Healthy Minds With Dr. Jeffrey Borenstein

- Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help there is hope.

(tranquil music) Today on "Healthy Minds"... - We found that borderline personality disorder is one of the most stigmatized disorders out there amongst health professionals, and a lot of health professionals have been taught that it's not favorable or good prognosis to tell someone that they have borderline personality disorder.

- It's important for people to seek help because, really, with help, this is a fully treatable condition and people can live full, happy, productive lives.

That's today on "Healthy Minds".

This program is brought to you in part by The American Psychiatric Association Foundation, The John and Polly Sparks Foundation, (tranquil music) and The Woodnext Foundation.

(tranquil music) Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

Borderline personality disorder, what exactly is it and how do we treat this condition?

Today I speak with leading expert Dr. Lois Choi-Kain about borderline personality disorder.

(tranquil music) Lois, thank you for joining us today.

- Of course, it's a pleasure to be here.

And thank you for the invitation to talk about borderline personality disorder.

- And I want to jump right in and ask you to tell us an overview, what is borderline personality disorder?

- Borderline personality disorder is a prevalent, potentially disabling, and sometimes fatal disorder that's actually very treatable.

It really encompasses a broad territory of psychological vulnerabilities, spanning emotion problems of dysregulation and instability, as well as behavioral discontrol that we oftentimes see manifested as self-harm or suicidality.

A lot of people now are focusing on how the interpersonal problems of borderline personality disorder, that is its interpersonal hypersensitivity, leads to severe ups and downs in one's relationship world.

Meaning that sometimes things are all good and feeling like there could be no wrong in the relationship to plummeting to a state of blame and despair, that the relationship is causing all the problems that a person has in their life.

Related to this are problems of identity functioning, meaning that one's sense of oneself is negative, unstable, and very prone to being shaped by environmental influences.

So these combinations of relational instabilities plus identity disturbance really fuel the emotional dysregulation and the behavioral control we see in the disorder.

- I wanna ask you a little bit about when do these symptoms first arise?

What's the typical course that occurs for people who experience borderline personality disorder?

- There are many diverse roads to developing borderline personality disorder.

Part of of it is biological, meaning that sometimes genetics has a strong influence over the tendency that people will have for impulsivity and emotional instability.

And they might just be endowed with more sensitive temperaments.

And when people who are born sensitive in both an emotional and interpersonal sense, interact with adversity in their environment, sometimes this is in severe forms like trauma, that might create a condition in which the stress in one's life overwhelms the capacity to cope.

So when someone is overwhelmed in their capacity to cope, they act in ways that are out of control.

And then what happens is that their social environment might respond in ways that cause a person to feel worse and not better.

And then a vicious cycle occurs where someone is acting in ways that are very difficult to cope with and understand.

And the environment is transacting or responding in ways that that person finds very stressful and rejecting.

- Almost a snowball effect.

- Exactly, it's a snowball effect, and that's where there's some hope because you can actually intervene on multiple levels to disrupt this cycle.

- I wanna talk about some of the treatment.

Tell us what are the modes of treatment that have been found to be effective?

- Well, the good news, Jeff, is that for a long time people thought that borderline personality disorder was untreatable because they were using treatments that were built for more general problems that people without borderline personality disorder also have, things like depression and anxiety.

Then when they found that people with borderline personality disorder weren't responding as usual to those treatments and therefore they were deemed treatment resistant, they started trying to adjust treatments to really address these core relationship and emotional sensitivities that people with borderline personality disorder have.

And when they focus those treatments on these core problems of BPD, the patients actually did better in most outcomes compared to those patients who are in these treatments that are for usual patients that don't have personality problems.

Nowadays, there's several treatments that have been proven effective for borderline personality disorder, ranging from very behavioral therapies, like dialectical behavioral therapy, to more psychodynamic treatments, like mentalization-based treatment, as well as transference focused psychotherapy.

And in between, there's a lot of other options as well.

- I'd like you to explain the dialectical behavioral therapy 'cause people have heard of that.

It's a complicated sounding term.

What exactly is it?

- Dialectical behavioral therapy is probably the best known effective intervention for borderline personality disorder.

And it was first developed by Marsha Linehan because she's trying to treat those people with suicidality that weren't responding to very effective cognitive behavioral therapy.

And she added the concept of dialectics, which really solves the problem of black and white thinking that people with BPD tend to have.

So dialectical thinking has to do with the idea that the opposites can coexist together, that you can be really upset with someone and still work it through in the relationship, or that you can fail at something and still be a good person.

And kind of domains of skills such as distress tolerance, emotion regulation, and interpersonal effectiveness, those things have been packaged up together to help people who have borderline personality disorder and the emotional dysregulation that's related to it so that they have the skills to deal with their particular sensitivities and be more effective in life.

- Lois, let me ask you about other types of treatment that's available.

- Like I said, Jeff, the great news is there's so many different options, not only for patients globally to try different treatments for borderline personality disorder, but also for clinicians.

Because clinicians gravitate towards different therapeutic approaches, whether they're psychodynamic in nature or cognitive behavioral.

