Podcast: Understanding and Addressing Borderline Personality Disorder

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.

Jeff: Welcome and thanks for joining us. My name is Jeff Bell and on behalf of McLean Hospital, I'd like to pass along our sincere appreciation for your interest in our educational webinar series.

Our topic today, borderline personality disorder or BPD. It is a complex and all too often misunderstood mental health condition. It's also much more common and treatable than a lot of people might think.

Over the course of the next hour, we're going to explore just what BPD is, how it's diagnosed and treated, and how loved ones, educators and clinicians can support someone living with the disorder. Our guest is someone with a lot of expertise in this area.

Dr. Karen Jacob is the program director of McLean's Residential Treatment Program for individuals with borderline personality disorder and other severe personality disorders, including those who experience co-occurring psychiatric conditions. Karen, thanks so much for joining us.

Karen: Thank you for having me.

Jeff: Well, I want to start by asking you to paint the big picture of BPD, if you will. How long has the diagnosis itself been around?

Karen: So the diagnosis was first identified by actually my mentor, John Gunderson, where he wrote a seminal article in the "American Psychiatric Journal" and coined the term BPD based on his experience with a cohort of patients that he found really challenging to treat.

So he kind of came along this population based on his experiences and his interest in a population that felt very challenging. And this was during his own developmental sort of process in his career in 1975.

The seminal article is actually fascinating to read if people have an interest to take a look at that defining borderline patients.

Jeff: So in the greater scheme of things, Karen, this is a relatively new diagnosis.

Karen: It's a relatively new diagnosis and we've learned a lot in the last 50 years about the diagnosis itself. So while it was first sort of identified and coined in 1975, it didn't really get into the DSM until a few years later.

And since the 1980s there's been a lot of work to better understand the diagnosis and the treatment itself.

Jeff: How do you define BPD? Are there certain criteria that need to be met, for example?

Karen: Great question. So the Diagnostic Statistical Manual, the DSM, which is our standard way that mental health professionals diagnose mental disorders and the ICD, the international sort of way that we diagnose personality or any mental health disorder defines BPD according to nine criteria of which five need to be met.

And I could go through the nine criteria, but I actually think it may be a lot easier for people to understand the diagnosis by defining it in a way that I've heard Marsha Linehan define it.

And Marsha Linehan is one of the pioneers for an empirically supported treatment for BPD called dialectical behavioral therapy, DBT. And I can get into sort of the criteria or the areas of interest when you are assessing somebody for BPD.

Jeff: Let's walk through those. You said there are five of them.

Karen: There are five of them. So there's sort of five areas of dysregulation, dysregulated thoughts, dysregulated behaviors, dysregulation in cognitions, so cognitions thoughts, interpersonal dysregulation, and sense of self, and dysregulated emotions.

And each one of those things actually have profound meaning. So I think it might help be helpful to walk through what it means to have sort of dysregulated thoughts.

Jeff: Definitely.

Karen: And I can start by that. So dysregulated cognitions really refers to somebody who has more extreme black and white thinking that can be viewed as polarized. So somebody can view something as all good or all bad.

This is often something that family members or others might see that we refer to as splitting. It's one version of splitting where somebody can be idealized and then devalued and it can contribute to some of the dysregulated interpersonal relationships that I referred to earlier.

In more extreme cases, when somebody displays dysregulated sort of cognitions, you may see somebody struggle with things like paranoia issues of trust in relationships.

Somebody who also has dysregulated thoughts has a hard time being flexible in their own thinking and picking up nuances not only in their own thinking but in other people's thinking.

And these folks may also display a real difficulty in understanding that what's in my mind may not be the same as what's in your mind.

So there may be assumptions made about what somebody else is experiencing because one uses oneself as the reference almost as though it's fact. Rather than acknowledging that two people may have different perspectives on the same issue.

So that's sort of the dysregulated cognitions. Dysregulated, sorry Jeff, go ahead.

Jeff: No, I'm sorry. I was just going to ask you to keep going with that list. So emotions being dysregulated as well as part of this mix.

Karen: Yeah. So dysregulated emotions refers to somebody who really has a hard time not only regulating emotions, but the sort of profile that people experience is what we call high sensitivity, high reactivity, and slow return to baseline.

What that means is somebody who struggles with BPD may be somebody who really is sensitive emotionally to what's going on in their environment and may pick up cues and have stronger emotional reactions.

And once they have those stronger emotional reactions, they have a really hard time what we say is getting back to baseline, sort of a stable functioning emotionally. And this can make life feel really painful for somebody struggling with BPD.

