What we’ve said about Borderline personality disorder

“I see borderline personality disorder as as fundamentally being a disorder of contradiction or a disorder of paradox. And I've written a little bit about this. I think the patient is trapped in what a psychiatrist named Burnham in the 1960s called a need-fear dilemma”

“borderline personality disorder, as people popularly talk about, is only one category within the organization, borderline personality organization, which would include things like narcissistic, antisocial, histrionic, and other types”

“If you don't understand the fundamental theory and history behind borderline personality disorder, you're going to think it's one very special entity that only a small amount of people have. Instead of it being a basically common broad spectrum area of problems that people have through development”

“Why would we think that there was some sort of threshold or cutoff for this thing? It's a trait. It can be really profound and really mess up people's lives and people can learn how to Combat this trait that they have of rejection, hypersensitivity, for example, overvaluation, devaluation, crisis-oriented thinking”

“I tend to agree with Kernberg's sort of biopsychosocial approach to BPD. I think we're in an era in which traumatogenic theories of personality disorder have become very popular, and certainly while BPD is related to trauma, abuse, and neglect”

“the patient's use of very primitive, if you will, defense mechanisms of projection, projective identification, identification with the aggressor. sort of our central core features of this disorder”

“splitting means in essence that the person has a very difficult time integrating one's sense of self and sense of the object as a whole entity or as a whole person. So, you know, in normal, quote unquote, object relations, we're able to say, you know, person X has good qualities”

“I think of it as they do not have the cortical capacity to modulate, to appraise, to handle those intense affective arousals, right? Every patient I meet that has severe borderline persona disorder, they're pretty much fine until they're not”

“how often in your life has someone carefully listened to and paid attention to your internal experiences and then communicated their findings back to you in a way that you can accept”

“I understand borderline issues stemming from issues with attachment and bonding, which occurs earlier than issues of the self and development of self and others”

“they're better at empathizing negative reactions. They're better at detecting interpersonal threat. Okay. And disapproval. But because they're so good at that, that also it ruins their ability to detect accurately other mind states”

“I was curious about whether neurodevelopment could explain what we today consider borderline conditions, BPD, even antisocial or narcissistic. What if it's a failure of empathy? Well, not a well-supported hypothesis. They've looked at empathizing. Systems in people diagnosable with borderline personality disorder”

“Within the personality disorders category, I think there are two personality disorders that are pretty robustly validated, and that's borderline personality disorder and antisocial personality disorder”

“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”

“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”

“the capacity for positive and enduring connections is significantly impaired. This is when you see the on and off again kind of quality to the relationships, right? Dropping some people even for years and then intensely being involved with them”

“what gets the most attention and what the patient most frequently complains of is abandonment anxiety. So, you know, intense fears of abandonment and rejection, usually in the context of romantic relationship, but sometimes friendships and family relationships, and certainly the treatment relationship”

“psychodynamic theorists talk about another core anxiety. And I sometimes call this sort of the twin anxieties phenomenon, where we've got abandonment anxiety on the one hand, and then we have enmeshment or engulfment or anxiety or annihilation anxiety”

“a borderline patient might come in and start talking about how they just had a wonderful trip with their partner, And it went really well. And it was, you know, we had such a nice week or such a nice week on a vacation”

“in a couple where one person is much more classically borderline, emotionally unstable, that will happen even if everything is peachy keen. Correct. Even if everything is perfect”

“I think that borderline patients also evidence paleologic thinking, usually around themes of abandonment and rejection. So they begin with the conclusion that someone is looking to hurt them or someone's going to abandon them. And then they actually see evidence sort of retrospectively”

“What makes them not psychotic is that they quickly reverse if the social context is improved or someone's paying attention to them”

“someone in the borderline range has almost like intermittent connection with reality testing in that it At their baseline, when they're unstressed, usually they have ability to reality test”

“I really like the McLean screening instrument for BPD. So if I have a patient that I'm starting to pick up, or I do this with a lot of patients when I'm seeing signs, especially if they ask, do I have CPTSD”

“someone who has really difficulty controlling their anger, but they've never overdosed. They've never cut themselves. They They have stable relationships, yet they struggle and they seek care”

“You have a patient who's cutting themselves, identity diffusion, chaotic, unstable interpersonal relationships, devaluing the therapist. And the therapist is reluctant to call that borderline personality disorder”

“The internal process is extremely important in identifying how people function in their interpersonal element, basically their level of personality functioning. OK, but it doesn't give you a diagnosis”

