we're doing this again it's afternoon oh well we're not going to do that bit again but i gotta tell you i have very negative feelings about what we're going to do today okay i don't think that we're going to have any interest in this talk at all nobody ever cares even a little bit about anything that doesn't have to do with medications so if we talk about something that isn't medication focused no one's going to listen and i that's all i can believe
You know, Dr. Fu, I think expectations are a big, big aspect of your experience. And when you go in with that negative mindset, you're going to make it true. So I think I want you to go in without those negative expectations. How would you feel about that?
That feels scary to me, but I think we better do it. I'll stop splitting my feelings about this. I have noticed, though, that I feel like people actually are a little less interested in the non-DSM, non-medication-focused ones, but we'll see what happens. What are we talking about today?
I didn't know if your little intro was supposed to be about negative expectations or that those are your authentic feelings.
Oh, not I mean, they're based on my real feelings, but actually the thrust of what I was going for there was splitting, splitting my expectations, all negative of this particular situation, you know, and saying that the medication episodes are all positive. So that probably leads us to our topic.
Oh, that's great. And I, you know, I feel like we missed in our first few episodes, integration was such a key, I would say, one of our core principles. And I feel like we've moved away. I mean, of course, it's baked in, but we haven't.
It's baked in, right? You got to integrate yourself back into life when you have a trauma treatment, but we haven't talked about it explicitly for a bit.
So, yeah, I think this is a good episode to bring back the importance of integration and, you know, multiple things.
We've been going too long without seeing the topic of the episode, please.
The topic, you know, it's not that well defined. There's what we're going to be talking about today is what's called good psychiatric management. This is the work of John Gunderson, one of the big guns in borderline personality disorder. Good psychiatric management is supposed to apply to patients with borderline personality disorder. However, and to me, it's a great overview of the approach to med management appointments for patients like that.
But I think the principles generalize so well. And I use the basics of good psychiatric management. Almost all diagnoses. I think it's helped keep me. It's helped me understand my limitations. It helps help me set limits. It's helped me have better appointments. I'm looser. I don't know. To me, it's been such a crucial framework for appointments.
And yeah, I totally agree. It's funny because I was thinking the same thing. We did not significantly discuss this. We've had the same experience. I think it's an undertaught modality. You know, some residents, I think, will even graduate without having heard of it, depending on your training program. My program did not have a formal... didactic related to it but i was lucky enough to have a great supervisor who was formally trained in some capacity at least with gpm and yeah i think that it's funny my understanding is the name good psychiatric management was chosen to make the treatment experience of treating borderline personality disorder less threatening and more accessible to general psychiatrists but I think it really is a manual for good psychiatric management in general.
Yeah. The title is very, it's funny cause it's so good psychiatric management. Um, But yeah, in terms of, you know, my experience with it, there's a manual that's like 150 pages. You can cruise through it. The first time I read it, I walked away like, I don't know, with just a few ideas of how to integrate it. The second time I read it with like a really discerning eye, it's one of those things that it's both specific.
It's a little vague. It's one of those things that like I walk away without necessarily having like specific things that I do, but I just feel more comfortable in appointments after kind of learning the basics of it.
You're pointing there to kind of an important phenomenon. And I think it's an important phenomenon that a lot of trainees today are kind of missing. I don't know. I don't know about you. I feel like reading has fallen out of favor. Oh, yeah. People used to read more. Maybe this is my old man shaking my fist at a cloud moment, but people used to read more and you can't just read once for the purposes of achieving a specific outcome.
You can do that, but you shouldn't only do that by simply reading and then allowing yourself to reflect. Subsequently, you can get a lot more from the text. So by the way, as you say, GPM text, super short, everyone should read it. Just read it. It's extremely short.
One alternative to reading is listening to our podcast and sharing with friends.
Yeah, that's right. Okay, I think we better get to the meat.
And, you know, okay, so let's get to the basics. And a big part of this, you know, at least my understanding is that borderline personality disorder. And again, the principles here are going to be generalizable to all people. diagnoses but uh yeah we'll talk more specifically about borderline things um people thought that for a while clinicians went into the diagnosis of borderline personality disorder and they thought it was an untreatable condition where uh patients sabotage treatment and um they make it they make your life hard and this was almost like a uh affixed to that in that it really shifts the idea of borderline personality disorder isn't this untreatable uh condition these aren't bad patients um a lot of patients uh they want to get better they don't know why they're suffering and um it really uh flipped the script in terms of like expectations um and that's actually what i thought you were kind of doing at the beginning was uh that that was how people approach borderline that like It didn't work like it's a tough diagnosis.
They don't get better. And good psychiatric management flipped the script entirely. And because of that, was able to actually treat it.