It can make it also very difficult to be in a relationship with somebody who has borderline personality disorder.

This sort of gets into dysregulated interpersonal relationships and I think it might be helpful to talk about that piece, which John Gunderson would say is really a centerpiece of the diagnosis where somebody who really struggles interpersonally has high rejection sensitivity and a real fear of abandonment.

So what you can see in these relationships are people who really are invested in wanting to connect, but so fearful that people will leave them. That there are a lot of desperate attempts to maintain the connection and the relationship.

And it's where people who struggle with BPD may have to show somebody their distress behaviorally. And that may be in the form of self-harm, which can really scare loved ones and often is what is the catalyst behind seeking treatment when a loved one is really struggling with self-harm or suicide.

And often the person is really trying to express their emotional experience and confirm somebody's willingness to sort of hang in there with them interpersonally. John Gunderson would say that's really the crux of the diagnosis itself.

So Jeff, I can also talk about dysregulated sense of self and behavioral dysregulation if that feels, you know, helpful at this point.

Jeff: Yeah, I think I'd like you to do that because we often hear about that dysregulation around sense of self in relationship to BPD. What should we know?

Karen: So dysregulated sense of self is really not having, a real confusion around one's identity, not really understanding one's own sort of thoughts and feelings, values, and goals. And one may present with a real sort of diffused sense of self where they're seeking "Who am I?"

You may see people, especially as they are young adults enter into life sort of aimless and not really being certain about a pathway forward or having real strong opinions based on their own thoughts and feelings.

And part of treatment aims to help people get a clearer sense of who they are. The last area of behavioral dysregulation is, I think the thing that ends up creating much more attention because it's such an overt way of struggling.

And somebody who has borderline that really manifests behavioral dyscontrol is somebody who uses sort of impulsive responses to manage internal experiences or uses behaviors to communicate. So if I'm really feeling alone, I might do something to enlist somebody else and that confirms their care and love.

The behavioral dyscontrol is very concerning because it can escalate to significant self-harm and even suicidal gestures or plans for that person.

So understanding BPD as it pertains to sort of these five areas of dysregulation can often give sort of patients and families a better understanding of what it feels like to either experience struggling with BPD or living or loving somebody who has borderline personality disorder.

Jeff: So Karen, one of our goals with this webinar series is to allow our attendees to ask some questions along the way. And you're getting a lot of questions coming in already. We can tell we're going to be very busy today.

This is a pertinent question here. Does someone have to be dysregulated in all of these areas to be diagnosed with BPD? Are these dysregulated areas interdependent?

Karen: Great question. And the answer is no. You do not need all of these areas to get a diagnosis of BPD. It is also true that somebody who has traits and not a full diagnosis of BPD can really be in pain and struggle.

And what I would say is somebody, whether or not somebody meets full criteria or not, if there's enough distress in that person's life in some or all of these areas, they may be interested in seeking treatment.

I think the second part of your question was are these interdependent? Are these areas reliant on each other? And that's not necessarily.

Some people really struggle with interpersonal relationships and emotion dysregulation, but may actually be in over control, very behaviorally controlled.

So it's not the case where if you meet criteria in one area of dysregulation, you therefore will meet criteria in other areas of dysregulation.

Jeff: We're going to circle back to these criteria in just a minute here. But first I want to ask about the prevalence of b- I'm sorry, with borderline personality disorder.

Are you aware of any statistics that can sort of put this in perspective for us in terms of how common or uncommon BPD is?

Karen: BPD is pretty common, and I think that's another misconception is that it's not common. About 2% of the population struggle with BPD. I would say maybe even more. About 20% of inpatient people struggle with a comorbid diagnosis of BPD or BPD itself.

And about 11% of psychiatric outpatients struggle with BPD. So that sums up to about 14 million people in the United States who would meet criteria for BPD. It's not insignificant.

And the reason I care so deeply about some of these statistics is it in many ways it's a mental, it's a mental health concern.

It's a public health concern where folks who struggle with BPD are self-harming and can be very suicidal. So there's a high risk for folks not getting diagnosed or treatment for borderline personality disorder and especially, you know, when they're actively struggling with it.

Jeff: What do we know about potential causes, whether environmental or genetics or brain abnormalities?

Karen: Great question. So I like to lean on Marsha Linehan's biosocial model of BPD. I think it's a nice way of describing the interface between biological and environmental factors of BPD. There is a loading, a biological loading for folks who eventually develop or are diagnosed with BPD about 50%.

