Podcast: Ask Me Anything About Emotional Regulation

Jenn talks to Dr. Lois W. Choi-Kain. Lois offers tactics to overcome challenges with emotional regulation, provides tips to improve interpersonal hypersensitivity, and shares information about the connection between emotions and borderline personality disorder.

Lois W. Choi-Kain, MEd, MD, is the director of the Gunderson Personality Disorders Institute at McLean Hospital. She has also led a number of projects to increase access to care for borderline personality disorder (BPD) worldwide through teaching, supervision, and consultation. As an assistant professor of psychiatry at Harvard Medical School, Dr. Choi-Kain actively conducts research on BPD, focused on personality disorders, attachment, psychotherapy, and accessibility of care.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

So, hey everybody, thank you so much for joining today. And we hope wherever you are joining us from and whatever time you’re joining us, you are doing well.

I would like to officially introduce myself. I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital.

And I’m thrilled about this session for a myriad of reasons, not just because when we first started these webinars Lois was one of my first guests, but that she’s come back after a year and wants to do it all over again with me.

Over the last, you know, year or so, we’ve been living in such an emotionally turbulent time. But for folks who are living with borderline personality disorder, which we’ll often refer to as BPD throughout this webinar, living through everything that we have endured so far, plus all of this on top of it is like cranking the volume up way past a hundred.

Stress has been rampant; it’s been hard for everybody to stay on track with what we need to in order to have good emotional and mental health. So, we’re going to talk about all of that today and more.

So, we have about another hour, we’ll be talking about emotional dysregulation, BPD, the impact of other people’s words and actions on our mental health, obstacles, conquering hurdles and so much more. I don’t want to take up any more of Lois’ time with an introduction because I’m already brimming with so many questions for her.

So, let me introduce her briefly and we will jump right in. So, if you are unfamiliar with Lois, Dr. Choi-Kain is the director of the Gunderson Personality Disorders Institute at McLean Hospital and her work spans both nationally and internationally to expand teaching efforts on BPD and its evidence-based treatments.

So, Lois, hi, and thank you so much for coming back to hang out with me for an hour. I would love to talk about everything BPD, but let’s get started with what are some of the telltale signs of emotional dysregulation? How can we tell if we or a loved one are struggling with this?

Lois: Great. well, first of all, I want to say Jenn and Scott, thank you for having me back. It’s kind of like our anniversary of doing this. It’s been so long, and a lot has happened.

And, you know, in this last year I’ve just realized how important it is that we at McLean and in our profession go public with what we know to help everyone through this really difficult time because while we’ve all adapted, maybe out of like resignation or out of effort, it’s a marathon. And going through this much transformation is really challenging.

So, I think that while, that a lot of these lessons are learned through the treatment of borderline personality disorder, I think they’re really important human skills that actually those with borderline personality disorder made us learn.

You know, we’ve developed these treatments to help them get to their clinical goals, why they come to treatment, what is it they want out of life. And those tools are now here for us during a time that we’re all at times emotionally dysregulated.

So, to this question, I think it’s such a good one, how do you know when you’re emotionally dysregulated? And you gave me a preview on some of these questions and I thought about it this morning and I have probably a strange story to tell because in this time of COVID we’ve all been like totally in our own worlds.

And I think it’s been a time to kind of get back to your roots, like think about yourself, where you come from, what matters to you, sources of self in the absence of these things we do daily to define ourselves.

And I was thinking about this thing I did once when I was in high school, believe it or not, I threw the javelin. Can you believe that? It’s like this really weird fact about me and it happened because I was actually a long-distance runner, but I was really mediocre at that.

And they needed field people, because like field is a whole field of track and field. And you got a lot of people who are running, but then some people who are throwing things and I learned how to do the javelin because they needed someone.

And I happened to play tennis, also very mediocre at that. And I had some basic mechanical abilities to serve a ball. And I worked every day, I stopped running long distances and I learned, there’s like 10 physical maneuvers that you put into a sequence to throw a javelin. I did it every day, like 30 times.

And then I actually had this really weird thing happen is that I was really good at it. And I went to the State Championship which was actually kind of like cool but also very anxiety provoking because I had never been to a state championship and there’s not a lot of people throwing the javelin, so I didn’t really know anyone.

And then I had to perform under pressure. And that’s where I started to understand emotion dysregulation, because I knew those 10 steps that I needed to take to launch that stick into the air. But managing all the feelings I had about it was a different category of skills that I had not thought about in terms of what I needed to do in that moment.

So needless to say, I actually didn’t do very well at the state championship. And I don’t think it was because I didn’t have javelin throwing skills, I think it was because I didn’t have emotion regulation skills in that moment that I had practiced to prepare me to coordinate the task with my own experience of it.

You know, my experience of what was at stake how exciting it was, but also like what I’d feel like if I lost and what it meant, you know, like how do people view me, how do I view myself? These are all aspects of what goes into emotionally upsetting and dysregulating moments.

Now I tell this story because it’s obviously not like a defining moment in my life, I’m not going to say, oh, that was a high point in life, but it’s a simple example that I think we can all relate to. That emotion regulation actually becomes extremely important when the pressure is on.