Yeah, and it's not a thing of the past, right? I think we should understand that, that there's a lot of work that needs to be done in our field and there's lost stigma. And I believe that stigma exists primarily because of clinician reactions, which are sometimes understandable to difficult patients. Let's face it, some patients are simply more difficult than others. You will feel differently. You will expend different levels and different types of mental energy with some patients than others.
But they're all our patients. They all deserve treatment. And most importantly, if you apply yourself, you can be successful, effective, and less burnt out than if you take that. old school erroneous approach of saying, hey, this is a patient who just doesn't want to get better. They're a bad patient, blah, blah, blah.
Yeah, yeah. And also, you know, one of the core ideas here is that you can treat borderline personality disorder. The patient doesn't need intensive treatment with a specialist twice a week that only treats borderline. For a good proportion of these patients, you can provide good psychiatric management at normal intervals and focus on the right things and the patients will actually get better?
Actually, the natural course of personality disorders, even without treatment, is to get better. The problem is that not all of it is going to get better. And the way it gets better seems more like the behaviors change more so than the underlying condition gets better. So don't rest on your laurels too much if people are getting better, but also don't despair. Let's try to split the difference there and take the middle path, right?
Uh, these patients do need treatment. They can get better if you apply yourself carefully. Uh, but also don't rely on the natural course of improvement.
Yeah, and I think it's almost you have to keep two things in your head at once in that letting the patient know that the natural course is to get better offers hope to a patient that maybe doesn't have any. But also, you shouldn't rest on your laurels and say, hey, the natural course is to get better. What are we doing here? Both are true.
Yeah, though it should be noted that even though good psychiatric management is called that, I believe the traditional model is still supposed to be weekly psychotherapy. So I will say that for moderate to severe borderline conditions, they should be in weekly psychotherapy, ideally. And we know that out in the community, things are limited. Not everyone can do everything. We have to start from kind of a model of something and then do what we can from there.
Yeah, and what I like about this is that you can use these principles in your outpatient residency clinic for the patients that you're seeing monthly, and you can get them set up with another weekly therapist and use these principles in your treatment while they do maybe more rigorous therapy. Split treatment is actually a huge component of this.
Yeah, and so not limited to your residency. Any outpatient psychiatrist today... Just remember, if you're working with somebody who seems to have a borderline condition, the primary treatment modality that you're going to recommend is a psychotherapy of
some kind. I think maybe we should talk about how we conceptualize borderline, and then we'll move into the principles of treatment. I have a spiel that I can give about borderline. Do you want to go first, or do you want me to go first?
Yeah, I'll go first. I think what we should do first is that we should note erroneous and poor conceptualizations of borderline out in the community, right? Unfortunately, for a lot of clinicians, borderline means unpleasant woman i don't like okay and that is the end of the diagnostic process for them but let's cast those people aside here and remember that the borderline condition is a well-researched well-established and True to life, I would say, true to life condition that has been described in the literature for decades.
And we are kind of in the golden age, I think, of having figured out how to get this condition better as a medical condition.
Yeah. And, you know, to your point, providers often have unnecessarily negative views of what the diagnosis is. And yeah, I see exactly what you're saying in that, like, it's code word for I don't like this person, rather than having any sort of real conceptualization of what the diagnosis means. Um, yeah, and I, the flip side is I also see a lot of patients who have a quiet borderline personality disorder, um, in that they're not loud, they're not problematic and it goes missed because, because people associate like person I don't like, they actually miss, uh, patients who are suffering from this condition that are perfectly pleasant.
Um, you know, if they're nice in treatment, they don't cause problems. Uh, but, but the aspects of the disorder manifest in their lives and cause a lot of problems.
I guess I'll give the short version of how I think about this. I actually do not particularly like the traditional DSM model of borderline personality disorder. I prefer Kernberg's borderline personality organization concept and the DSM-5's alternative model for personality disorders in section three, where essentially we just think of impaired personality functioning. okay so that's any kinds of significant impairments in identity functioning self-direction empathy intimacy any of these kinds of problems being persistent across a lifespan that is what i would begin to consider more borderline condition uh i'm not gonna get into the details that's gonna fill up with like two other hours so i'll let you describe how you think about that
Sure. And I agree with what you're saying about the organization, but I will give a more colorful of what borderline personality disorder proper aspects that people consider. There are really like four or five main aspects. In good psychiatric management, the first one that's considered the core, the different theorists think that there's different cores to what borderline personality disorder is. In GPM, it's the interpersonal dysfunction that is the core of the problems.
So these patients have intense, unstable relationships. The common pattern is idealization, where this person is the greatest person in the world, followed by devaluation and quick shifts that someone is either all great or terrible. In their relationships, you see patients vacillating from over-involvement in that they want to spend absolutely every minute to under-involvement, which is related to the idealization, devaluation. At the core of this is a fear of abandonment and fear of rejection.