And the other part is environmental. Linehan describes the biological piece plus what she calls an invalidating environment. So an environment that responds to internal emotional or thought cognition's cues as one of the influences to eventually receiving the diagnosis of BPD.

And what that actually means is, and what sort of my patients would say is there's a biological piece coupled by what's called an invalidating environment that can yield BPD. And what an invalidating environment looks like is actually very important.

People I think use the term but may misuse it at times. And invalidation is really even well-meaning loving either caregivers, friends, teachers may respond to somebody's internal experience in an invalidating way.

So an example I often give people is if you're in the car with your parents and you're a little kid and you stop to get something to eat, you get back in the car and 10 minutes later the child says, I'm really hungry, I'm starving. We need to get something to eat.

And a parent may say, you're not hungry, you just ate. Right, that seems like a very reasonable response. For somebody who's sensitive to external cues, this may mean to that person, huh, am I hungry? Am I not hungry? They may start questioning their internal experience.

And when you get into the emotional realm, it can be very confusing for somebody without a consolidated sense of self where they're sort of seeking that validation, that confirmation from their external environment in order to confirm like, oh, it's reasonable for me to be hungry.

Maybe it is, maybe it isn't. But there's some level of understanding that somebody's experience needs to be sort of acknowledged at some level.

Jeff: We have a number of age-related questions coming in. Let me just couple these together here. How young can someone be diagnosed with BPD and can BPD start in your 30s?

What age do people typically get diagnosed?

Karen: These are all wonderful questions. So, and BPD was initially thought to be a real adult disorder, which was not diagnosed until about the age of 18.

My colleagues and I would say that you can actually diagnose BPD earlier and often seen in sort of later adolescences and mostly actually when kids try and take flight and leave the sort of nest of their house.

So we often see people who receive the diagnosis on the heels of going to college where they're needing to be a bit more independent and forge their own pathways, have a little more sense of self, feel sort of safe and connected in their relationships and kind of can explore this new environment and take on that responsibility.

When people struggle in those areas, it's kind of like they unravel and all of these areas that I referred to earlier become more pronounced. So we often see people get diagnosed around that time.

And then I would say just anecdotally, we often see in my residential program people who get diagnosed in midlife, when kids kind of leave the home and they're left to sort of forge the pathway forward where their identity isn't tied to say parenting in some way.

Jeff: And teasing out the impacts of therapy, which we're going to talk about. Is there a natural waxing and waning of the disorder over the course of time?

Karen: So BPD is a disorder interestingly, that will improve as you age for the most part.

So if you struggle with some of the areas of dysregulation that I referred to earlier, by the time you're my age and you're sort of midlife, your symptoms settle down, you sort of have learned how to deal with some of these intense emotions, behavioral reactions and worlds has somewhat shaped you and you've kind of gotten tired really over time.

So there is this natural resolution over time. Now this is the problem. For the most of us, we develop meaningful relationships in our 20s, we find our partners in our, you know, 20s and 30s.

We start building families around these times. We identify a profession and when you're struggling in these areas of dysregulation during that time in your life, it makes it very hard to have stability in your professional career, in your relationships.

So you might feel a lot better when you're in your 50s, but you've sort of missed a very critical time in your life where you're building your life.

So an early diagnosis and treatment can actually be really helpful so people can work to reach whatever goals they have for themselves in their life.

Jeff: It's a perfect segue to my next topic, which is diagnosis and assessment itself. Are there specific assessment tools that professionals use?

Karen: So there are tools that one can use to diagnose BPD. There are things like what's called the SCID, which is a structured clinical interview to help with diagnosis in the DSM. There's also things like the MMPI, which is a self-report assessment.

The most effective and I would say accurate way for somebody to receive a diagnosis is through a clinical assessment ideally by somebody who has some specialty or has some knowledge of personality disorders.

So if somebody thinks that they may be struggling with this or a loved one may be struggling with this, I often get this question and I think a very important next step is getting a comprehensive assessment to suss out is BPD active or not?

Jeff: From what I gathered, there is often some confusion with BPD and complex PTSD or bipolar disorder for example. Can you speak to that?

Karen: Absolutely. It is very common for somebody to look like they're struggling with a particular diagnosis. Bipolar is often misdiagnosed where borderline may be the primary and perhaps only issue going on.

And that's really because what you see in somebody with bipolar are these very rapid shifts in moods. You might see irritability, depression, anxiety. As a result, there may be some of the interpersonal challenges, but bipolar and borderline require different treatment interventions.

