HealthyGamerGG - Borderline Personality Disorder 101

Episode Date: December 22, 2022

BPD 101 Learn more about your ad choices. Visit megaphone.fm/adchoices

If I want this person to like me, what I'm going to do is I'm going to pretend to be into the stuff that they're into. Right. So if this person is into metal bands, I'm going to pretend to like, oh, I love metal too. So you kind of become this chameleon in life where you don't have your own joys, preferences, desires. You kind of adapt and absorb the desires of other people. All right. So let's talk a little bit about borderline personality disorder today. So borderline personality disorder, I think, is one of the most misunderstood and stigmatized disorder. out there, a couple of the most common misconceptions are, first of all, borderline personality disorder is like permanent, right? Because when we think about certain illnesses, these are things

that happen to you. So something like anxiety is something that happens to you and hopefully with treatment or therapy or medication can be cured. But when we talk about personality disorders, like borderline personality disorder, narcissistic personality disorder, we think about these things as part of your personality, which means if they're part of your personality, you're kind of screwed because it's like who you are. So that thankfully isn't true. The other big thing about borderline personality disorder is that these people tend to be stigmatized very, very, very heavily. So sometimes it's very hard to form and maintain relationships. People with BPD are oftentimes viewed as manipulative and very like prone to doing things like lying and stuff like that will be sort

of very like emotionally contentious. And the last thing with BPD is that they tend to be very poorly characterized in media. So if you look at things, like the crazy ex-girlfriend. This is something that's usually viewed as like BPD. So what I'd love to do today is talk to you all a little bit about what BPD looks like from the outside. So what other people see when they look at someone who has BPD, what BPD feels like on the inside? So what are sort of some of the subjective experiences of people who struggle with BPD? We're then going to talk a little bit about the formation of borderline personality disorder, i.e. where does it come from? Is it genetic? Is it in your brain, is it controllable? Is it psychological? And then we're going to end with sort of talking a little

bit about treatment and prognosis. So are there treatments for BPD? Do they work? What can I expect if I have BPD? So let's start first with talking a little bit about what does it look like from the outside. So people with BPD tend to have, there are three sort of big things that people tend to see with people who have BPD. The first is a pattern of unstable relationships. So what this sort of means is that people with BPD can become really, really good friends with other people, like very quickly. They can sort of fall into something like, oh, I've never played guitar, but like now I'm going to join a band and I'm going to play guitar and we're going to go touring like for three months all over the U.S. And it's going to be fantastic. We're going to go over the world.

So they can fall into things really quickly. They can also like fall into romantic relationships really quickly. Like I met this person a week ago and now we're talking about moving in. The problem is that these kinds of relationships tend to be really unstable. So it's very, very high octane, high speed, but also like things crash pretty easily. Yeah, I moved out of my apartment. I bought a guitar. I've been touring for a month and now there's all kinds of interpersonal conflict.

Or I moved in with this person two months in and now we're fighting all the time. So they tend to have a, what people sort of see from the outside is that this person, it's hard for them to maintain stable relationships over time. The second thing that we tend to find is that. that they have, if you look at this person, what you're going to see is strong emotional reactions. So this can be very frustrating from a relationship standpoint because if you're in a relationship with someone with BPD, romantic, platonic family, or any of the above, you may find that small things that you do will evoke strong negative reactions. So for example, like, let's say

you forget a friend's birthday. And then what's going to happen is the friend will get really, really upset with you. And they'll start like doing all this weird kind of stuff where they're like, you ask them, hey, what's wrong? And they're like, oh, nothing's wrong. But you can tell that something's wrong, but they kind of like won't communicate it to you. So you'll see strong emotional reactions. Like if you get the wrong birthday present, maybe they'll sort of explode. Or what you'll kind of see is that they're, if you start to pull away, if you don't talk to them quite as much, like they'll start to engage in a lot of what feels like manipulative behavior or guilt tripping or gaslighting to try to get you to kind of re-engage.

age. If you're friends with someone who has BPD or maybe you experience this as well, sometimes there will also be like benign things that will cause you to feel really, really, really angry or really, really ashamed of yourself, or really, really guilty, that there's essentially a strong emotional response. The last thing that we tend to see kind of from the outside of someone who has BPD is that this is someone who may not really understand entirely who they are. They get really excited about stuff, but they don't seem to have a consistent trajectory in life. They may get excited by particular things very easily. But if you sort of ask them, like, who are you? What do you want from life? Sometimes they'll be able to give you answers, right? They'll say things like,

