Key moments, in order
GPM is meant for patients with borderline personality disorder, but it is a great overview of how to run med-management appointments for them, and the principles generalize very well.
Stigma exists mainly because of clinician reactions to difficult patients. It is not an untreatable condition with bad patients; many want to get better and do not know why they suffer.
Say at the outset that the expectation is they will get better; many patients get a lot better in time. Personality disorders tend to improve even untreated, though more in behavior than in the underlying condition.
Psychotherapy is the primary treatment. Moderate to severe borderline conditions should ideally be in weekly psychotherapy, though community resources are limited.
Clinicians reserve the diagnosis for patients they dislike and give CPTSD, or nothing, to patients they like. Borderline has become code for "I don't like this person" or the most annoying patient in the hospital.
We prefer Kernberg's borderline personality organization and the DSM-5 alternative model to the traditional criteria: think in terms of impaired personality functioning.
The core is interpersonal dysfunction: intense, unstable relationships with idealization, where this person is the greatest in the world, then devaluation and quick shifts.
Mood changes in BPD happen in a social context: they reflect interpersonal events, and that is what distinguishes them from depression or bipolar disorder.
Transient paranoia or hallucinatory experiences can occur under intense interpersonal conflict and distress. What makes them not psychotic is that they quickly reverse when the social context improves or someone pays attention.
A plain explanation: persistent problems in thinking and feeling about yourself and others in relationships, from inadequate parenting for any reason combined with a strong tendency toward negative emotions.
Share that the heritability of borderline is 40 to 60 percent, compared with 35 to 40 percent for major depression, 30 percent for GAD and 75 to 80 percent for schizophrenia.
Something biological can respond to therapy, and something environmental can respond to medication.
The aim of treatment is for the patient to get a life. Getting better does not happen in treatment; it happens when you help them have better relationships and more involvement in work.
The analytic tradition of not giving advice goes too far. Good treatment needs some normal psychoeducation and suggestion: "Did you ever consider doing this other thing?"
We can and should give direct advice on matters beyond a layperson's normal awareness, anything specific to the mental health sciences.
Once borderline fits better than ADHD or depression, frame the presenting symptoms as secondary to interpersonal dysfunction.
If concentration problems come from fear of losing a relationship or fights that keep happening, the treatment is not going to be sertraline.
If a patient pushes back, do not denigrate your own formulation. Build some rapport first and gauge whether the patient will accept it.
The primary goal is to put the patient on a trajectory toward long-term executive function improvement and a life worth living, in the way they want it. Look for functional, long-term goals, not short-term ones.
Medications are secondary and adjunctive. None is FDA approved for BPD and none reach the core issues, which are largely psychosocial; it is symptomatic treatment, like aspirin for a fever. Frame every medication as treating a secondary symptom.
Do not assume a personality disorder means no other condition. In uncomplicated cases the most common are PTSD and perhaps dysthymia.
Be honest about medication. Promise it will fix the depression and the idealization wears off in a month, leaving them right back where they were. If they decline therapy, say plainly that you do not think you will find the medication that fixes these problems.
SSRIs can help some of the anxiety and depression, but a big goal is connecting the symptoms to the interpersonal problems.
No medication, including the mood stabilizers and antipsychotics, beat a stable, trusting therapeutic relationship with any clinician. That is the primary treatment.
Patients really appreciate a psychiatrist who considers the underlying problems and the whole picture rather than just trying the next medication.
It is much easier to identify a symptom cluster and talk about medications until the cows come home than to do the hard work of diagnosis.
Borderline conditions are the great mimicker of psychiatry; they can look like so many named conditions that they are hard to understand accurately.
These conversations go well nearly every time, whether you say BPD or traits. Patients feel understood and less alone, and it is a relief to have an identifiable condition instead of a treatment-resistant depression no one can figure out.
The main problem in the clinical treatment of personality is clinician feelings: countertransference about the conditions, about themselves and much else.
A life worth living is not solitude in the forest. It is a life with trustworthy, stable people and a system that offers more support and room to grow than what came before.
Beware the rescue fantasy that you can do everything for this person. If you cannot do this work well and responsibly, refer out, or rely on a very strict, concrete agreement about what you will do.
Explain the relationship cycle: they seek an exclusive relationship that meets all their needs, the other person feels swallowed up, and tension inevitably follows.
Be active, not reactive: being responsive assures patients you are interested and involved and that you do not catastrophize. Be thoughtful: you are a container for the patient's anxieties and a role model for thinking first.
Most people have some subtle early onset of problems that has pulled them off the path to the life they want. Focus on one diagnosis and one medication and your treatment effects will be limited.
Enforcing accountability is not about making somebody culpable or blaming them. Accountability is equivalent with agency: we are trying to build agency in our patients, making them able to control and direct their lives.
Reframe the frame, the limits and the difficulties of treatment as the treatment itself, not disruptions to the real treatment.
If you expect the treatment to fail or expect not to get along with the patient, you make that more likely.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.