So if somebody struggles with bipolar disorder, the primary treatment intervention is medication management. For somebody with borderline personality disorder therapy is the primary intervention.

So it's really a different trajectory moving forward for treatment itself and one can have a comorbid diagnosis for bipolar and borderline. So what we may see is somebody who is diagnosed with bipolar but continues to struggle.

And the questions we have to ask ourself is this somebody who has both bipolar and borderline or is this a misdiagnosis? And the real issue is borderline.

Jeff: We had a very specific question come in around this, how does complex PTSD play into BPD characteristics? If you deal with your trauma, will your BPD characteristics lessen?

Karen: So let me start by saying one of the main differences between complex PTSD and BPD is that somebody who has a diagnosis of BPD doesn't necessarily have trauma in their life. So just based on that alone, we can sort of look at the different trajectories.

There's a lot of overlap in what you might see as the sort of symptoms of both complex PTSD and borderline because somebody who has complex PTSD also struggles in some of the areas of dysregulation that I outlined earlier.

Differential is actually really important to look at and some of my colleagues have done some more sort of research on this topic, but I would say as a just a basic more simple response, somebody with borderline does not need to have trauma in order to get a diagnosis of BPD and many don't.

Jeff: How does substance use disorder affect BPD?

Karen: Substance use disorder and BPD can go hand in hand. So when I see folks who struggle with BPD, it's almost like a unicorn if somebody comes in only with borderline personality disorder. We often see people who have comorbidities of what I call axis one disorders.

So that might be a mood disorder like depression or anxiety. It might be a substance use disorder, it might be an eating disorder.

When you have an eating a substance use disorder alongside BPD, the challenge is not just the chemical addiction if it's a true substance disorder independent of BPD, but when any one of us uses substances, we become a little less able to manage ourselves a little more uninhibited.

So if you're somebody who is prone to having dyscontrol behaviorally, then you can see the real challenge with adding substances into the mix where substances may make people a little more unhinged when it comes to some of these criteria.

What I often say to folks who struggle with both is that the first thing that needs to be treated is the substance use problem. So if you're somebody who struggles with both or you know somebody getting sober for at least 30 days is actually an important first step before seeking at least intensive borderline treatment.

Because treatment would be very sort of limited if somebody's actively using while also seeking active intensive treatment for BPD.

Jeff: Let me squeeze in one more question about co-occurring disorder. Social anxiety disorder, one of our viewers would like you to speak to the coupling of that with BPD.

Karen: So we see social anxiety, lots of anxiety disorders, and often what we have to ask ourselves is, is this social anxiety or is this interpersonal hypersensitivity?

They may look alike, the treatment may not be super different from each other because ideally, whether you're dealing with social anxiety or you're dealing with somebody who's incredibly interpersonally sensitive, what we really want to help people do is like some kind of exposure of those interpersonal sensitivities while trying to understand what's going on sort of in their mind.

And challenging those fears in social relationships to help them become a little more flexible in their thinking and a little more nuanced not only in their thinking but also being able to hold what's going on in their mind separately than somebody else's.

Because often social anxiety is about fear of being judged, fear of what other people think about you and it makes it very hard to build relationships when somebody's really struggling with that level of social anxiety.

Jeff: We've covered a lot of ground in terms of the professional assessment and diagnosis of BPD, lest it be too overwhelming for a lay person in the audience who is concerned about a loved one.

Bring it back to the real foundational basics here. What should I be looking for in a loved one with BPD? That would be a flag that maybe I should get some professional assessment.

Karen: You know, it's interesting when you, if somebody is thinking somebody is really struggling with BPD, it's worth getting that extra professional assessment because what you're probably noticing is somebody who really struggles with their own capacity to communicate through words and not actions.

You may see somebody who's more behaviorally communicative or self-harming. That's actually one of the reasons that people often seek treatment or suggest treatment for a loved one is because they're worried about the person's safety.

The other thing that activates somebody to seek treatment is when there are a lot of relationship problems. So you're in a relationship with somebody but it's filled with a lot of tension and angst where you might feel like you're walking on eggshells where anything you say can sort of cause the other person to explode.

There's actually a book called "Walking on Eggshells" and it's about BPD and I often tell families it's helpful to read because it's very relatable for families or loved ones who are in a relationship with somebody struggling with BPD. It's like anything you say could set them off.

So you notice being really careful around them or trying or being overly worried about their safety and wellbeing and those are real good signs that something needs further inquiry.