So, I find that I’m most emotionally dysregulated when I notice like I’m getting carried away with something, either I’m getting carried away with an argument I’m making, you know, and sometimes at home, my parents, my husband’s like, okay, I hear you.

I’ll just keep going and going excitedly, that’s me getting carried away. He’s like, I got it, 10 minutes ago. That’s getting carried away, not keeping track of who you’re interacting with and what their response is to the conversation.

Getting carried away can also mean like doing something excessively in another way. Like some people will shop too much, or they’ll drive too fast, or they’ll eat too much, or drink too much, drink too much coffee.

Sometimes that happens to me because they want, they don’t know how to modulate a good thing and they just get carried away because they’re not monitoring themselves in their experience and managing what they’re doing.

And another way of thinking about it is becoming mindless about things. So, on the one side you can get carried away, on the other side, you get mindless about a lot of things. Like you just kind of disconnect and you go into autopilot and that’s another response to emotional dysregulation, is just getting so overloaded and burned out that you’re just going through the motions.

So, you may be like kind of disconnected in a way that you sometimes find yourself, I think this happens a lot in COVID, where you’re like, oh my God, what day is it? Did I do this thing that I, I have a vague recollection of doing this thing, but I’ve done so many things and can’t like locate it.

That has become actually, like, I think a big coping response. I can acknowledge for me some parts of COVID, I was just like, I’m just here. And so, we’ve all had variations on this. I think the thing that distinguishes people with borderline personality disorder is that they’re more likely to have this happen at lower levels of stress.

So, you can imagine if COVID was all the time and you’re constantly going through fluctuations of getting carried away or shutting down and not feeling like you could predict how well you’re going to perform when you have to throw that javelin. Because an errant javelin is not a good thing.

So that shouldn’t be taken lightly because it’s not that all the things we do when we’re carried away or being mindless are destructive, but the problem is they can be on small and large levels. And that’s what I think we’re coping with in the world right now, is that life is emotionally dysregulating, we’re all isolated and its difficult coordinating responses to things.

We see that here more than maybe anywhere else. And it makes everyone feel insecure. So that is my answer to the question of how do you know if you’re emotionally dysregulated or not and maybe that will begin the conversation.

Jenn: So, with the understanding that there are some things that are truly out of our control, like a pandemic and the response to it, the emotional regulation that we can control, if we don’t address or treat dysregulating in a timely manner, what types of impacts can we expect?

Lois: Well, this is actually a very good question that makes me think of how much I’ve learned from dialectical behavioral therapy. I want to first say that that’s not the only treatment for BPD. That’s a misconception, that DBT is the only treatment for BPD, it’s really not.

There are many treatments that work for BPD but DBT is based on the idea that borderline personality disorder is a disorder of emotional dysregulation. And actually, my one caveat to that is that a lot of disorders in psychiatry are problems of emotional dysregulation.

It’s not just BPD, but one of the ideas from DBT is that people who are emotionally sensitive they end up having a bigger reaction to upsetting things and they also have a slow return to baseline.

So, if you can picture this, say you’re late for something you’re supposed to be at, and then this has happened to me, I have like the smoothie that I drink instead of eating a real meal breakfast, and then I drop the smoothie all over the garage and then I don’t have time to clean it up and I’ve left a mess and I’m getting in the car, and like I close the door on my skirt.

So, you see that one event can get you really off-kilter so that you keep doing things mindlessly and then it keeps generating upsetting events. So, in the short run, if you don’t actually take a deep breath and you think, okay, I need to slow down and think about this. I’m already late, how can I just like do some damage control and not make it worse?

But what can happen is that you have all these little trips during the day, and not only are you already upset without being able to kind of settle yourself, you get more and more upset and then you end up becoming extremely irritable, like sensitive.

So that anything that happens afterwards you’re just more likely to feel reactive to and then have a loss of control. And that actually brings this second layer of problems which is that I don’t know about you, but when I’m acting in a way that is not my goal or in line with who I want to be, then you get actually upset about that.

So, do I want to be someone that’s late, spilling drinks all over the place and then like showing up with like torn clothes. I mean, is that who I am? There is this idea that when there’s a discrepancy between who you want to be and how you’re understood by people or seen or acting, it’s actually very upsetting and uncomfortable.

And that leads to a sense of insecurity about yourself. And that translates into some issues of self-esteem. So, you know, I generally, I mean some would tell you Lois has too much self-esteem, I wish she would like actually tune it down a little bit.

But basically, I think that on a day like that, where I’m running late and feeling really off, I am more self-conscious, like, what am I doing, why am I doing this? And being like more self-critical and also more defensive towards others because I’m already feeling sensitized.

So, it’s an illustration of how then there’s a third layer which is then your relationships get influenced by all of this, not just your negative emotions and your emotional dysregulation and your mindlessness and getting carried away, but then also your insecurity and your sensitivity about how people are reacting to you.

