Managing the intense, explosive dysphoria experienced by patients with borderline personality disorder (BPD) is one of the tougher challenges we face. These complex states, with elements of anxiety, rage, depression, and shame, are hard for patients to tolerate, let alone examine. Worse, they can generate dangerous solutions: suicide, self-harm, and overuse of substances or medications to alter the experience.
Rescue medications can help, but they rarely work completely and come with risks, like addiction and disinhibition with benzodiazepines. Non-medication tactics such as exercise, music therapy, and mindfulness exercises are useful, with an aim toward adaptation rather than elimination of the state.
The Mindful Breather is a brief (1–5 minute) routine I’ve developed for these dysphoric crises. It’s based on mindfulness skills that are a core part of dialectical behavior therapy (DBT) and can be readily taught in a 25-minute visit.
Teaching the Mindful Breather
The Mindful Breather routine involves 3 steps: 1) some basic concepts of mindfulness, 2) the technique of relaxation breathing, and 3) review and practice of the routine.
Step 1: Mindfulness concepts
In teaching mindfulness, I find it useful to split the concept into 3 parts. Here are examples of things I say to my patients:
Physical experience. Attune to your interior sensations of breathing, heartbeat, and pain; and your sensory impressions of sight, hearing, smell, taste, and touch.
Emotional tone. Feel your emotions, which might be located in your chest or anywhere else in your body. What are you experiencing right now? Is it calmness, anxiety, anger, sadness, happiness, or something else?
Thoughts. What are your thoughts? Are there memories? Judgments? Worries? Notice their intensity—are they “flurries” or “blizzards?” What kind of familiar, personal reactions are you having to outside events?
With more advanced practice, we will work to identify our “mind’s eye.” This is our own awareness, our capacity to observe all of the features above.
Step 2: Abdominal breathing
Next, briefly teach abdominal or “belly” breathing. Instruct the patient: Fill your lungs with air, like filling a water balloon. Inhale so your belly pushes out first, then your upper chest. After a brief pause, exhale slowly to near-empty.
Step 3: The Mindful Breather routine
In the final step, guide the patient through the full routine in the style of a meditation exercise. Here are my instructions:
Set up. Find a place to take a breather. If you are in a public setting, excuse yourself to a quiet spot—step outside or head to a restroom. If available, find a place to sit down or take a walk without being interrupted. Take a deep breath to settle yourself.
Focus your attention through 4 deep breaths. With each slow, deep in-breath, imagine gathering energy and attention in the chest. As you breathe out, focus your attention on each of these features in sequence, one breath at a time:
Breath 1. Imagine you are directing the breath into your whole body. Notice tension, restlessness, pain, calm… whatever physical sensations are present.
Breath 2. Imagine directing the breath into your emotional state—often located around your heart. Notice what that state is: anxious, angry, sad, content… whatever is there.
Breath 3. Imagine directing the breath to your thoughts. Is your head full of them? Kind of quiet? Is one of the thoughts crowding out the others? Try not to chase them. Just observe whatever is there.
Breath 4. Imagine pulling your attention back and just observing your whole experience. Notice whatever is there in your body, heart, head, occurring together. You’ve filled yourself with awareness and are observing it all.
Wrap up. If needed, repeat the sequence or some part of it until you feel in better control. Then take a final, deep breath. Notice the difference in how you feel. You may find some comfort and gratitude for managing a difficult moment. Open your awareness outward again, reorient yourself, and return to your day’s activities.
After practicing these steps in session with the patient, I’ll finish with instructions on how to apply this routine as a first step in a broader game plan for managing dysphoria. Ideally, the Mindful Breather can be used at the earliest signs of distress. From there, we define thresholds for when the patient may need to move on to second-line strategies, such as rescue medications, emergency contacts, or other distress tolerance skills to prevent self-harm (see “Distress Tolerance Skills” sidebar below). Reinforce the routine in subsequent visits.
TCPR Verdict: The Mindful Breather helps mitigate crises and dysphoric moments in patients with borderline personality disorder.
Patients can download a guided audio version of the Mindful Breather in our 7/20/20 podcast, “A Mindful Routine for Bipolar Depression.” Search for “Carlat” on your podcast store.
Distress Tolerance Skills
When dysphoria becomes too intense for an organized, sequenced response, mindful exercises may be too difficult for patients to take on. At that point, they can turn to distress tolerance skills. Based on dialectical behavior therapy, these skills serve to self-soothe and prevent self-harm.
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