This all reflects fears of being alone, which we can go into like kind of the common scripts of Borderline, but I want to get through everything here first. Second huge component is affective lability, emotional dysregulation. These patients have a lot of anger. Oftentimes they don't own their anger and that they get angry and are not aware of it. often inappropriate anger, often difficulty controlling their anger, a lot of mood changes.
But the important part and the thing that distinguishes this from, you know, depression or bipolar is that these mood changes are in a social context and the mood changes reflect interpersonal events in that the trigger is usually the result of an interpersonal event and it can get quickly fixed if that interpersonal event is fixed or if... Yeah, they feel better about the problem. Related to this is an ill-formed and unstable identity.
Kernberg thinks that this is the core problem, emptiness. There's a long-standing sense of being neglected, an inner emptiness that's been described like a hungry child that hasn't been fed enough, that's just constant throughout their life. Two more major aspects, deliberate self-harm. So patients hurt themselves and they do it repeatedly. The reason they hurt themselves, often it's self-punitive and a way to ease dysphoric states of mind. It also can be a way to call for help.
So the self-harm elicits some sort of supportive response. This is also related to patterns of impulsivity. You see a lot of patients who maybe manifest their self-harm in reckless sex, reckless use of drugs, in eating disorder. The last core aspect or the last aspect is cognition. So patients often have lapses of reality testing. They have paranoid ideas. These are usually again in an interpersonal context in that when they feel alone they have experiences that don't match up with reality or hallucinogenic phenomenon like hearing voices.
What makes them not psychotic is that they quickly reverse if the social context is improved or someone's paying attention to them.
Yeah, thanks for that excellent rapid-fire review of many of the core aspects of the syndrome. I think it really highlights how complicated this is, and I genuinely think that would take approximately a minimum of four hours of theory and history for us to adequately explain the real cores and how this condition seems to work. In terms of a short version, less clinician-focused, how I talk about those patients, it's persistent problems in thinking and feeling about yourself and other people in relationships that comes from a combination of inadequate parenting for any reason combined with very strong tendency towards internal negative emotions.
That, I think, is pretty complete as far as something that you can explain to other people. And I also like to say, when I talk about personality with patients, I say, also, this does not mean what you might think it means or what maybe some other clinicians sometimes mean. Okay, I'm not saying that you're a jerk or that you're a bad person or that this is just all your fault.
okay you've been through a lot and normally the things that we live through and the kind of parents that we had and those experiences that's going to shape who we are
and that's the main problem that we're dealing yeah that's great and um psycho ed is a huge part of i'm just gonna call it gpm from here on out um one of the big psycho ed to provide to patients and families if you look at the heritability it's higher than conditions uh that we think of as more biological um so The heritability of borderline is 40 to 60 percent.
Just for comparison, major depressive disorder is in like the 35 to 40 percent range. Generalized anxiety disorder is 30 percent. Schizophrenia, which I think of as one of the more biological conditions, is 75 to 80 percent. So it can actually be helpful to explain to patients and to family members. This isn't your fault. This isn't... There is a major genetic and neurobiological component to this condition.
I will adjust that a little bit, if you will, though. I want to... keep it with the term heritability. And I want us to remember as clinicians, and you can talk about this with some patients if they're interested, that genetics is not the same as heritability, right? Most psychiatric conditions have some component of nature or nurture. And I think in the case of borderline personality, it's one where you definitely need both and both are extremely important.
So it's not just the genetics. Genetics matter. But the fact is the dysregulated or poorly adapted or just misattuned ways of relating to yourself and others runs in that family. And if we even delete the genetic component, the behavioral components are going to be passed on and persistent in that family system.
Yeah. And I think that's why this stuff is... you need to be careful. I think it's helpful because it's a counter to the narrative that I think a lot of other providers and people thinking that like you have full control over this, you're being manipulative. This is the result of, you know, your choices. This runs counter to that narrative. And it's weird because you're balancing the fact that this is, there's imprinting in their biology and their neurology that's causing this, but they also still have control over these behaviors.
So you're kind of trying to balancing those two different aspects.
I suppose why I like to emphasize that development is the most important ideological factor is because my belief is that the treatment processes across all the different modalities and treating borderline conditions are about essentially recapitulating, reactivating, or allowing for a psychological development that was not possible before for whatever reason.
And yeah, I think I think Gunderson talks about this, that we have to get rid of the narrative that if something's biological, then it requires a biological solution. And if something's environmental, then it requires therapy. The truth is, is that something can be biological and therapy can help it or it can be the main aspect of treatment. And the flip side, something can be environmental and medications can make a big difference.
Yeah, definitely.
All right, let's, because we've been pushing this off too much, let's talk about kind of the core aspects of treatment of GPM. I'm going to go into some of the distinctive features. And then we can kind of talk about them at length. The first one is that the core aspects way we view treatment is that you're trying to have them get a life. Them getting better doesn't occur in treatment.
It occurs with you helping them to have better relationships and more involvement in work. So there's an aspect of case management in that you're providing general wisdom and advice that focuses on the patient to have better relationships and get more involved in work.