And then you start doing things in the relationship that are only likely to make things worse. So, it’s like, you know, sometimes when I give lectures it’s like kind of like a fireball of psychological problems. That’s what personality disorders are.

A lot of people say to me like, oh, isn’t that bipolar disorder? And I’m like, well, some people have bipolar disorder but that’s actually only a very small fraction of people even who have borderline personality disorder, but of the world.

There are not that many people who have bipolar disorder but guess what? Everyone has a personality, even those who don’t have a personality that is their personality. So, personality functioning is how you cope and how you feel and your self-esteem and your sense of self. And the other side of personality disorder is about your relationships. So self and other.

So, you can see how emotion dysregulation can also then destabilize your self-functioning and your relational functions. So that that’s why it causes a personality disorder.

Jenn: We’ve received a ton of questions already about the relationship part of BPD. So perfect segue into it. We had an individual ask a member of my immediate family has a diagnosis of bipolar II.

However, many of the symptoms I see sound exactly like BPD. Is this common, and should I address the possibility of this with her provider?

Lois: I think that’s a great question because I was just at a conference, a very high-level impressive conference for the American Society of Clinical Psychopharmacology. And I got to hear a lot of lectures about mood disorders and their management.

And I think the broad strokes of it is that bipolar II is different than bipolar I. And it overlaps with borderline personality disorder. The distinctions between bipolar II and borderline personality disorder, I think are less clear than the distinctions between bipolar I and bipolar II.

So, the issue that I would say is practical is that borderline personality disorder has a lot of treatments that are proven to work for it. None of them are psychopharmacologic.

So, if you’ve tried a lot of medications and haven’t found what you need, actually going down the road of the BPD diagnosis, the borderline PD diagnosis, actually opens up a whole new range of options that do not involve medications necessarily.

You might take those adjunctively, but really they’re about coping with your negative emotions, your ways of getting carried away or shutting down and your ways of managing your self-esteem and your relationships.

So, who wouldn’t benefit from that? We all benefit from those skills. And in fact, there is some research that shows that some of the treatments that work for BPD actually do help with bipolar disorder in general.

But I would say that it has no negative side effects for a person who has bipolar II to try to increase their coping responses, their social behavior, or their self-awareness. I mean, that can help anyone with any disorder and those without disorders.

Jenn: So, if a family member of an individual is living with BPD, how would you advise that they remain stable and not ride along the roller coaster of emotion?

Lois: That is a tall order, because if you love someone you’re going to be on a roller coaster with them, if they’re struggling. Like whether they have BPD or if they had COVID, you’re going to be on a roller coaster, that’s unfortunately and fortunately how relationships work, is that relationships are really sustaining for all of us, but they can also be very stressful because we care.

So, what I generally say, and this is a mantra in the field of family therapy or family work for BPD is put on your oxygen mask first, because like they say, on an airplane, it’s simply that your child is not going to benefit from you being dead, basically, or unable to breathe yourself. That’s actually going to put them more at risk than, you know, like them not having their oxygen mask on.

So I think that what I always tell family members and clinicians working with patients who have problems of volatility and dysregulation, is that you’ve got to take care of yourself because no one else is going to do that.

And that’s actually going to put you in the best place to be effective and feel in control about what you are doing in relationship to your loved one who’s struggling ‘cause all you can manage and control is your own reaction to things rather than somebody else’s situation.

Jenn: So, I know that you’ve mentioned DBT, you’ve also mentioned other treatment methods for BPD. Can you dive in a little bit into which treatment methods have been proven to be successful in treating BPD?

Lois: Well, the good news is there’s actually a lot of them and it depends on what you mean by proof but starting with the major ones, mentalization-based treatment is a psychotherapeutic approach that comes out of the national health service Peter Fonagy and Anthony Bateman developed this approach that is totally the opposite of DBT.

It doesn’t have an encyclopedic set of skills and a structured approach or protocol, but it’s actually really focused on a process of helping people stabilize their ability to understand what’s going on for themselves and in the minds of others, in their interactions.

So, I think that’s actually mentalizing is something that we all would get better at over time. And the better you are at mentalizing, the better your life will be in many ways. There are situations where mentalization is actually really not advisable. Like when you’re performing a surgery, thinking about how much it hurts the person is probably not going to help you do the surgery.

But when you’re trying to buy a present, you need to mentalize what this person would like. When you’re having a difficult conversation trying to mentalize what is going on in the mind of the other, so that you can relate to them but also not get so paranoid and defensive yourself about what they’re up to and what their intentions are.

So that is something that can help us through difficult times, just mentalizing more and the whole theory in the treatment is that a number of psychiatric illnesses, including personality disorders and other disorders are characterized by problems in being able to stably understand oneself and others. And you can see how broad that is.

So that’s actually an approach that has a lot of good data behind its effectiveness in terms of a comparison to other, you know, treatment as usual in actually an organized healthcare system.

Now there’s other treatments including transference focused psychotherapy which has been trialed against other manualized treatments and found to be either effective, as effective, or better in some ways.