I've mentioned dialectical behavioral therapy, which is a cognitive behavioral treatment, but there's others such as mentalization-based treatment that has more psychodynamic roots.

What that means is that it's more focused on concerns about attachment and how one thinks or represents what they experience in their own mind.

Because of course the way we think things influences how we react to them.

But there are other treatments as well.

And on the topic of generalist treatments, the treatment called Good Psychiatric Management, which was inspired by the work of John Gunderson, is a treatment that involves far less intensive clinical resources and is less specifically psychotherapeutic and more care management oriented.

This is an approach that was compared to BPD in a large randomized control trial and found to be just as good.

And what that involves is what most good clinicians do, that is making a diagnosis, teaching their patients about what it means to have that diagnosis, and then setting up care in a way that's goal-oriented and accountable to outcomes.

Meaning that the treatment is working if it reduces symptoms and increases functioning.

And the last thing I would say about Good Psychiatric Management, which has a lot of common features of the other treatments that work, is that it focuses on helping a person with BPD become more self-reliant.

That is cope more effectively, interpret their social realities more accurately so that they don't have to depend so much on other people all the time and keep over activating their relationships so that they inevitably fall apart.

- It's good to have options if one doesn't work or if one can't get one type of treatment, you could try another.

I wanna ask you about medication and borderline personality disorder.

Tell us about that.

- There are a lot of psychiatric medications that are used for multiple purposes.

People with borderline personality disorder tend to have other co-occurring disorders that might be treatable by medications.

For example, major depressive disorder or PTSD or substance use disorder, specifically alcohol use disorder or opiate use disorder.

These things all respond to some sort of medication assisted treatment.

However, the symptoms of borderline personality disorder themselves do not resolve with medications alone.

Medications are adjunctive and oftentimes kind of decrease the intensity of some of the symptom domains of BPD.

That is that it might reduce distress and impulsivity in the short run.

But in the long run, what is really needed is the psychosocial approach to helping people with this disorder learn how to manage their distress and impulses more effectively, and manage their relationships so that they're more likely to get their needs met.

- You mentioned the issue of suicide, and suicide attempt, suicide risk, could you speak a little bit more about that in the context of borderline personality disorder?

- Suicidality and non-suicidal self-injury, that's also known as deliberate self-harm, these are kind of the clinical hallmarks of borderline personality disorder.

This is what oftentimes brings people to the attention of mental health professionals.

Suicidality is really common amongst those who have borderline personality disorder.

It's thought that like four out of five people who have borderline personality disorder will experience suicidality in their lifetime.

While most people with borderline personality disorder will experience intermittent bouts of suicidal thinking, only a fraction of the time will they be engaged in more serious intentions to harm themselves.

Studies more recently really estimate that it's about 1 in 10.

Sometimes 1 in 20 people with borderline personality disorder will have a fatal case that ends because of suicide.

- Which is a very high number.

- Yes, borderline personality disorder represents a high proportion of cases that do end in suicide amongst all psychiatric illnesses.

So it is of utmost importance that this diagnosis is identified as early as possible and treated.

But unfortunately, what oftentimes happens is that it's a diagnosis of last resort and it's only until it becomes very severe and has been subjected to a lot of other treatments that haven't worked that people come to specialists' attention that this is borderline personality disorder instead of just depression or substance use disorder, or an eating disorder or some other common diagnosis.

And the problem is that by that point there's sometimes a feeling of therapeutic nihilism, which essentially means that patients and their support system become hopeless about the possible relief of a treatment that could really help their core symptoms.

- Yeah, after receiving treatment that hasn't helped them for so long, it's natural to sort of give up.

And the important point you are making is going to somebody who specializes in borderline personality disorder treatment can make a very big difference.

One of the areas that you've looked at is the issue of accessing such care, 'cause there aren't really enough specialists in the area.

And I'd like you to talk about some of the work that you're doing to improve that access.

- Well, Jeff, one of the great optimistic truths about psychiatry at large and this domain of psychiatry specifically is that there's always a lot of progress made.

I entered the field 20 years ago now, and in those 20 years I've seen a remarkable revolution in the attitudes that mental health professionals and the public at large has about borderline personality disorder, which I had mentioned was really regarded as kind of a hopeless situation.

Now there's even better news, which is that there are a lot of treatments that have been proven effective that are in that domain of specialized psychotherapies that require its practitioners to undergo not only extensive training, but a lot of supervision and teamwork in a certain setup that's oftentimes not compatible with, for example, insurance reimbursements or how clinical programs might work in more recent resource constrained environments.

If we can diagnose BPD more readily and connect people to more access to good enough resources that might be practiced by generally available mental health professionals, we can give more people a starting dose of treatment.

And I'm convinced that a lot of people with borderline personality disorder will respond to that good enough dose, and then we can save the more intensive, more chemotherapeutic doses of treatment for people who have more advanced stages of illness, who will just need more.

And that might spread the access further for everyone involved, including clinicians, because a lot of clinicians out there want to help people with borderline personality disorder, but can't practice these treatments, such as dialectical behavioral therapy or mentalization-based treatment because their situation or clinical setup doesn't enable them to do so easily.