Yeah. Advice giving, right? That can be a mainstay for some clinicians trained under certain models that can be anathema to other clinicians. That's kind of an interesting topic. How much advice and what kind of advice should psychiatrists be giving? Right. Do you have a general line on that? How do you draw the line? What kind of advice do you give?
That's a good I don't have a I don't have a ready made answer. And I think GPM actually helped me to like go against the like psychoanalytic tradition of like don't give advice and that there is. you know, wisdom to offer to patients. But I don't have a, I think, I hope you have a nice answer to give.
Oh, yeah. I definitely have a whole spiel on this. And by the way, the whole problem with the not advice giving practice in psychoanalysis, I don't think that's actually true in reality. The point was that you were supposed to prize the analytic process over giving advice, but you can't do good treatment without giving some degree of normal psychoeducation, and at least advice in the form of not direct advice, like, I think you should do this specific thing, but in suggestion.
It's interesting that you did this one thing. Did you ever consider doing this other thing? Why or why not? Those are different, and the second one is technically not advice. It's suggestion or exploration of alternative behaviors. What kind of advice should a psychiatrist or any mental health clinician give? I like to go to the forensic rules of evidence concept. It comes from case law that an expert is only supposed to give an opinion that is beyond the ken of the normal person.
A normal juror member or judge, right? The expert isn't there to say stuff that anybody could say or know, right? So what kind of advice do we give as clinicians? I think we can and should give direct education advice on matters that are beyond the normal awareness of a layperson. So anything that is specific to the practice of mental health sciences, right, the knowledge that is and the practice of clinical mental health, if it's pertinent to their mental well-being, if it's supported by evidence, those are the kind of advices that are OK to give that we should be giving.
So there's a difference between right. Taking regular walks can increase the speed of your recovery from this major depressive episode or you should break up with your boyfriend. He's a jerk. Those are two very different things. And then on the end of relationship advice. Right. Continuing with this relationship may risk you being killed. Right. If supported by the evidence is also still different advice than he's a jerk.
Yeah, and one thing, Gunderson used a term that I had to look up. He said, and this might run counter to kind of what you're saying, it's okay for the psychiatrist to be a Dutch uncle, which is, I had to search the definition, it's a person giving firm but benevolent advice. And the manual does discuss, like, passing on wisdom as a provider, which, yeah, is rife with vagueness and being abusable, but...
Yeah. You know, it's one of those things, a statement like that, that I think would have been really obvious to clinicians in the 80s and 90s who were being trained in this backdrop where every almost every senior psychiatrist was an analyst. Right. Yeah. So there was a lot of assumptions back then culturally that no longer exist. So. Anytime today that we think about what we should or can be doing, I do think that we have to modernize our framework and deliver a message to learners, clinicians in a way that accounts for this loss over the last few decades and kind of institutional assumptions and knowledge.
All right, I want to keep going with the aspects of treatment. Another big aspect is, and we talked a little bit, this is psychoeducation. So it's super important to clearly give a diagnosis, clearly explain what you do or don't know about the diagnosis and its treatment. And just give, you know, I think it's important to communicate your confidence in the diagnosis. A huge aspect of improvement with Borderline is understanding what the condition is.
Now, one of the core aspects, I keep saying core, one of the biggest aspects of psycho-ed here is the involvement of interpersonal problems as the core of the dysfunction. So patients come in, especially with today's paradigm of psychiatry, saying, I can't pay attention to things, or I'm depressed, or I have mood swings. And once you have the assessment that you feel like it's more of a borderline personality disorder than, say, ADHD or depression, And framing those symptoms in the context that they are secondary to interpersonal dysfunction is crucial.
Yeah, and you got to keep in mind, you have to have the adequate basis to make the diagnosis. So you have to know what you're doing, right? And why is that diagnosis important? It's exactly as you say. We're trying to come to a reasonable reality-based understanding of the cause of the patient's problems so that we can come to an agreement about it with the patient so that we can actually take the right actions.
right? If your problems of concentrating are because of a completely unrelated to stressors, no stressor related major depressive episode, then yeah, we should be seeking more biologic treatments most likely to improve your concentration. But if your problems with concentration are happening because of a stressor of fear over losing an unfortunate relationship or all these fights that keep happening over and over in your relationship, then the method of successfully treating that is not going to be Zoloft.
Yes. And it's, um, Very, another, you know, I think we should kind of maybe review other important aspects of psycho ed. Providers should be able to communicate their confidence in the diagnosis. There was like a recent thread on Reddit that people were saying, like, if someone rejects the borderline diagnosis, you know, what should you do? And people were saying like, oh, you just say like, I'm just some guy.