And that’s more of a psychodynamic approach, that’s twice weekly with one individual therapist in the office, it doesn’t involve groups like DBT and MBT and it really looks more at the way we represent things in our mind.

It’s a little bit like mentalization in that regard, but it’s more focused on the way we get black and white about our relationships. Like this person is either like the best thing that ever happened to me or this person has ruined my life. And we’ve had a lot of black and white polarizations in the time of COVID because it’s stressful.

When there’s a very highly negative, aggressive environment, and there’s a lot of threat, which we’ve had this year, then people naturally start splitting in terms of seeing people as good or bad or right or wrong or helpful or destructive. So that treatment has a lot of relevance right now.

And lastly, while this is not an exhaustive list, I’m going to talk about general psychiatric management or good psychiatric management because that’s the treatment that I am most involved with and know the best because it was developed by my dear mentor, John Gunderson. I was lucky to have really known him, both as a psychiatrist and a scholar, but also as a person.

And I really value the way that he really tried to translate these really complicated scholarly ideas that he had from doing a lot of very high-level federally funded research into relatable terms that most people can understand.

And I think that’s where a lot of the treatments have gone wrong because I often joke at conferences, that we somehow have thought it was okay to talk to people like they’re both mentally impaired and scientifically psychological, using all sorts of words that are a complete tip off that you’ve been in that treatment.

So, John Gunderson really wanted something that was just good enough. So, its good psychiatric management, how we talk about it. Now, and it really looks at the concept of interpersonal hypersensitivity as the basis of borderline personality disorder. And this is, Jenn, where I’m going to show some slides.

And, you know, in thinking about this in the time of COVID, I’ve been taking lots of walks where I process my thoughts. And I think that John was onto something about all of us especially during a time like this, because our personalities are structured by our identities, who we are, what we do, how we interact with people.

And that’s been like radically reduced over the time of COVID. So, we all have this interpersonal hypersensitivity, partly from the social distancing. I don’t know about you, but I kind of like, don’t want to be around people these days, ‘cause we’ve been slowly-

Jenn: Absolutely not.

Lois: Yeah, so isolated?

Jenn: No way.

Lois: The whole idea of it sounds like actually kind of threatening in and of itself. Like I used to go to hot yoga, and that now sounds like a really terrible public health maneuver. So, you know, our ideas about everything, our opinions about everything has been like completely influenced by world events, public health events, political events.

So, I’m going to show the basic idea of good psychiatric management and the whole concept because I think everybody can relate to it. So, the whole idea behind this interpersonal hypersensitivity concept is that the way our presentation or the states we’re in, evolve, has to do with our sensitivity to others because on the one hand, other people can be really helpful.

On the other hand, people can be really destructive and there has been no time in history where that has become more obvious. So, when we’re on a good note with people, we may feel positive things, like we feel connected, we think that people can be essentially good and do no wrong.

And then we can like kind of depend on them and like really be receptive to what they have to offer and give them the benefit of the doubt most of the time. But things happen in relationships that are interpersonally stressful.

Like someone might disagree with you or they might reject you or leave you out in the cold or exclude you in some way, shape or form that feels threatening to you because it brings up negative emotions. It may actually make you feel unsafe. You know, when you’re not a part of a group, you feel more vulnerable.

So, in that threatened state, people naturally become angry and act as though they’re threatened. Even if something was only threatening in their mind, you know, they may perceive someone didn’t say hi to them, or they didn’t call them back.

And for them, that might be perceived as a threat, even if it was because you lost your cell phone or you didn’t know they were there, but regardless of whether it’s real or perceived, they will feel threatened.

And they either turn that anger inward towards themselves and do things that are self-injurious or self-sabotaging or they will turn that anger outward and become argumentative, de-valuing, blaming, contentious, all of those things.

And believe it or not in these two states, whether it’s connected or threatened, you’re still in the ballgame of relating. It’s just whether you’re relating positively or negatively. And both things are actually important in close relationships. You probably have received a lot more of the threatening side because we’re all trapped together.

But when you start to act threatened, people back away because they don’t know what to do with it and it causes them a lot of negative emotion, right. And it’s then that a lot of more difficult things happen. People become more difficult to reach because then when they’re alone and they feel vulnerable on their own, that’s when they start to think these dark thoughts.

Like these people are out to get me, they’re trying to harm me. They’re dangerous, they’re neglectful, they’re abusive. And then you also feel like less anchored in like this kind of structure of consequences or action reaction.

So, you might just do things without thinking about the long-term effects. And when you’re in this space, it’s really because there’s a lack of holding. You’re not contained, you’re not connected to others. You’re not connected to reality. And that can actually segue into real feeling of despair. Like what’s the point.

And that’s when people with BPD are more dangerously suicidal because they get in a state of it doesn’t matter if I live or die. And whether you have BPD or not, a lot of human beings get in this state and they become extremely self-destructive. And we’ve seen that this year.

So, what’s the solution? What happens for people with BPD is that they’re actually somewhat adaptive and there’s this idea, there’s this evolutionary biology to it, is that their flares that they send up in this threatened state or in this impulsive state or in this suicidal state, gets other people’s attention. And then people like lean in and provide a container.