the only thing I want from life is you. I just want you. I just want you. I just want you. But that's not really, that's not them, right? They sort of almost have this distorted sense of self-image. So that's sort of what borderline personality disorder can look like from the outside. Once we move to internally, so what is the subjective experience of people with BPD? So the first is that they tend to have a fear of abandonment. And what that sort of means is that if you have BPD, what people with BPD are oftentimes afraid of is screwing up relationships. They're really, really afraid that, like, if I say the wrong thing or if I do the wrong thing, that I'll drive this person away. They really do believe, like, people are going to leave them. People are waiting to leave them. People are looking

for any kind of excuse to leave them. And if you have those kinds of thoughts, like, oh my God, like, this person is looking for an excuse to break up with me. We've been dating for six years. and since the third month, they've been looking for an excuse, they've been looking for an excuse. That's what your subjective experience is like if you have BPD. And so oftentimes what it feels like is that relationships are incredibly, incredibly stressful because you're walking this tightrope of if you seem too clingy, they're going to break up with you. If you seem to stand offish enough, they're going to break up with you. And this isn't just, we're sort of using romantic examples here, but this is also in like family relationships.

So if you have like a parent-child relationship with B. This is the kind of thing where your parents are terrified that you're going to leave you. Or you're going to be terrified that your parents will, you know, marry someone else and then, like, abandon you. And they're going to be like, they're going to have stepkids and they're going to love their stepkids more than they love you. Or if you're the parent, you're afraid that your kids are going to leave the house and then they'll never call you again. They hate to come home for Christmas, which oftentimes happens, right, because you use them to meet your emotional needs, which we'll get to in a second. So what we sort of see is that there's a fear of abandonment. subjectively what that feels like is sort of a fear that you're going to screw up relationships

and that these people are going to leave you. The other thing that's really interesting about the subjective experience of people with BPD, and this is something that I think we really lack compassion for because some of the behaviors that people with BPD exhibit can be so frustrating is that their internal emotional experience hurts so fucking much. So people with borderline personality disorder, their experience of life can be incredibly painful. So I want you all to kind of think about it this way where like I can rip a band-aid off and that's like it hurts for a few seconds like maybe it hurts for maybe 10 seconds and it's like a six out of 10 pain but if I've got BPD the pain signals of life especially emotional pain are actually amplified so things like

breakups will actually like almost in an objective way we're talking about subjective but if you kind of rate the emotional pain from a breakup and if you if you take two people one person with BPD one person without BPD. It'll hurt way more for the person with BPD. So it's almost like their nerves are on fire when it comes to emotional pain. So it can almost be really confusing for people with BPD because they recognize that this life feels harder than what my other friends are kind of going through. That I've had three friends. They all, let's say, went through a romantic breakup and they're able to bounce back after like two to six months. But one year later, I'm still feeling so, so, so hurt over this kind of thing. And this sort of complicates relationships because what ends up

happening is that I don't get over it, right? So I'm hurting. And normally like two months after a relationship, people give me a lot of support, but then they get tired of it after four months, five months, six months, eight months. And so then what ends up happening is that like people stop supporting me emotionally because I kind of need more emotional support because it actually hurts more than the average person. The other very common experience in BPD is subjective feelings of emptiness. So this is where we kind of like, you know, you kind of feel like empty on the inside. Like you don't really know who you are. You don't really know what you want from life. A lot of times, the goals that you set are just to get rid of the pain. It's not necessarily moving towards

something. It's moving away from something. So what I really want is I want to get rid of this loneliness. And I'm even willing to get back together with my abusive partner because unless they're around, I feel really untethered in life. And I feel kind of empty on the inside. I don't really know who I am. The last thing that oftentimes happens with people with BPD is that they'll sometimes dissociate or disconnect from life. And this is probably a neurologic coping mechanism

where since there is so much pain that we experience subjectively, and we'll get to the neuroscience of why this happens in a minute, what they end up actually doing is like detaching or dissociating from that pain and they kind of feel disconnected. And if you kind of think about it, that relates to the feeling of emptiness. because the more that I disconnect from myself, the harder it is to discover who I am. So in terms of the subjective experience of BPD, the four kind of most common things that I've

seen as a clinician, first is a fear of abandonment. Second is just really intense emotional suffering. Like, as a clinician, I think my patients with BPD emotionally suffer more than the ones without BPD. And I know that's sort of a comparative statement. And I'm not saying that someone who has severe depression or schizophrenia and psychosis suffers more than someone who has BPD. but I mean on average, the normal experience of life if you have BPD is more painful than not having BPD.