And I disagree with that. I think... With the patient, I communicate why I think what I think and my confidence in the diagnosis. And it's a disservice if I say, if I truly believe that borderline personality disorder is the result of a dysfunction, for me to say, oh, you know, this is just one opinion. You can communicate that, you know, they're welcome to get second opinions. But I think denigrating your formulation is not helpful to the patient.
What you can do is say, and I've done this a million times with patients on intakes, as I say, maybe not intakes, because you need to build some rapport and gauge whether you think the patient will accept it. I'll say, you know, I see this aspect and this aspect, which really fits this, but I don't really quite see this aspect. And I'm not quite sure when these symptoms spark up.
And I'm hopeful that as we get to know each other better, as we see each other month to month, I'll have a much better idea of if I feel like this fits more into a bipolar picture or a borderline picture. But it's certainly on my differential as a possibility. Versus, you know, there's patients that fit it perfectly. And I'll say, you know, looking through the criteria and I'll review it with them.
I'll go through the different criteria and say, you know, it's funny. You fit every aspect of this. I really feel like this is the diagnosis that fits you.
Yeah. So I guess the universal aspects of what we've been talking about so far, what can be applied to all patients are essentially you need an accurate diagnosis. and detailed assessment of the patient and their problems right we want to know if the problems are of relationships in the self or of some biological issue some medical biological issue or some combination of both right and in order to communicate that to the patient in a way that they'll accept we need to have shown adequate attention to detail, to their story, to their lives, to their problems in order to communicate that.
And in the case of borderline conditions and in the cases where even if you're not borderline, it's social or behavioral issues perpetuating the problem, we need to correctly identify that as the treatment, right? In terms of doing more activities, changing dynamics and relationships, having new relationships. And I think that takes us to the topic of the goal, which is one of the distinctive characteristics of GPM goals.
Yeah, well, I'll let you go to goals. I will say that, yeah, in terms of other generalizable aspects of kind of what we're talking about, this applies really well to somatic symptom disorder in terms of offering psycho-ed and saying that, you know, maybe the depression is identifying the core issue and then not, you know, basing your psycho-ed and treatment on fixing that core issue and that medications, their role in terms of fixing that issue.
I do want to talk about medications, but do you want to go to do goals first?
I think, yeah, because goals and medication are kind of wrapped up. It's very easy in the post-psychiatric FDA pharmaceutical company world to just focus almost entirely on symptoms and medications. And so many clinicians are almost kind of Pavlov's dog matter, just conditioned to think that way. But there are primary and secondary goals, right? Our primary goals in any treatment are geared towards the values and desire of the patient and towards whatever the fundamental aspects of the psychopathology are.
And then secondary goals are things like behavioral or symptom levels. I'll use a non-borderline example. Let's talk about ADHD. A lot of people, patients, clinicians, feel like the goal of stimulant treatment is reduction of reported or observed ADHD symptoms. Or subjective feeling of being better organized day to day. I say, no, the primary goal is to put the patient on some trajectory for long term executive function improvement and a life worth living in the manner that they want it.
OK, look for the functional goals. The long-term goals, not the short-term goals. And so in the same way, the goals in GPM-focused treatment of borderline conditions is not symptom reduction, reduction of behavioral self-harm. It's success in their work, in their relationships, in their lives.
What you just said is gold. People should be, that is the most important aspect of what, I don't know, that's such a huge, important thing that everyone should re-listen to that if that's the first time you've heard something similar to that.
Too kind.
I wasn't being nice to you. I was being nice to GPO. uh all right let's talk about medications let's talk about medication so i wish i wish i got to do my opener uh okay hold on i'll uh i don't want to be too there was one of my favorite uh reviews so far is um on our podcast i love listening to you both it's funny how you talk to each other as if you're annoyed by one another i just like that all right i apologize let's get to medications um so i have to do medications what are you talking about okay um all right so it's this is linked to psycho ed in uh with regards to borderline person and i apologize if i say borderline i mean borderline people with borderline personality disorder medications are secondary they're adjunctive we know that none of the medications are FDA approved for borderline personality disorder and none of the medications get to the core issues now you need to frame anytime you use a medication that we're treating a secondary symptom so now we don't want to go too far and say because there's nothing that treats the underlying condition that we shouldn't use medications and But we should understand that the medications are there to treat symptoms that are secondary to the primary problem and that our expectations for how much they're going to do is quite limited.
And this should be communicated while you're giving the medications. I, you know, I can see how depressed you are. You know, I think... an SSRI might relieve some of your function. I don't think it's going to get to the core problem, and I think it might make it a little bit more tolerable. I'm not sure, but I think it's worth a shot. I do think that these things are going to keep occurring until we start addressing the more core issue, but I do think that the benefits of a medication potentially outweigh the negatives.
I just don't know how much of a difference it's going to make. That's very, very different than here's an antidepressant to treat your depression.