They put them in the hospital, or they do an intervention, or they take them under their wing, or they put them in even prison sometimes. And that’s actually a holding environment, physical holding environment where there’s other people to interact with.

And that actually gets people back in this mode of being connected. And some people will just get back to being threatened but actually that’s a more workable space than being alone or despairing ‘cause you can still reach someone who’s threatened.

You just have to know how to talk to them. And this is where we suggest that where the money is with all this is staying involved, engaged in interaction or dialogue. When they, we go up and down between being connected and threatened, because we all get threatened sometimes.

Like if my child needs me to be somewhere when I need to be at a meeting, their scheduling needs, threatens my schedule. Is it intentional? No. But does it bring up stress for me? Of course. And it’s all about the management.

So, what we would say is, actually this is a big belief of John Gunderson, is that fighting is better than just going your separate ways and never dealing with the problem. And that is, I say that with a grain of salt, because sometimes you do have to go your separate ways so that you can have a constructive conversation, but this isn’t bad.

Having like a intense conversation is not bad, it actually has a lot of positivity to it. If your relationship can endure these kinds of arguments, that’s a strong relationship.

And that’s what all the treatments for borderline personality disorder teach it’s clinicians, is, you know what, it’s alright, they have BPD, they’re going to get angry, they’re going to get emotionally intense, hang in there with them.

We’ll teach you how, either with these DBT skills or with mentalizing or with understanding their object relations and their black and white ways of thinking about people or because you know they’re interpersonally sensitive and you’ve just made them feel like you’re going to reject them or abandon them.

But this is where I told Jenn, that I would get a little controversial, in the sense that I think we’ve all been through something this year that has something to do with John’s theory about interpersonal hypersensitivity ‘cause we had this happen.

And talk about emotion dysregulation, sense of threat, sense of exclusion, sense of impulsivity without regard to consequences, sense of paranoia and then ultimately despair, but as terrifying and horrific as that is, just like with these crises in BPD, I think there was this moment that we all leaned in.

And I have to say that kind of moment in the Senate where they’re all talking after they were just under siege where even some of the people were like, what in God’s name just happened? It was this moment of everybody getting into a conversation and everyone’s trying to figure it out.

And that’s really the goal of all of this, to try to stay on the same page, even when people’s needs conflict. Your patient might want you to do something that you cannot do, but it doesn’t mean you’re evil for not being able do it. And it doesn’t mean they’re evil for wanting it.

But just try to hang in there and work it out and accept the fact that people are disappointed sometimes, we are disappointing sometimes. Sometimes you throw the javelin the way you want it, sometimes you don’t. And that is, that acceptance of all sides of things is also the key to emotion regulation. Okay, so that’s my slideshow, Jenn. You can stop.

Jenn: It was so well done too. I love all the graphics.

Lois: I have a lot of free time these days.

Jenn: Oh yes. One of the busiest people I’ve ever encountered has a lot of free time these days.

Lois: No, John used to think it was very strange that this is what I did in my free time, but it makes me happy.

Jenn: That’s okay. I grew up to be a mediocre tennis player and mediocre distance runner. So that’s what I do in my free time.

Lois: We’ll play tennis, we’ll both be mediocre.

Jenn: Perfect. So, someone wrote in saying that what you were describing sounds like a trauma response. So why is there not a greater acknowledgement of BPD as a trauma disorder?

It seems like this may contribute to stigma around BPD and makes people think that they’re the problem and not the trauma that they potentially endured?

Lois: Well, this is also a very important question. And one I get almost every time I speak. I think there’s a real misunderstanding of whether or not trauma makes something better or not because let’s face it, trauma’s horrible.

And people who experienced trauma have heightened risk for every psychiatric disorder, not just BPD and not just PTSD. It is true that trauma is more prevalent among people with BPD, but it’s also more prevalent among people who have other psychiatric disorders. And trauma is neither necessary nor sufficient as an explanation for why BPD occurs.

Because there are plenty of people with BPD that never had trauma before they developed its symptoms. But having BPD actually puts people at risk for future trauma, because we actually see this through the longitudinal data is that kids who have early symptoms of BPD, like negative emotion, sensitivity, poor self-control, they’re actually bullied more and they’re also the recipients of more punitive, less warm parenting.

And it’s not to blame that individual, but rather to actually indicate a pathway for preventing all of this is to pay attention to the BPD as the good thing that we can intervene on because BPD does remit over the years even if people don’t get treatment.

That’s not always like just a happy life, but BPD does remit in the majority of patients over 10 years. But what I’m saying about this is that if we can de-stigmatize BPD by not making it only okay if someone has trauma and intervene earlier, people can actually disrupt their whole course of painful living by treating the BPD first.

And that doesn’t diminish the role of trauma, but I think the answer is not changing the name of BPD to de-stigmatize it, it’s not calling it PTSD because those symptoms are actually quite distinct. PTSD has it’s own symptoms that actually have nothing to do with the BPD symptoms.