Jeff: Let's talk about treatment. I know there's a lot to talk about on this front. DBT, we often hear DBT associated with BPD. Lots of acronyms here, but why don't we start there?

Karen: So dialectical behavioral therapy, which I referred to earlier, which is Marsha Linehan's empirically supported treatment for BPD is probably the most well researched though I will say there are other empirically supported treatments that are kind of right behind it now.

But Linehan really developed this treatment in the '80s, right after John, several years after John sort of coined the disorder itself. And DBT is a treatment that really looks at cognitive behavioral therapy plus acceptance/mindfulness.

So sort of a Buddhist approach of accepting life on life's terms, life as it is, accepting oneself as they are, while also marrying that with change. So what can be changed and what do we look at in a cognitive behavioral orientation that's really about change versus what is it that we can't change and what do we have to accept?

And those two pieces are the core of DBT. There are five modules that are, that encompass DBT. There's an interpersonal module, a mindfulness module, emotion regulation module, a distress tolerance module, and an interpersonal module. And these different modules outline sets of skills.

So for example, interpersonally, there's a set of skills that helps people identify their own sort of needs and wants or learn how to say no. That's sometimes very hard for somebody who struggles with BPD.

In distress tolerance there are a set of skills that helps people learn how to regulate kind of in a crisis. Emotion regulation, there are a set of skills that help people learn how to plan ahead, like these are certain situations or my life in general needs some form of structure that can be active in advance, so I can work on regulation before anything activates me.

I can be sleeping and not taking, you know, illicit drugs. I can be sort of minimizing what's called my vulnerability factors. And then there's mindfulness being present to the here and now, being present in a non-judgmental way where you sort of take one thing at a time.

Jeff: So that's DBT. Are there other treatment approaches that are also used for BPD?

Karen: There are several other treatments. Probably the ones that are most well-known include mentalization-based treatment, which was developed by Peter Fonagy and Anthony Bateman in England.

And that's a treatment that is, oh, I should say DBT before I move on. DBT is actually sort of used to be like a standard treatment for BPD up until the last couple years where these other empirically supported treatments have kind of caught up.

The thing about DBT is it's pretty intensive, so it's multiple times a week and it's a group, there's also a group therapy session where people are learning skills, so skills-based. Additionally, it requires the clinician to go through pretty intensive treatment to make sure they're adherent to the model.

MBT, mentalization-based treatment is different not only in terms of its orientation, it's really a relational, a little more psychodynamic, approach that's really based on helping somebody understand their mind, their thoughts, their feelings, while also considering somebody else's mind thoughts and feelings at the same time.

And that treatment takes a lot for clinician less time to learn in terms of training, but also requires less from patients on an outpatient basis. With something like DBT, therapists are often available for coaching in between sessions.

For something like an MBT therapist, that is not the case. Maybe it might be the case, but most likely not, it's not part of the treatment sort of organization.

There are a few other treatments for empirically supported treatments for BPD, one of which is transference focused psychotherapy, which was developed by Otto Kernberg and that's much more of a psychodynamic approach based on what's called object relations.

And it's really focused on looking at splits in sum in psychology, that thing I mentioned earlier, the ideal versus the devalued where somebody who has BPD can really flip from one to the other.

Another book that I can mention is, "I Hate You Don't Leave Me." And that sort of encompasses the same sort of psychic split that somebody can manifest. And TTFP is very much based on these splits to help somebody hold various parts of themselves at the same time and learn how to integrate all of those pieces.

It's a longer treatment and there is like no contact in between sessions. And there's a frame by which a patient agrees to as they enter into this kind of therapy.

Jeff: Generally speaking, these treatments, are they done outpatient as part of partial programs or residential programs or a combination of all the above?

Karen: There are different levels of care. So most people that struggle often enter treatment through an outpatient basis where they, my hope at least for them is that there is a way in which they enlist themselves with a mental health professional that can accurately assess the problem.

And many of these treatments are well done and done on an outpatient basis. In fact, all of the treatments I just mentioned are outpatient. One can pursue higher levels of care. Those higher levels of care, I would say tend to emerge when somebody really can't make use of outpatient or when they're in a more of a crisis or at risk of self-harm.

So they need additional supports which residential programs can provide a program like mine where there's around-the-clock support and containment so the person can do the work of DBT or MBT in more of a contained supportive setting.

One of the things I didn't mention about empirically supported treatments, John Gunderson prior to his passing, developed a treatment called GPM, good psychiatric management, or general psychiatric management.

