Key moments, in order
Borderline personality disorder is fundamentally a disorder of contradiction or paradox: the patient is trapped in what the psychiatrist Burnham in the 1960s called a need-fear dilemma.
Its causes are biopsychosocial. It is related to trauma, abuse and neglect, but trauma-only theories have become too popular.
Primitive defenses, namely projection, projective identification and identification with the aggressor, are central features.
It is a major error to see all of BPD as complex PTSD.
Renaming it will not end the stigma, because the stigma comes from the pathology itself: these patients can be very disturbing to others.
BPD resembles psychotic illness in some ways: on unstructured psychological testing these patients show much of the same thought disorder. The most severe BPD may be a crossover of a severe personality syndrome and a genetic vulnerability to psychosis.
In rare cases an antipsychotic helps, which is hard to explain, and some patients without other comorbidity improve significantly on clozapine.
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.
Listen for paleologic thinking: starting from the conclusion that someone will hurt or abandon them and then finding the evidence afterward.
In borderline states, the preoccupation is typically around relationships or a general sense that people are going to hurt me.
Borderline patients need structured treatment: even transference-focused therapists call for a contract at the outset and careful attention to the frame, boundaries and ground rules.
Abandonment anxiety is what gets the most attention and what patients most often complain of: intense fear of rejection in romance, friendships, family and the treatment relationship.
The other twin anxiety is engulfment or annihilation anxiety, so neither closeness nor distance is tolerable.
A typical pattern: the patient describes a wonderful trip with their partner and then picks a fight on return. Devaluation is used unconsciously to push the other person away.
Splitting is difficulty integrating your sense of self and of others as whole people, with good and bad qualities together.
On the borderline-narcissistic continuum, narcissistic personality disorder is the less severe condition, and as borderline patients improve they can look more narcissistic. Overtly borderline patients may be undiagnosed narcissists destabilized by life, unlike quieter types whose deficits are in identity and self-direction.
BPD presentations vary widely, from severely impaired patients who cannot work or live independently to higher-functioning patients who look more narcissistic but have core borderline pathology.
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.
Transference plays out around medication: a prescriber who will not prescribe something becomes the withholding persecutor who claims to help but really wants to hurt.
Medication treatment of BPD should generally be short-term relief of the most acute symptoms, and the topic of medicine should be revisited; the guidelines may say about every six months.
Knowledge does not protect you from enactments. Be aware of your feelings when you feel compelled to act.
Be wary of being the patient's hero; it is short-lived. Patients may try to get you to comment on another clinician's treatment.
Communicate the diagnosis; do not withhold it. Some patients feel that finally what has been so confusing makes sense.
If they ask whether it is their fault: it surely was not your fault that you developed this, though your biology and what you went through both contributed.
Supporting and validating alone reinforces the defenses ("all your problems are other people").
Every treatment has to settle what the patient can't do versus what the patient won't do, whether or not you put it in those terms.
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.
Good therapy leaves the patient feeling more responsible for their choices, freer and more self-responsible. Therapies that move people in the opposite direction are potentially quite harmful.
The APA now says there is good evidence for transference-focused psychotherapy, mentalization-based therapy and good psychiatric management. More important than the specific model is that the patient is in a talk therapy they commit to.
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.
Do not hesitate when the evidence is there. Nobody says they do not like to jump to bipolar disorder or schizophrenia; go off the clinical evidence.
Another view is that there is no hierarchy: you weigh each possible diagnosis and find which ones are supported. A hierarchy applies only when there are clearly enough symptoms of mania, hypomania, acute psychosis or OCD to impair your ability to elicit or observe the features of another condition.
Even simplified and imperfect, the hierarchy keeps you from diagnosing conditions that are secondary to another one: ADHD before treating mood symptoms that impair concentration, or a personality disorder before treating mood symptoms that may be exaggerating personality traits.
Clinicians find major depression and stop, as if they cannot or need not make any other diagnosis. Keep observing, re-diagnosing and re-testing over time.
Personality is the most clinically neglected category today. What we mostly see is clinicians ignoring it, or diagnosing off vibes and countertransference rather than digging up the clinical data across the lifespan.
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.