Yeah, absolutely. Really worth emphasizing, you know, forget FDA approval. They've directly studied multiple classes of medications in borderline conditions, and there's not really any support for their use when it's only the borderline personality that we're treating right now, of course. Also, do not fall into the trap of thinking if you identify a personality disorder, there's no axis one condition. No, you must always thoroughly assess and reassess for the presence or absence of axis one conditions because you're allowed to have more than one problem.
And plenty of people do. i find that for uncomplicated personality type cases the most common axis one issues are ptsd naturally trauma being important for much of the etiology of borderline conditions and maybe a dysthymic disorder but this is a situation where i think it's really really important to actually try to get to the dsm-3 style of diagnosis and looking for criteria try to only rule in conditions if you can find that definitively the dsm-3 type criteria and there's no other better explanation such as the personality that only then should you make the code diagnosis in my opinion because um why so many patients are being bombarded by huge amounts of all kinds of side effect causing medications that they actually don't quite need and in many cases it simply functions as sort of a sedative or a substitute coping skill when they aren't getting the treatment they should be getting and so medications aren't just possibly causing side effects, but they can also distract both you and the patient from focusing attention and efforts on the treatments that matter.
Yeah. And being able to communicate expectations with medications goes a long way in that, you know, if you communicate to a patient like, oh, this is going to fix your depression, they're going to get really, they're going to have hope and then they're going to get really disappointed when, you know, after a month and the idealization of the medication wears off and they're right back to where they were.
So it's really helpful for the provider and the patient to have expectations about what a medication can and can't do. And to me, it makes treatment so much easier because you're not giving these patients false hope and you're not distracting from the core problem. You're not waiting four to six weeks to fix the problem when you know like this might help a little bit so that you can address the core problem.
Very, very different. And let's talk about the medication. I mean, let's do a brief, super brief. I keep saying this and then we go on too long. In terms of the approach to medications, SSRIs can help with some of the anxiety and the depression. But of course, it's not going to fix the core issue. And one of the big goals of treatment is to be connecting the symptoms to the interpersonal problems.
So you don't want to do it at that expense. Antipsychotics and mood stabilizers can help with some of the impulsivity and the anger. The mood stabilizers can help with some of the affective component. Again, you're conceptualizing these as decreasing the intensity, not fixing the problem.
yeah um in the broader analyses i believe it was the mood stabilizers and then the antipsychotics that showed the most quote evidence but that none of the medications including the mood stabilizers and antipsychotics strong and side effect producing medications were better than a stable and trusting therapeutic relationship with any clinician okay that is the primary treatment uh so be careful um Personally, I actually try to just do things like sleep support.
I try to minimize medications and pick the ones that have the least amount of side effects because, again, they are not the main issue unless you can identify another Axis-1 condition, which does happen.
Yeah, one thing I want to say is... One thing that's helpful is APA recommendations recently said that medications are adjunctive, which is helpful that like, you know, we can point to our organization to psychoeducation patients. I found that patients really appreciate this psychoeducation in that like, uh it goes really really well and they actually appreciate that they have a psychiatrist that is considering underlying problems um and considering the whole picture rather than being told okay let's try the next one let's try the next one let's try the next one um to me it helps really build rapport uh in terms of
offering limitations let's face it it's so much easier uh to just identify a cluster of symptoms and then prescribe a medication and talk about that medication. You can do that until the cows come home and you don't have to do any difficult work in terms of diagnostic assessment and talking about the therapeutic relationship and history of troubles in relationships. That can be scary stuff, right? That can be difficult.
So watch out for that. It's a trap to fall into when you just focus on medications all the time. Another trap that I wanted to mention, it's been so long since medical school at this point. Do you remember they would talk about certain diseases that would be the great mimics? Was tuberculosis one of them?
Yes, syphilis, I think was one of them, lupus.
Oh, syphilis, yeah. There's been several throughout the history of medicine, okay, where there's some complicated syndrome that does have a real cause, and then it's just very easy for it to look like other known disease entities. Borderline conditions, I think, are the great mimicker of psychiatry, right? It can look like so many other known and named conditions. It makes it particularly difficult to accurately understand. identify and so if you're gonna accurately identify it you have to understand the underlying disease entity itself um and not just the dsm criteria and uh so be careful and be knowledgeable too and don't let the mimics drive your medication
decision making yeah um and uh you know as providers um i think once you start practicing this way uh Like early on, you know, patients, I had colleagues who were like, oh, I'm so scared to give someone a borderline personality disorder diagnosis. I've very rarely had it go poorly in that, you know, I think what's dangerous is if you have negative, inappropriately negative views of what it means and what treatment looks like.
Whenever I've discussed it with patients, it's gone really well. Patients have appreciated it. And it's been just a great learning experience for them. It makes them feel understood. It makes them feel less alone. It's nice to know that I don't have some treatment-resistant depression that no one can find out, figure out, that there's an identifiable thing that's going on and that other people experience it and that there are treatments is...
really helpful.