- So in many ways, an earlier diagnosis before things get too severe and then a broader availability of access could really make a big difference for people with borderline personality disorder.

- Exactly.

- In many ways, for both the person and family members, understanding what's going on, having a name to it, understanding that these are symptoms, nobody decides they want to become dysregulated, these are symptoms that a person has like any other kind of symptom a person could have medically or psychiatrically, understanding that can give more control to the individual and their family members.

- Absolutely, I think we'd all want that.

You know, whenever we have something like when I had COVID, I really wanted to know everything I could about what it meant, what the symptoms were, what the course was, what I could do about it to optimize my chances of not having a negative outcome.

And I think everybody who has borderline personality disorder deserves the same.

Families oftentimes really benefit from knowing how they can be helpful, and it's in the absence of such knowledge or education that they oftentimes are just really reactive and unintentionally making things even more stressful for their loved one with BPD.

We found that borderline personality disorder is one of the most stigmatized disorders out there amongst health professionals.

And a lot of health professionals have been taught that it's not favorable or good prognosis to tell someone that they have borderline personality disorder.

But in reality, what I found clinically through experience with patients and their families is that having a constructive, treatable diagnosis is always easier to manage and more constructive than thinking you're a bad kid or a horrible student or a failure as a friend.

So that if you have a framework for understanding why those things have been hard for you, that you can change and transform with the right help, I think that provides always a more helpful message than not diagnosing someone's disorder.

- I wanna ask you about co-occurring conditions such as chemical dependency, depression.

Could you speak about the relationship between borderline personality disorder and other conditions?

- Borderline personality disorder is thought to be a problem of stress sensitivity.

The reason for that is that as we grow up, especially through the teen years, you develop a sense of self and identity, if you will, and that kind of container for how you function allows you to be consistent and predictable, both to yourself and to other people.

And if you have difficulties generating a positive and stable sense of self, then it's going to be really hard for you to manage stressful life challenges.

So what happens for people who have borderline personality disorder is that the condition itself makes them more reactive to emotions and relationship difficulties, and then they act in ways that they feel a lot of regret about.

And that causes a lot of different problems on top of the borderline personality disorder, including depression, anxiety disorders.

Sometimes it promotes vulnerability to trauma so that they develop disorders like PTSD.

They may develop behavioral coping patterns that help them deal with their stressful emotions such as substance use disorder or eating disorders that then become problems that also generate stress on top of just having borderline personality disorder.

The progress that we're recently making in the field is this realization that we can't just rely on treating one disorder at a time, because people typically have more than two disorders if they have borderline personality disorder.

So finding treatments that are more comprehensive and can treat multiple problems at the same time is what we as the the psychiatric profession need to figure out to do so that we can meet the urgent needs of patients to stabilize them faster with all of the diagnoses that they're coming to the table with.

- If somebody's watching right now and they think that they themselves may have BPD or a loved one has that condition, what do you say to them?

- For anyone out there that either has the symptoms of BPD or they love someone who does, there's a lot of hope because there is not only something that can be done, there's good treatment out there.

But there's a whole army of professionals and researchers trying to improve the state of treatments for this condition, which is gaining recognition amongst all healthcare professionals.

People are starting to realize that it's a problem that if it can be intervened upon, the benefits are wide, not only to stabilizing a person's clinical status that is reducing their symptoms, but then enabling them to function in life so that they can build a life that allows them to generate a more positive sense of self.

And also more positive ways of relating to others so that when you treat the borderline personality disorder in one individual, it can have a huge ripple effect on all the people connected to that individual and wanting what's best for them.

What we still need to do is, like we've been talking about, make that treatment more available, and it's things like this, which just enables people to learn more about borderline personality disorder.

That starts empowering people to go in the right direction and not keep seeking solutions such as treatment for the other illnesses they have, like depression or just treating the substance use disorder or trying to do everything with medications which are not proven to work for borderline personality disorder.

- Right, it's important for people to seek help because really with help, this is a fully treatable condition and people can live full, happy, productive lives.

- Absolutely, I think for all the professionals out there too, working with people with BPD is one of the most rewarding things you can do because these are patients who seek care and want help.

They're interpersonal symptoms may make it more challenging to stay in a steady therapeutic alliance with them.

But the good news is that the treatments that have been proven for BPD pay attention to this.

And then over time you see remarkable recoveries and adjustments to the endowments each patient is provided in life.

And that's why we're in this line of work, right, is to help people recover functioning, and get back on the road of life with a little help from treatment.

- Lois, I wanna thank you for joining us today and more importantly, for the work that you've done, both the research and the clinical care that you've provided to so many people.

Thank you so much.

- You're welcome.

Thanks for having me.

- If you or a loved one are living with borderline personality disorder, don't suffer in silence, seek help.

Remember with help, there is hope.

(tranquil music) Do not suffer in silence.

With help, there is hope.

(tranquil music) This program is brought to you in part by The American Psychiatric Association Foundation, The John and Polly Sparks Foundation, (tranquil music) and The Woodnext Foundation.

(tranquil music) (tranquil music continues) (tranquil music fades)