And there are overlaps but they’re very distinct disorders that often co-occur. But what we need to do is de-stigmatize BPD. It’s common, we’re all vulnerable to interpersonal hypersensitivity and emotion dysregulation.

We will do better for these patients by saying, hey, this is understandable, we need to treat it more actively so that it’s not a treatment of last resort. And unfortunately, while non-intended, I think this focus on focusing on the trauma, actually prevents people from getting the treatment they need to recover from all their emotion dysregulation and interpersonal hypersensitivity.

That may be a product of trauma, but maybe a product of their genetics and also all the adversity they have experienced over their lifetimes. So that doesn’t just restrict it to trauma. You can be extremely deprived in life and have a BPD-like reaction.

That would be completely understandable. But the goal is to actually build your sense of self and your sense of being able to manage your emotions and your behaviors so that you are seen the way you want to be seen and so that people support you.

What could be more important than that? And you shouldn’t just get that because you have trauma, you do need it if you have trauma, but everyone deserves that.

Jenn: So how do professionals know if somebody has a diagnosis of PTSD or a diagnosis of BPD?

Lois: There’s a book called the DSM and they have all these symptoms. So, the DSM is a really thoughtful book. It’s not perfect, but as Beyonce says, nothing’s perfect but it’s worth it. And there are a lot of very smart colleagues that I have been totally inspired by all of the scientists, researchers and leaders in the field who are working to refine all this.

Talk about threatened states. They’re arguing their faces off to try to refine it in the best way possible. And PTSD has symptoms that are related to a traumatic event that is defined by certain set of criteria, like really feeling threatened in a loss of life or seeing somebody else, threatened in that way or a kind of abject torture or abuse.

Those kinds of things obviously are traumatic. There are a lot of upsetting things that happen to all of us that some people call traumas but are like really just very painful situations.

But when people have capital T traumas, like life-threatening abusive, torturing events, they develop a set of adaptations where they manage those reactivities to that very painful feeling of helplessness and like your life is being threatened by either avoiding or escaping.

And a lot of the symptoms have to do with numbing or become, and at the same time becoming very hypervigilant, to any cues that you could be traumatized again. So, then you get trapped in the trauma because you’re constantly reacting to things as though they’re traumatic. BPD is a very differently organized phenomenon.

It really is rooted in this fundamental instability of self and instability of relating to others. And people who have been traumatized, naturally may have that because of some of the symptoms of PTSD. But BPD actually starts really early.

We know from the longitudinal literature of kids, now a lot of researchers have studied kids in a normal community and seeing how many of them develop BPD or BPD-like symptoms. And actually, there’s a very discernible set of factors that can be identified that put people at risk.

And I wrote about this with some of my colleagues in a paper on the longitudinal course of BPD, what clinicians need to know, but basically the idea that all kids are a little borderline, there’s some truth to it, although those who actually meet criteria stay very high and then become very disabled over time.

But the point being is that all kids they are not born with emotion regulation skills and they do not understand people and relationships automatically. So, as they’re verging into the world and having to deal with lots of people and deal with themselves on their own, they have symptoms of BPD, self-management concerns, relating problems, sensitivity to others.

And then actually once they actually get a hang of it, they level off and then go down. But those who develop BPD, they tend to go higher and then stay higher and then they get isolated from their peers.

And this is why delaying diagnosis and thinking BPD is an insult to people, is really actually harmful, because when they end up just staying high throughout their high school years, college years, the formative years where you start to put down roots in your life, they miss out on all the things that generate personality functioning for all of us.

And that is what’s most deadly for a person who has BPD is keeping them excluded from a pathway to life because they can’t do school or vocational development or a job or volunteer work or domestic work. They can’t do those things because no one’s given them the tools to be able to manage their special sensitivities.

And in light of that, and those people who have BPD symptoms very early on, are at much higher risk to be on disability and disabled by the time most people are in their prime and that is devastating to one’s sense of self.

We’ve written about this in a new book that’s coming out called “Good Psychiatric Management for Adolescents with Borderline Personality Disorder,” that’s coming out this summer.

My colleague Carla Sharp at the University of Houston and I worked on that with a bunch of really excellent collaborators who are all child psychiatrists who have seen these phenomenon and become very skilled in doing basic things that help people like diagnosing it, educating people about what it means and what they should do on a very fundamental level.

Jenn: I know that you had mentioned adolescents, which cues me up beautifully for someone who wrote in saying their teenage sister has BPD and has recently isolated herself and refuses to open up about her feelings.

How can they encourage healthy conversations about emotions and feelings in their home in a way that would both benefit and help her?

Lois: Such a nice sister you are for really wanting to figure out how to be helpful. That in and of itself is going to be helpful. And I would say that first of all, there’s a number of excellent resources.

The webinar is one of them, but there’s also a bunch of webinars that maybe, Jennifer, you can give everyone the information about the McLean webinar prompt on the website, but there’s also this wonderful organization called the National Education Alliance for BPD and also TARA for BPD and Emotions Matters.