Yeah. And I think that can't be under-emphasized. It's so important. The main problem in the clinical treatment of personality, in my opinion, is clinician feelings, the counter-transference feelings about the conditions, about themselves, and about a lot of different things. Because We fear, I think, what is closest to us. I'm not saying these clinicians are borderline. That's not what I mean. What I mean is if not all of us have had hallucinations and delusions, right?
Not all of us have had a major depressive episode, but all of us have had relationships, parents, and challenging issues in interacting with ourselves, our identity, and other people. So it can be a scarier area to delve into, I think. And so unfortunately, some clinicians won't believe in personality at all. They won't diagnose borderline. I once had a clinician tell me, Oh, I don't like to jump to borderline.
What does that even mean? Jump to. You either find the diagnostic evidence or you don't. You don't jump to one thing or another. Imagine if you said that. I don't like to jump to hypertension. I like to look at other causes. What does that mean? So, yes, you need to be knowledgeable. You need to be aware of your own emotions and your dynamics. And you got to be honest.
I think you have to identify this correctly in order to give the right treatment.
All right. Just to recap where we are right now and where we've gone through, one of the core principles here is you're trying to get the patients to get a life and that life outside of treatment is what treatment is.
I like the idea that- Meaningful life, get a life. Keep saying that. It's a funny way of saying it. A life worth living, developing a life worth living is
Yeah, one way I've heard it framed is that life has all these lessons to offer, and a patient will eventually learn them, or a good practitioner can help introduce them a little bit earlier. But for the most part, it's life that needs to offer those lessons.
And by the way, this is not a life of solitude in the forest by life. It means a life with other people, trustworthy people, good people, stable people, some environment, a system that offers more support, trust and the opportunity for growth than what came before.
Yeah, and that moves us to the other thing we talked about, which is psycho-ed, what you kind of just said is super important, letting the patients know that stability is really important, having a stable work. Some patients want to avoid work, whereas it can be such a stabilizing factor. In terms of psycho-ed, I think it's important to let patients know that it's the heritability of the condition, that getting family involved and letting them know the limitations of the patient, doing psycho-ed in regards to what medications can and can't do.
Goals here in GPM, primary is success at work and relationships. Secondary is the symptoms and reduction of symptoms and the reduction of self-harm. Primary is getting their life and getting it on track. As we mentioned, medications are adjunctive, kind of focusing on the core pathology, which is interpersonal dysfunction. I think the next core aspect is a focus on multimodality in that other aspects of treatment that are really helpful are group therapy or family therapy or other helpful evidence-based treatments for borderline are helpful to be done alongside psychiatric management.
Yeah. Resist the urge to manage everything yourself as one clinician. It's pretty much not doable. And I think that it's particularly easy to get into that because in so many treatment dyads with people with borderline conditions, the clinician falls into a rescue fantasy. OK, clinician is drawn or puts themselves into this idea that I'm going to help this poor person and I'm going to be able to do everything for them.
And that is not true. OK, you need to know the limits of what you're supposed to be doing, what you can be doing and refer out for all the conditions that you can't manage and you shouldn't manage within whatever time you have in your treatment frame.
That actually makes me want to come to another aspect of psycho-ed, which is explaining the cycle of relationships in borderline personality disorder. So patients who develop this often have a sense, and there is some truth to it, that they didn't have their needs met as a child. And they form this belief that if they were just able to find the ideal relationship, that they would be better and that their life would be better.
So as a result, they try to find and form an exclusive relationship with someone that meets all their needs. And this inevitably creates tension. The other person feels like they're going to get swallowed up, like they're going to get, I don't know. Yeah, like there's just too much neediness. Eventually, this will cause the other person to withdraw. The withdrawal will make the person with the borderline personality disorder anxious.
And then the anxiety will take the form of devaluation where they say, you never cared about me. Our whole relationship was a lie. I should have never trusted you. Or another alternative, which is similar, but the flip side of the self is that yes, this is proof that there's something inherently wrong with me, which triggers the self-destructive, self-harm, suicidal behavior, alcohol, substance use seeking, which in a sense can be a form of cry for attention, not necessarily, but often that it causes other people to help rescue them.
And then once that is met, things flip back to finding... Having the other person be idealizing and the person is hopeful again and they feel like they're a good person and lovable. And that's the cycle of relationships, which can also be recreated in the therapeutic relationship with the provider.
Not the only cycle, mind you, but certainly a popular one that is seen.
All right. Why don't I just quickly recap all the basic principles? I have a nice little table in front of me. I'll just go through it and then we can, you know, maybe... give some closing thoughts. There's eight principles here. One is offer psycho-ed. We talked a lot about that anyway. Two is be active, not reactive. Being responsive assures patients that you're interested, involved, and don't catastrophize.
Three is be thoughtful. So you're a container for your patient's anxieties and a role model for thinking first. That's a crucial thing I wish we had talked about a little bit more that you should always be trying to model that you Don't react. You think and really consider the situation at hand.