“in the emergency room, unless you have somehow found that information in the chart, because they've been there so many times and you know this patient, Or you have their medical records. They came in with some medical records. You shouldn't be making a borderline personality diagnosis”

“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”

“I think you really need to have at least some evidence of like a, you know, neurobiological type depression where there's episodes or stark changes in total functioning rather than simple mood or reactivity between human beings, interpersonal issues”

“mostly it's because people are ignoring episodes. They're just taking yeses at face value and they think that mood lability is a major feature in bipolar, which it is for some people”

“some inpatient providers think that pressured speech means the person's talking a bazillion miles per hour there's a lot of patients with bipolar who present with in terms of it just in the moment they feel like they're borderline”

“they may have those personality tendencies, but without the added weight of a untreated mood disorder, it doesn't really come out with the same severity. So you got to have nuance and you have to monitor or treat and, you know, think over time”

“major depression plus PTSD with an agitated state, major depression plus generalized anxiety disorder with an anxious state, major depression with attention deficit disorder with irritable phases, major depression with borderline personality disorder with phases of variety of symptoms”

“Depression of personality is what I call it. Really should not be overlooked because it very much looks like and even feels like to the patient major depression. But you can tell you based on the life course and the onset and various other factors that it's not quite the same”

“However, if the depression is what James Masterson called abandonment depression, or it's the chronic dysphoria that we see in borderline personality disorder, or it's what the old psychoanalysts used to call neurotic depression, which is probably a valid diagnosis, by the way. Then psychological formulation makes a whole lot of sense”

“For instance, hyperthymia and narcissistic personality, cyclothymia and borderline personality. And the misdiagnosis can go both ways”

“I think now of CPTSD as a big bucket that contains a bunch of small buckets. And one of those small buckets is BPD”

“I think it's a major error, uh, to, uh, to conceive of, of the entirety of what we call borderline personality disorder as simply being complex post-traumatic stress”

“Because there's a lot of patients who don't have typical BPD symptoms. And I do see a lot of the CPTSD stuff. So I do think it's actually... I don't know. I think it's a useful term”

“externalizing behaviors are more part of BPD. So things like impulsivity, attempts to avoid abandonment, temper outbursts, theoretically those are more BPD type traits”

“BPD isn't the person's fault, and they deserve understanding. And CPTSD people can be manipulative, and they're responsible for what they do”

“Survivors of childhood abuse often accumulate many different diagnoses before the underlying problem of a complex post-traumatic syndrome is recognized”

“the problem at the outset was not the diagnostic categorization the problem was the lack of general practice in building therapeutic alliance and having collaborative care where both the patient and the physician are equal parties”

“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”

“unlike Obsessive Compulsive Disorder. They do not respond well to ERP and SSRI treatment. Why? Because I think what's happening in this subset of patients is that the underlying problem is the self and other relating, the personality functioning problem”

“I'm open to the possibility that the very severe borderline personality disorder is comorbidity, that it's some kind of a crossover of both a severe personality syndrome and some kind of genetic vulnerability”

“We can call it voice hearing, right? Reported voices instead of hallucinations. We can call it fear or hypervigilance instead of paranoia. And we should call it an overvalued idea or inflexible belief instead of delusion”

“I'm very fond of Gerald Adler's conceptualization of a borderline narcissistic continuum in which narcissistic personality disorder is the less severe condition and borderline personality disorder is the more severe condition. And Adler thought that as borderline patients get better in treatment, they actually look more narcissistic”

“Just because someone has an erotic transference is no diagnostic information about their psychological functioning”

“We have to understand that personality disorders can come with a lot of maladaptive coping or emotional dysregulation that will then disrupt sleep considerably”

“they frequently get diagnosed with multiple axis one conditions. And really it is all, or often I should say, is the result of the core borderline disorder”

“for some people, they do simply have at their baseline, even without a particular stress in their life, just thoughts about not wanting to be alive, wanting to hurt or kill themselves. most of the time”

“sometimes the indicated treatment may not be hospital admission. Sometimes hospital admission can potentially slow down the overall progress towards getting better”

“patients with borderline personality disorder are at an elevated risk compared to patients without borderline personality disorder of completing suicide”

“It is a risk factor. It's just not as serious of a risk factor as perhaps severe, agitated psychosis with command auditory hallucinations to make suicide, right”

“If you have intense counter transferential feelings of any type, that's a sign of self and interpersonal functioning. And that can, especially under distress, be quite dangerous”