There’s all these kind of groups of people trying to promote awareness and provide support for those who have BPD and their families. On the NEA BPD website, John Gunderson wrote something called the family guidelines with a colleague, Cynthia Berkowitz.

Basically, they’re very straightforward things that families can do to adjust to the special needs of a person who is sensitive and has BPD. So, you can kind of reference those guidelines. They’re free and they’re actually in a number of different languages. I know they’re in Spanish and Italian.

My research assistant Evan, put them into Greek. So, there’s a lot of great resources out there. And there’s also a lot of videos you can watch.

So, there are videos on those websites, also Rebbie Ratner has an amazing website called Borderliner Notes where she has interviewed a number of the biggest experts in the world on personality disorders including the developers of all the treatments I mentioned, Marsha Linehan’s on there, Peter Fonagy’s on there, Otto Kernberg is on there and I’m on there actually.

And John Gunderson is on there. And now that he’s passed away, it’s a very special archive of him being him and talking about why he did the work he did. So, you can use all those resources, but what I would say more personally is that just listen, don’t try to change them at first.

If they are isolating themselves, try to figure out why that is and how that makes sense for them in the moment, but also try to figure out ways to be together. That doesn’t involve so much looking at what’s wrong with them.

And I find that when I’m upset about something, if someone came up to me and said, what’s wrong with you? I wouldn’t like want to talk to them either. You know, like, so try to be considerate that they’re just like a human being and figure out like, what would you want in their shoes, if you’re really feeling upset and out of control, and like you can’t communicate well, like what would you want to do?

And just try to work with that and then ask them what they want to do. I think that some people end up walking on eggshells ‘cause they’re terrified they’re going to make it worse but that just makes everybody more uncomfortable. And I think people do that because they’re just trying to keep the tone down. But actually, BPD is actually really characterized by mistrust.

So, if you’re doing something different than what you feel, actually people with BPD are so sensitive, they kind of know that. They can read me BSing them better than anyone else. So, if I walk into the office and my patient is like, you’re angry.

Sometimes I’m like, no, I’m not. Oh yeah, actually I am. Because every time I walk in here, you’re like you’re angry at me, but actually they can sense something before we sense it within ourselves.

So, if you’re anxious and worried about your loved one, which you naturally would be, sometimes they like withdrawal because they don’t know what to do with that. And this is where putting on your oxygen mask first also helps. I hope that answers your question and good luck with that.

Jenn: Someone wanted to know what are your top three tips for people who find themselves having a difficult time regulating their emotions?

Lois: The cheapest skills are about to come your way. Number one is breathing. Now when I started out, I was like breathing is like stupid, anyone could do it. You know, I was very judgmental.

I needed things to be really amped up and fancy. I mean, I’m at Harvard after all, I like am very grandiose that way, but I’ve learned everything and what I think works best are the things that are free.

Breathing actually does something to you physiologically that nothing else will ever do that involves thinking. And basically, if you breathe in certain ways that you’re regulating it, it really helps. Now I’m going to take a diversion to the fact that in my boredom, I got an Apple watch, and the Apple watch tells me to breathe.

And at first I was kind of like, I’m not going to listen to my watch. I’m going to breathe when I want to breathe. But actually, it like regulates your breathing by having a certain number of counts in and then trying to control your counts out so that you’re matching the pace.

But you don’t need a watch to tell you that. You can also breathe, like actually my colleague, Daniel Crump taught me this the other day. If you breathe in and then hum out, That actually grounds you in your body if you’re feeling really disconnected and helps you focus on something. I thought that was genius.

And also, my colleague, Betsy Ressler, taught me this one where you breathe in like seven counts, hold for seven counts and then breathe out eight counts. I probably got it totally wrong mathematically, but basically the whole point is set the number of counts you breathe in, then hold it, actually the hold is very important, and then you exhale.

And then you get a little bit more in tune with your body because there’s this thing called top-down regulation in your brain. And if you’re actually thinking about the things you sense which is the definition of mindfulness, it is going to actually regulate you.

So that’s the free tip number one. Free tip number two is walking. I could have walked to like California during COVID because I walk so much since there’s nothing else to do. And actually, there was a study done with a giant sample. I can’t remember the details of the sample, but it was on depression risk.

And they found that walking in a number of different functions really was more preventative of developing depression than most things. So walking is free.

I understand some people may be limited in their mobility, but walking is something you can do, moving your body in some way that is not going to take too much energy but that puts you in a place where you’re moving and getting fresh air.

The third thing is music. Music is something that has really helped me through COVID because it’s like you don’t feel alone when you’re listening to music.

Like you can think of the words and actually, like I think a lot of singers know what it’s like to be emotionally dysregulated or interpersonally sensitive because all the songs are about that.

And so it really goes to show that sometimes your dilemma is like so universal that someone sang about it or TV, or like one thing I’ve done during COVID is watch a lot of Trevor Noah, Stephen Colbert, Seth Meyers. I don’t like watching the news ‘cause it really makes me sad and upset.

But when I watched them deliver the news it helps me laugh and feel better. So, these are all things we can all do. It’s just a matter of like giving yourself a break so that you can take care of yourself and put on your oxygen mask so that you can get through the emotional challenges of what we’re all dealing with.