And one of his real desires was to educate mental health professionals across the world. And he and his, many of the his colleagues, my colleagues, went to places all over the world to offer free training in GPM.

And the point of GPM was to train sort of the average mental health professional psychiatrist/psychologist in personality disorder, specifically BPD, to give certain pointers and pieces of psychoeducation that would allow general practitioners to treat borderline personality disorder without having to go to expert care.

So more affordable, insurance could pay for those kinds of interventions. And so that GPM model continues to be thriving and alive.

Jeff: Let me tap into our viewer question bag, if you will here. What medications are used for BPD and what symptoms does the medication address?

Karen: Great question. So what we would say is medication management is not the primary intervention, generally speaking for borderline. That's said, so when somebody comes to a program like mine, we actually try and minimize the number of medications because we know that that's actually not going to be where the money is for that person.

That said, there are medications that can be helpful. Often those are medications that may help with somebody's sleep or mood stabilizers. So mood stabilizers differently than like lithium, which is often the standard of care for bipolar.

Things like Abilify that are more like mood stabilizers and hit different receptors and can help with sort of containment of these more extreme emotional experiences that somebody with borderline struggles with.

Jeff: A viewer asks how can a family member assist someone who is refusing treatment?

Karen: That's painful. So I first, my heart goes out to folks who know that a loved one is struggling, even a loved one knows, but they really struggle getting treatment.

The one thing families can do, depending on the severity of the problem is continue to sort of be available when the person's ready to seek treatment. But in more extreme cases, one may have to set some limits or boundaries.

So we often hear from families who have grown adult children that are highly dependent or have a hostile dependency. So there's a lot of tension in the relationship yet the adult child is very dependent on the parent is to sort of set limits around accessibility, around financial support.

And sometimes that can allow the person to have to contend with themselves in a way that may eventually motivate them to seek treatment. There is one site that families may really benefit from, it's called "Family Connections."

It's a site that Perry Hoffman developed years ago for families of somebody struggling with BPD. And that offers webinars, it offers free information and there's actually different trainings that are run by families who have been through trainings for other families.

So there's sources of support for family members who are struggling with somebody who has BPD.

Jeff: Talk, if you would, about post-treatment expectations. What can someone with BPD expect after they've been through some treatment?

Karen: So I'm doing a lot of quoting John Gunderson, but this is one of those areas as well is John would say somebody who has BPD will rise and fall based on your expectation.

Jeff: Hmm.

Karen: So as a clinician, if I am seeing somebody with BPD, I'm going to aim for the highest level of functioning for that person. Not out of matter of just because, but because many people who have BPD and receive treatment, get better.

You know, 85 to 90% of people who in studies who received DBT after two years are looking pretty good and sometimes do not meet criteria anymore for borderline.

Now what, when I say that and I say this to my patients, we're not going to take away your emotional sensitivity that's a little biologically based.

You may always be somebody who's more emotionally sensitive, but your understanding of why you're emotionally sensitive and what you do with that becomes more understandable for you and more relatable and more stabilized in a less problematic way for you, but also for those around you.

So what I would say to somebody is many people can go through treatment for BPD and live a very fulfilling functional life when they finish treatment.

Of course that's not always the case, but there are a couple things that can really help, one of which is getting a job and learning how to participate in that job, learning how to take ownership and autonomy over that experience, building some close relationships and having those relationships really stabilize over time.

Jeff: We have so many questions coming in for you Karen. Let me just see if I can squeeze a few more in here. Is there any evidence to show that children with parents who are diagnosed with BPD are more likely to develop BPD themselves?

Karen: So there is that biological loading of about 50% that you can see borderline in families. So there is that higher likelihood.

However, when parents, a parent who struggles with BPD, when those parents are really aware of their own vulnerabilities in these areas and seek treatment themselves, I am, it's a little bit of a protective factor to allow for a different environment that might be helpful.

Now that said, I think one of the myths, and Jeff, you and I were talking about this earlier of BPD, is that it's a parent's fault if somebody has BPD and that's really just not the case.

Often I meet parents who are very caring and loving and invested in their child and they may contribute to an invalidating environment, they may not contribute, but it is not their fault if their child struggles with BPD. However, they can be part of the solution.

Jeff: I'm so glad you mentioned myths because we were talking before the webinar about all the misconceptions about BPD. Let's run through some of the other ones. What are some of the more common myths about BPD?

Karen: So one myth is that this is a problem for women that most women struggle with BPD, but men do not or not as much so. And what we know now, early on BPD was diagnosed almost three times more so in women than men.