Number four is the relationship. That should take a little bit more time, as you say. Trying to teach, develop, model the capacity to draw back, observe yourself and think and feel before acting rather than acting impulsively. Anyway, I'll let you continue.
Please note that Dr. Fu interrupted about impulsivity. Number four, the relationship is real as well as professional. Number five, convey that change is expected. We talked a little bit about that. Offering hope as a clinician is maybe something that's been missing in that person's treatment. Six, foster accountability. Encourage that the patient's responsible for their behavior. If they act out, if they call you in between appointments, these are things that you can't just skip over.
You need to talk about the issues that come up and not have an elephant in the room that you're both not addressing. Number seven, maintain a focus on life outside of treatment. Dr. Fu doesn't like my get a life pippy phrase. Number eight is be flexible, pragmatic, and eclectic. Those are the eight basic principles.
And can't emphasize enough, this is all relevant to most psychiatric practice. It's rare, in my opinion, that you find a case where everything was going exactly great and exactly how the patient wanted directly before the onset of a recent illness that you're going to manage now as a psychiatrist, okay? Most people have at least some kind of a more subtle early onset of axis one problems that have essentially deviated their path towards the life that they want to have.
And so if you just focus on one diagnosis and one medication and not everything else, you're going to be a little limited in your treatment effects. That's my opinion.
Talking about generalizability, I think aspects of this apply just to every diagnosis in that communicating the psycho-ed of how you identify their core problem, which doesn't necessarily need to be interpersonal dysfunction like it is for borderline personality disorder. Uh, you know, like I said, for somatic patients, it might be that they somatize their feelings, um, for, for borderline or for bipolar. Um, to me, I think, you know, the psycho, I provide a ton of psychoad on stability on, on routine.
Um, you know, I, I feel like this has really been a core aspect of, of treatment that I've adapted to different disorders, um, with like little different rules for each one.
Mm-hmm. It's good psychiatric management. Practice it and you'll be able to apply it to pretty much everything you do.
I don't think we captured absolutely everything. Like I said, the manual is not too, too bad. It's 100 or 150 pages. It's readable. It's enjoyable. I do recommend diving into it.
Can I add something that would have to be edited in as well? On the topic of accountability, by the way, I think it's important to remember that enforcing accountability is not just about making somebody culpable or blaming them, right? Accountability philosophically is equivalent with agency. We're trying to build agency in our patients, make them able to control and direct their lives to their liking to a greater extent than what they've been able to do before.
Yeah, and it's almost like you learn with parenting. Kids want structure. Kids want limits. Kids seek out those things. Patients, if it's done properly and done in a way that is in the patient's best interests, appreciate being held accountable. They appreciate knowing what the limitations are of treatment. They appreciate knowing the frame. And thinking... One of the issues, or not issues in terms of predictable problems, is that providers go in with an expectation that like, oh, this patient's going to push my boundaries.
Oh, this patient's going to, you know, they're going to text me after appointments, which there it's like, One thing that could be really helpful is reframing psychiatric treatment. Your job is not prescribed medication, medication makes them better. Part of your treatment is the frame. It is setting the limitations. It is that communicating like the medications, you know, we shouldn't switch medications. Because, you know, I'm a provider that goes for the core issues and we've been trying new medications and now treatment involves not changing medications.
So reframing things that like the frame and the limitations and the difficulties that you experience in treatment are the treatment itself. They're not disruptions to the real treatment.
Yeah, and be careful of those feelings, right? Just as the patient can bring in an expectation of an angry interaction or a hostile interaction and make it happen, basically, in the session. So can the clinician. If you're expecting that the treatment's going to fail, if you're expecting that you're not going to get along with the patient, you're going to make that true to some extent, or you're going to make it more likely for it to be true.
So you've got to monitor your own feelings and regulate them, just as we want to expect that from the patient, too. I gotta say, we're coming up on time, and I feel like this has been a relatively meandering episode. I don't think we meander too bad. You don't think so? I think that's just how complicated this topic is. And I do wonder if we should have a part two.
And the idea I have for a part two is that we could cover something that a lot of people feel uncomfortable with. We can get a little more concrete, and we can talk about the practical assessment of personality, how to diagnose personality as a non... Someone who doesn't have that much time with the patient, basically. Right. If you don't have much time, how can you be reasonably sure that what you're working with is personality as opposed to other things?
That's one option. The other option is that we can do a deeper dive into theories and phenomenology. underneath personality disorders. But I kind of feel like that gets too psychoanalytic for most viewers, even though I think it's extremely important in understanding the condition. And that covers things like what trauma does to people, theories around how people learn to think at all, and how people learn to relate to other people at all.
Maybe the commenters, both on Reddit, YouTube or whatever, can vote or express your preferences. Thanks for listening.