There are also a lot of feelings of emptiness and some amount of dissociation or detachment. So what this sort of results in is when you take these two kinds of things, like these internal feelings, what this results in is a number of different behaviors that BPD, people with BPD engage in. So as I'm going through life, afraid of abandonment, feeling empty on the inside, feeling a lot of emotional intensity. In order to cope with that, I'll engage in certain kinds of behaviors. And this is really where the disorder part really comes in

because the more that we see these kinds of behaviors, the more outcomes get worse for people with BPD. So the first thing that they tend to do is engage in impulsive behaviors. Right? So this goes back to the like, I'm going to fall deeply, deeply in love with this person because I'm going to feel such an emotional high hanging out with them. This is the best person.

even though my last 10 relationships have been train wrecks, this person feels different. This person truly loves me. This is real love. This is what everyone's talking about in the movies. So I'm going to move in with them. So we see a lot of impulsive behavior. There's also high correlations with eating disorders in BPD.

We also see self-harm behaviors, which I think are really interesting because self-harm behaviors aren't always suicidal in nature. This is something that a lot of people don't understand. Self-injurious behavior and suicidal ideation are not always the same thing. suicidal ideation is when I want to kill myself and end my life, which by the way, people at BPD are very high risk of. So that's a very real risk. But the self-injurious behavior doesn't necessarily correlate with that.

When I work with patients who have BPD, when I ask them, why do you cut or why do you burn or why do you do self-injurious behavior, what I tend to find is that it's almost a meditative practice for them. I'm not advocating for doing that. But if you ask them, okay, when do you cut? while I cut when I feel emotionally really, really, when the pain gets so intense on the inside and I'm so unloved, if I start cutting, that pain, the pain of the physical sensation of the cut actually knocks the emotional pain and the fear of loneliness and abandonment out of my mind. It's a very intense focusing technique. And even if you look at the methods of self-injurious behavior that people with BPD engage in, it's oftentimes things that are not damaging to the body, but actually, experience the highest amount of pain. So if we look at people who cut in BPD, what they tend to do

is very superficial cuts. They don't do deep cuts. They're not trying to hurt themselves. But if you look at the superficial part of the skin, that's when we actually have very, very sensitive nerves. So we have these nerves that will do light touch. So you can just do a very light touch and you can feel it, right? Even if you think about tickling, right? It's a very light touch evokes a lot of response. So a lot of pain, actually, if you sort of focus on just on the very surface, the intensity of the pain is actually higher. So I'll engage in self-injurious behaviors. We'll also see substance use disorders as being very comorbid with BPD. And what's that about? It's once again, I'm feeling so much pain on the inside. I want to forget it. Right. And if I get high, if I get drunk,

if I use some kind of drugs, then it's going to make all that pain go away. And the last kind of behavior that we'll sort of see from people who are who have BPD is what from the outside looks like manipulative behavior. And we'll kind of get into that in a second. But essentially what happens is that there are different ways I can deal with feeling empty or bad on the inside. And one of the ways I can feel better is to feel loved by someone else. Right. So if I'm feeling very abandoned and I do something that evokes love and caring from other people, then I'll feel better about myself. So these are some common behaviors which oftentimes create all kinds of problems in the lives of people who struggle with BPD. Now, what I'd love to do here is actually pause for a second and just share with you all my understanding.

So if we take all this stuff and we kind of boil it down, at its essence, what is BPD? Here's what I've kind of come to understand. This is sort of a clinical perspective and also based a little bit about on my years of training is in yoga and meditation. So when we go through life, we have a sense of self. And that sense of self is something that we carry with us and can respond to the things around us. So, for example, if I am confident in myself and things don't go my way, let's say I get fired from a job, I won't let getting fired from a job determine my value as a human being, right? So if I've done good work in this world and I believe that I'm a good person and I'm a parent and I'm a good friend and I'm a good husband and I'm a good doctor,

even if I get fired from a job, that one incident doesn't determine who I am. So we have this sense of self. And what we know from BPD is the core issue, in my opinion, is that the sense of self is distorted or not formed very well. So I don't really know who I am. So this sort of results in feelings of emptiness. We also sort of see a link with trauma. So oftentimes what happens with BPD is that people will grow up in traumatic situations. And when they grow up in traumatic situations, the sense of self cannot form in a healthy way. So where does that confident sense of self come from? It essentially comes from like a nurturing and caring environment.

We'll get to that a little bit in a second too when we talk about the development of BPD. But the core thing is that I don't know who I am on the inside. That's the core feature. So then we can see a lot of other things. One is that how I feel about myself is determined by how people treat me. So if people treat me with lots of love and care, I in turn love and care myself. If people treat me with hostility, anger, resentment, then I will sort of feel like a really terrible person.

So who I am is determined by how I'm treated. That, in my opinion, is the core feature of BPD and explains all kinds of other things, because this explains why I need people to love me all the time. Because if someone stops loving me, and it's not necessarily if they stop loving me, if they travel somewhere for a week. And then without that daily reassurance of their love, I'm not able to love myself. And I start to feel empty. I start to feel abandoned.