But what we're seeing is it looks like it's actually more equal than people had originally thought. So part of the reason for the difference in the prevalence of diagnosis is that more women actually seek help than men.

And what I would say is many men who struggle with BPD from my anecdotal and clinical experience end up looking like they're really struggling in other areas, for example, substance use or anger problems. They may even land them in jail.

So it's not the case that this is a disorder for one sort of, one slice of the population. This is really something that is very prevalent across all walks of the human race.

Jeff: It seems to me that there is sort of this notion that BPD is not that treatable, and yet what you're describing today, it sounds like it can be very treatable.

Karen: It is very treatable. And I think where that myth comes from is early, early on when folks would get a diagnosis of BPD.

Not only is there a stigma attached to that diagnosis, like mental health professionals don't want to treat somebody with BPD, people who have BPD are manipulative and controlling. They'll kind of ruin the clinician's life and they won't get better anyways.

That's just not accurate. So people with BPD do struggle interpersonally and emotionally.

When you as a clinician understand those problems, it becomes much more manageable and treatable not only from a clinical, the clinician's perspective, but they can actually be very helpful guide and provider for people struggling with BPD themselves.

BPD is very treatable on an outpatient basis. Years ago in the '80s, '90s, you'd see somebody who have a, who had a diagnosis of BPD and they'd be in an inpatient unit for months if not years.

And so what we can now know is that this is a disorder that's very treatable on an outpatient basis. The earlier that you know that it's there, more likely you can intervene effectively. And the prognosis is quite good.

One, I run a residential program for folks struggling with BPD and it's based in a community and that was actually very intentional that John Gunderson was sort of spearheaded the, this residential program that I run now.

And his real goal was to sort of take people out of these inpatient months and years on end treatments, offer residential treatment that allows somebody to reintegrate into the world and really develop a life worth living.

Jeff: A question about the mechanics of BPD and how it works. Can you explain what triggers or activates the disorder itself?

Karen: That's a great question. I don't think I can pinpoint one thing that would trigger or activate. What we do know is that there are these components that together really contribute to the likelihood of somebody receiving the diagnosis.

Somebody who is receiving the diagnosis, I would say though interpersonally is incredibly sensitive. So we're always kind of as a clinician in this field is I'm always sort of looking out for those interpersonal vulnerabilities and that piece where there's like a divorce.

Whether it's in a friendship divorce or a partnership divorce, those things can really trigger somebody's sort of flourishing in all BPD symptoms. So, of course any one of us would probably be saddened by the breakup of a close friend or a partner.

But somebody who has BPD struggles in a particular kind of sort of more extreme way where their emotions are very high and their reactivity is very high and their ways that the reactivity is high is concerning and often self-harming.

Jeff: I want to ask you to provide some specific practical tips for people who support someone, a loved one for example, or a student with BPD. And this question came in, can you give some guidance for family members to rebuild a relationship to safely include our loved one with BPD?

Karen: So family therapy is quite important and it is often welcomed by somebody struggling with BPD because then some, I've often heard this, I'm not necessarily the identified patient, we all are.

And I would say that somebody who has BPD is in a system and the system itself can benefit from psychoeducation and therapy.

So if it's possible to enter family therapy where there's a level of psychoeducation and understanding of the disorder in general, how the disorder manifests for that particular person and then different ways of understanding and relating to each other can really bring a family together in ways that they, that they initially felt me might be unimaginable.

I've had people come into our program and as a family therapist I've had patients say to me, I refuse to do family therapy, my family will not change or it's their fault.

And we really want to reorient to not blaming anyone, the person or the family, but inviting families in when they can really get some good information about the disorder and where they can learn how to have a kind of a different language with each other and connect on a very different level.

Jeff: Here we often have a lot of providers, clinicians on these webinars and I want you to speak specifically to someone who is watching right now who is a professional and is looking for some guidance as to when it's appropriate to refer out as opposed to address this work themselves.

Karen: I think if somebody is treating somebody with BPD, I would highly recommend some training in at least one of these empirically supported treatments. GPM is probably the most accessible.

It's sort of easy to be trained in it, meaning it's a one, sometimes two-day training. There are books that clinicians can read. Lois Choi-Kain has written some books as well recently who is one of John Gunderson's close colleagues.

And those books or trainings would be really helpful. What I would say to clinicians who don't have a particular expertise in BPD to either get their own consultation with a colleague that isn't more of an expert in the field or to refer to somebody who does know how to treat somebody with borderline.