“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”

“It's more important to me that they're actually in a talk therapy that they commit to and they're engaged in than specific recommendations”

“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”

“borderline patients require more structured treatments. Right. So even Kernberg and the transference focus people, they talk about the need for a therapy contract at the outset of treatment for for for very careful attention to the frame and the boundaries and the rules, the ground rules of psychotherapy”

“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”

“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”

“If we get into a pattern in therapy where all we're doing is supporting and validating the patient especially the patient with borderline personality disorder, what ends up happening is their defenses just become reinforced. You're right. All of your problems are because of other people in your life”

“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”

“targeted, Scheduled and regular specific mindfulness practice again titrated and geared towards the individual patient is definitely a core component of the long-term treatment of DSM defined borderline personality disorder”

“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”

“If this is not the kind of work that you think you can do well and responsibly, refer out. Don't be afraid to refer out. Or rely on a very strict and concrete and reality-based agreement about what you're going to do”

“we ought to be wary of being the patient's hero. You know, it's a very short-lived experience in working with a treating borderline patient. So Very often the patient will try to get me to comment on, well, do you think Dr”

“we often see transference and countertransference issues play out around medicine. Where the prescriber... if he doesn't or she doesn't agree to prescribe something as seen as a withholding persecutor, as someone who says he wants to help me, but really wants to hurt me”

“knowledge is not enough. to guard you against the enactments and the misbehaviors that may happen in complex treatment. Uh, you gotta be aware of your feelings. It sounds like, uh, because people are feeling compelled to act even when they know better reflection of the patient's experience”

“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”

“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”

“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”

“medication treatment of BPD should, um, generally be short-term, you know, alleviation of the most acute symptoms, and the topic of medicine should be revisited. I think in the guidelines, I think they say every six months”

“I'm definitely against that, personally speaking. I know some people are believers in that, and there's this tiny little signal from that old UK study. But I don't really believe in that”

“Not SSRIs, you know, not necessarily serotonin-based medications primary because of the risk of agitating bipolar disorders because in undifferentiated patient, we don't know which is which, but just smaller things, you know. your gabapentin hydroxyzine your uh buspirone uh propranolol”

“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”

“sometimes I have found in rare cases that An antipsychotic does help. And I can't explain that, you know, because phenomenologically it's different than a schizophrenia. Sure. Sometimes you see a response and there's a lot more murkiness”

“I try and bring up emotional blunting. I hear a lot of patients, especially if you get into the, I think the more borderline or the more severe end of it, that because they're so prone to feeling things so intensely, they're very prone to reporting the emotional blunting”

“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”

“I take the approach that the diagnosis ought to be communicated to the patient, that we should not withhold the diagnosis or mentioning the diagnosis. First off, I mean, it's hard to comment sort of broadly about this because I do”

“every single time I've had this conversation of whether I say you have borderline personality disorder or I say there absolutely are traits, the conversation has gone really well. Most patients really just want help”

“I think that the conversation going well or good is not about so much the specific words you use. It's about what you feel inside. If you truly feel care and that you want to help, 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”

“it surely was not your fault that you developed this condition. Now, there may be certain things about your biology that contributed. And most certainly there were certain things about what you experienced in life that contributed to developing this condition”

“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”

“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”

“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”

“I ask, what's your understanding of what this means? Because... It's very interesting that it's very possible you and the patient will be in agreement with a diagnosis, but then you hear what they think that actually means”

“calling a personality disorder is a wild thing for some patients. And we can't cram them in a box. And I feel like the borderline concept would give us a vocabulary for talking to patients that would allow us to say, this isn't a mood disorder”

“Instead of telling someone, hey, you have a personality disorder, sucks to suck, you can say this is one way to think about your problem. And the good news is calibration can change. You can engage in the process”

“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”

“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”

“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”

“borderline personality disorder is basically reserved now for patients that the clinicians dislike and complex ptsd is being given to the patients who they like because if you look at the life history of patients with borderline personality disorder they have a lot of trauma”

“i don't think that manipulation and being a bad person is part of the diagnosis whatsoever”

“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”

“it's really the core essence of the pathology that creates the stigma. These patients can be, unfortunately, very, very disturbing to others. And I think that whatever we change the name to, I think that the stigma is going to remain more or less because of the nature of the pathology itself”

“people need to have a deeper understanding of the personality and how it's conceptualized and what the borderline conditions are not just the stereotype versions”