 20 years. The sense of relief from the intensity of that late-night depression was a source of positive energy, a wonderful injection of spirit and joy into my life. The significance of the depressed phase of BPD has been markedly underestimated not only by those familiar with BPD but by the wider society. Bipolar depression accounts for most of the morbidity and mortality due to this illness.
1.21.5 Narcissistic personality disorder (NPD) is a personality disorder defined by the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic classification system used in the United States. Although I do not fit the narrow definition of NPD: "a pervasive pattern of grandiosity, need for admiration, and a lack of empathy," it could be argued that I am excessively preoccupied with self-centeredness, and issues of personal adequacy, power, and prestige. In the list of diagnostic criteria, there is no doubt that I have an element of NPD. As is the case with any personality disorder, the details are complex and require much discussion if they are to be teased-out and understood. The extent of my NPD is only partial like so many of the personality disorders associated with BPD.
220.127.116.11 There are several sub-categories of narcissism or narcissistic personality disorder and the one I come closest to exemplifying is the amorous narcissist with its emphasis on the erotic and exhibitionism. I may have had an oversensitive temperament at birth; I was certainly overindulged and excessively admired and praised as a child and adolescent. Life for those living with a person who has NPD can be very difficult indeed, formidable and isolating. My wife has often expressed this view. When people with NPD are criticized they often feel rejected, humiliated and threatened in the context of their ambitious and capable selves. A hypomanic mood can be coupled with a sense of grandiosity. NPD is sometimes seen as a defence against shame. I seem to exhibit some of the characteristics of the many sub-types of narcissism. I also utilize some of the narcissist’s coping strategies. NPD commonly coexists with: hypomania, histrionic PD, borderline PD, antisocial PD and paranoid PD. I have aspects of all of these personality disorders. NPD is not due to a chemical imbalance but, rather, is an ingrained personality trait. Since some narcissistic traits are common and normal; since self-love is part of the very clay of man, I find it difficult to assess the real extent of NPD in my life.
18.104.22.168 A. M. Benis(1939--), now a retired physician, developed what is now called the NPA theory of personality on the basis of the concepts of psychiatrist Karen Horney(1885-1952). This trait theory of personality posits that narcissism is one of the three major behavioural traits underlying personality and human character. It is indispensable, so goes this theory, to human development. I advise readers to read about this theory if they want more detail on the nature of narcissism and what is, in many ways, a naturally occurring trait in all people or which, in some respects, I am one.
1.21.6 Antisocial personality disorder (ASPD or APD) is defined by the American Psychiatric Association's Diagnostic and Statistical Manual as "a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood." The individual must be age 18 or older, as well as have a documented history of a conduct disorder before the age of 15. People having antisocial personality disorder are sometimes referred to as "sociopaths" and "psychopaths", although some researchers believe that these terms are not synonymous with ASPD. Impulsivity, superficial charm, inflated self-appraisal, irritability leading to aggression, disregard for social norms and extensive rationalization of one’s behaviours all characterize ASPD. I have had all of these traits at one time or another and sometimes many of these traits at once.
22.214.171.124 Readers are advised to go to the online encyclopaedia, Wikipedia, to get a fuller picture of the various mental disabilities I refer to in this account. It is possible, or at least one could argue, that I do not fall into these categories in even a minimal sense. I have certainly never been diagnosed by a psychiatrist and treated for other disorders. BPD is the only label which has stuck since 1980. It is important to include a note of warning here, namely, that: once one goes trolling among the pages of disorders, mental and otherwise, that exist in the medical and psychiatric literature, one can find all sorts of data that applies to one.
1.21.7 Cyclothymia is a rapid-cycling form of bipolar affective disorder which creates alternating short periods of hypomania and depression, with periods of stability in between. Cyclothymia is often regarded as the poor cousin of BPD, but should not be underestimated as a very serious condition that needs long-term management and support by the sufferer and the health care professionals who deal with the sufferer. Cyclothymia is a milder form of BPD. Like BPD, cyclothymia consists of cyclical mood swings. However, the highs and lows are not severe enough to qualify as either mania or major depression.
126.96.36.199 To be diagnosed with cyclothymia, a person must experience numerous periods of hypomania and mild depression over at least a two-year time span. I did and for the first time from 1963 to 1968. Because people with cyclothymia are at an increased risk of developing full-blown BPD, it is a condition that should be monitored and treated. My four years at university, 1963-1967, could be said to be a form of cyclothymia. In 1968 I experienced that full-blown BPD, although it was given the label “a mild schizo-affective state.” The famous English actor Stephen Fry says his BPD is of