Jenn: So, an individual said I find myself having a much shorter fuse than usual and I can’t figure out if it’s stress, manifesting in anger or if there’s something bigger going on.

Is there a good way to manage this greater sense of annoyance and anger that I feel when presented with situations that a few years ago would not have elicited the same response?

Lois: No, I mean, totally can relate to that. I mean, the rage we sometimes feel when we’re in the grocery store and people are going the wrong way. I mean, why do we get so upset about that? I mean, people used to go wherever they wanted to go but now we’re very vulnerable to people following rules because it’s like a public health thing.

So yes, that’s totally normal. But what I would say about it, and this is why I’ve been walking so much and taking such good care of myself, ‘cause I know that these things are going to happen right now because we’re all under various amounts of pressure. If you have family at home, you’re all trapped. Your kids are not getting the social development they need.

They’re in cabin fever, you’re in cabin fever. And there’s a lot of worries about what’s going to happen. People’s livelihood are at stake, their health is at stake. People that they love might be in danger, people they love may have died. So, there’s so much volatility that, of course you’re going to be irritable ‘cause we’re all so sensitive right now to what’s happening in the world.

So, taking really good care of yourself and validating yourself for your difficulties and then talking to people who can validate you because having others verify that you’re okay, that’s like understandable, it’s not nuts or crazy, that helps everybody feel less alone and more self-accepting.

Jenn: Do you have time for two more questions?

Lois: I do.

Jenn: Fantastic. I wanted to get some information in for clinicians too, ‘cause I know we’ve got a bunch in the audience. So, someone said as clinicians, how do we increase engagement and trust with our patients that are struggling with BPD?

Lois: Well, this is a good question ‘cause I’m supposed to give a lecture on this, like in a couple of weeks for the John Oldham Memorial Conference which is all about trust. And what I’m thinking about saying is something really basic because like I was saying before, we have a tendency to make things so complicated and COVID has really forced us to focus and prioritize.

And my thought is to do things about the real lives of patients in a way that really matters to them, not just the things we think matter, you know, we can get caught up in trying to get people to think the way we do, you know, like act the way we do, think the way we think, but in this multicultural, diverse world, that’s not, that’s not tenable and maybe not desirable.

We want people to be able to be themselves and co-exist harmoniously. So, what I would say is you gain people’s trust by understanding what matters to them, helping them towards their own goals which might be different than yours as a clinician.

So, if, ask them what they want, what do you want in life that you can’t have now because of your psychiatric condition? And oftentimes they’ll surprise you. They might say, you know, I want to go to the Olympics and then you ask them like, you mean like as a spectator or as a participant?

And you just listen and figure out like what do you need to do then to make that happen? What are the barriers and the obstacles? And helping them overcome challenges is what helps people feel efficacious and competent. And then they’ll think you’re competent.

If you help them reach the goals they’re looking to reach, then they will feel like they can rely on you. But sometimes the goals that patients have are not compatible with the jobs doctors have, or physicians have because sometimes they may want something for good reason but that’s not what’s in our lane of activities. And I think you also have to accept your limitations about what you can and cannot fix.

Jenn: So very last question is I’m a clinician and I’m curious about upcoming learning opportunities. Do you have anything that you would recommend to do in 2021?

Lois: That question was probably planted by my business office manager about the Gunderson Personality Disorders Institute.

But you know, the exciting thing that happened during COVID is that while I really loved doing clinical work and running clinical programs, I moved to full-time research and running the training institute so that we can support clinicians around the world in doing their best work to de-stigmatize BPD by treating it more effectively.

You can de-stigmatize a disorder by showing there’s a cure for it like rheumatoid arthritis. When they were able to advance the treatments, it prevented all sorts of deformities that then stigmatized the patient. So, the best way to de-stigmatize people is by helping them get better and making it very visible that people can do it.

So, we’re doing lots of courses, we have one actually on parenting because actually patients who are parents or people who face a lot of adversity and stress who are parents, which is like all of us, have trouble understanding our kids and what they’re going through because they don’t have the best communication skills yet.

And they may communicate in ways that upset you or that make you feel frustrated. And being able to try to put that aside and really understand what they’re going through and then also as clinicians help parents be able to understand their child better so that they can be better parents.

That is a greater gift to kids than taking them out of their homes. So that is coming up in a bunch of family intervention courses, but you can find everything on the Gunderson Personality Disorders Institute website, and you can contact us and get on our mailing list via that site. Free advertising Jennifer.

Jenn: Hey, I do what I can, shameless plugs over here. I am happy to do that for you after you’ve provided so much insight and knowledge over the last hour. I cannot thank you enough for just increasingly shedding light on a condition that so many can find overwhelming and stigmatized, but you’ve done such a great job of making it approachable and understandable.

So, I can’t thank you enough for this. And thank you to everybody who joined. This actually ends our session. So, until next time, be nice to one another, be nice to yourself and please do not forget to breathe. Thank you again, and thanks Lois, take care.

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Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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