What we do know is that if you are really struggling with a primary diagnosis of BPD and you enter into a treatment without that knowledge that the person struggling with BPD or one of these sort of ways of treating somebody, people can get worse, not better.

Well-meaning clinicians can provide lots and lots of support and that can actually reactivate things like dependency or the clinician to go above and beyond for that person.

And those are kind of these areas that as a BPD clinician we're trying to not do. so unintentionally undermine treatment that could be more productive and helpful for that individual.

Jeff: And let me ask you to speak directly to educators as well. What would you like to see school systems and teachers and other faculty members train in to be able to better recognize BPD on campus?

Karen: So this is such an important issue because there are many kids and often in high school that are really, really struggling with mood disorders and maybe BPD that feel really alone and don't know how to manage, don't know what they're feeling, don't know how to manage their emotions.

Across the board my wish would be for something like a DBT protocol or at least awareness of emotions, what they are, how to identify them, and some basic emotion regulation skills to be introduced early on, kind of like we do for anything else, the sciences, physical education.

There should be something like emotional education early on where kids and later adolescents can learn what are my emotions, how do they feel and how do I talk about them and how do I regulate myself in a way that is actually productive?

Jeff: We go back to the viewer questions here. A lot of questions have come in about BPD and ADHD, whether confusion between the two or co-occurrence of the two. What can you tell us about that?

Karen: So BPD again is one of these disorders that usually does not stand alone and ADHD is often, you know, associated or can be associated with BPD. They are very different problems.

ADHD is more of a neurological issue that would need a neuropsychological assessment to really formally be diagnosed. We often see folks who come in say like on a stimulant with ADHD, but they don't actually really have necessarily ADHD.

Sometimes they do, sometimes they don't. So what I would say to folks who are curious about this is that if you have not had a neuropsych assessment, that would be an important critical step to really actually determine whether you are struggling with ADHD to begin with.

And then the treatment would actually look quite different. So treatment for ADHD is really stimulants or biofeedback.

Jeff: You have mentioned a number of resources along the way today, a couple of books for example, I want to ask you to put out for our viewers anything else that they should know about websites, books, organizations, any place that you might point them for additional important information.

Karen: So some of these resources are really helpful. The first I would say is McLean. McLean has great webinars from really expert clinicians on BPD. It's a fabulous resource that I would encourage people to look at.

Family Connections is another place for families to look for resources, as I mentioned earlier, through webinars and other sort of psychoeducational materials that they offer. Emotions Matter is another resource for folks that they can look into.

And then there are a couple of books. So for clinicians, if clinicians are interested to sort of understand more about BPD, there are some standard textbooks. My colleague Brandon Unruh and Brian Palmer wrote a clinical guide where I feel like it's very user-friendly.

It's based on a lot of case examples of people struggling with BPD and different sort of pointers for clinicians to use if they're treating somebody with borderline.

And then there are some other books that I mentioned that are really, I think, helpful.

More than what I'm mentioning now, but things like "Walking on Eggshells" or "I Hate You, Don't Leave Me." Those are really good resources that are easy reads for families when their loved one is struggling with BPD.

Jeff: So Karen, we have covered so much ground today and you've done an amazing job running us through all this information. What haven't we gotten to, in the final couple of minutes we have left here?

What do you want to leave people with when it comes to identifying and treating and addressing borderline personality disorder?

Karen: What I would say is that BPD is more prevalent than people realize that when you, it's kind of like where there's smoke, there's fire.

When you see something and you're really concerned about it, it doesn't hurt to get a more formal assessment early on because early intervention does matter and can really help people earlier, earlier on in their life, reach their own identified goals when they are, when they're able to actually engage in effective treatment that might be really helpful.

For clinicians, what I would say is that it's very treatable and there are resources and trainings that can help clinicians become more adept at treating somebody with BPD. But I always say if something isn't working that it doesn't hurt to consult with an expert in the field or to refer.

And those are two really important things because when we, sometimes, when I eventually see a patient who's been struggling with borderline for a long, long time and they haven't really received an accurate diagnosis.

And they finally get to a proper diagnosis and treatment, there's often a lot of hopelessness from various attempts to get the help they need, but to no avail. So those are the, I think, the take home points.

Jeff: Karen, I want to thank you again for being our guest today. Phenomenal job. We very much appreciate not only your time, but your commitment to helping other people.

Karen: Thank you for having me.

Jeff: For those of you watching, thank you for your interest in our educational webinar series. We hope you'll come back for our future sessions, and we wish you a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

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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