Even though I logically know that this person still cares about me. But I require that kind of input from the outside to determine my worth. And so what that also results in is like kind of becoming a chameleon. And so this kind of creates a lot of problems in relationships. Because if I want this person to like me, what I'm going to do is I'm going to pretend to be into the stuff that they're into. Right. So if this person is into metal bands, I'm going to pretend to like, oh, I love metal too. So you kind of become this chameleon in life where you don't have your own joys, preferences, desires.

You kind of adapt and absorb the desires of other people. The problem, though, is that as you kind of become this chameleon, you're like, yeah, I'm super into metal too. In order to engage with them, you may not actually be super into metal. So you almost create this kind of false contract with the people around you, that you pretend to be into metal, you pretend to be into metal. you're super into it, and then three months go by, four months go by, five months go by, you're not really into metal. So it starts to become hard to maintain that facade. As it's hard to maintain that facade, people start to like realize, oh, you're actually not

that into metal so that they stop inviting you to stuff. And if they stop inviting you to stuff, that triggers the fear of abandonment. And then you're like, no, no, no, I'm really into metal. I promise I'm into metal. I'm into metal. I'm into metal. One of the most tragic things that I ever saw was a person who had BPD who was in a relationship with someone who wanted to be in an open relationship. And they were sort of like all in

because this is what my partner wants. I don't want them to leave me. So I'm going to agree to an open relationship, even though it's not what I want. And then once you enter into an open relationship and your partner is like, you know, having sexual relations with a lot of other people, that actually exacerbates the fear of abandonment and really just causes all kinds of behaviors to explode. So the core issue here is that we don't really know who we are on the inside. And so how we feel about ourselves is determined by how we're treated. Now what we're going to do is get into a little bit about how BPD develops. So we sort of know, just a couple of like neuroscience things to start off with.

The first is that BPD has a high level of heritability. So there's a strong genetic component. So the genetic component of BPD explains about 37 to 65% of BPD. So what that sort of means is that there's a strong genetic component. Now, I think some of these studies are a little bit flawed because I think that it's not just the genetics, it's also the upbringing of the household. So if you have a parent with BPD, I think that accounts for a lot of the development of BPD in the child. So it could be some amount of nurture as opposed to nature because you've got a parent who's got BPD. So what we see in the brains of people with BPD is that they have increased emotional responsiveness.

So what that sort of means is that if something bad happens to me, it may take me 10 seconds or 15 seconds. to get really angry, whereas someone with BPD will get angry within a single second. So the amygdalas of people with BPD are actually a little bit smaller, which people may think, okay, so they remember that the amygdala is our fear center of the brain, is our survival center of the brain. So does smaller mean less? No, usually smaller in the brain means more, because we're not able to regulate it as much. So people will feel negative emotions more intensely and faster. The other thing that we know about the brains of people with BPD is that they experience those negative emotions for longer than someone who doesn't have BPD. So that sort of means

is that I'll get pissed over 30 seconds and then I'll stay pissed for about an hour, hour and a half, whereas someone with BPD will get pissed within one second and they'll stay pissed for like eight hours. So their experience day to day of life changes because of the way that their brain actually works. So we also have evidence that there's a dysregulation of the stress system. So people with BPD will be in high stress states for longer periods of time. And they're also very sensitive to stimuli. So what does that kind of mean? So there's a really one of my favorite studies on BPD is one where they looked at facial expressions.

So what they did, what researchers did is they took a facial expression like this. And then they videotaped going from a smile to an angry face like this and then this. Right? So if you actually take that clip and you turn it into a hundred stills, what you'll find is that there's 100% happy and 100% angry. And most people, if you look at the middle, when I'm halfway between smiling and angry, most people can't really tell what I'm feeling. Like if you take a normal brain and you show them that picture of 50% happy, 50% angry,

people will be kind of confused. What happens is I need to get to 70% anger for a normal brain to tell that I'm angry. Right? So if I'm 50% angry, like, people can't really tell what I'm feeling. Once I hit 70% anger, then people can tell. The interesting thing is that for people with BPD, they can detect the anger at only 30% anger. So even when someone is 70% smiling and 70% happy, the brain of the person with BPD actually detects anger in that situation. So I want you all to imagine what it's life to go through life when the people around you, even if they're 70% happy, if they're only unhappy,

with you 30% if what you detect there is that this person is unhappy with me. Imagine how life, how hard it is to go through life when you're doing 70% right, but all you can see is the 30% of unhappiness that people experience. So what we tend to see in people with BPD is that they're very, very, very sensitive to the negative emotions of others. They're very, very empathic, which once again fits in with this idea of I don't know who I am. So my sense of self is going to be determined by how other people treat me. In order for that to work, I have to be very, very empathic. The challenge is that the kind of empathy that I have is biased. It's biased towards the negative. So what I tend to see is the dissatisfaction, the fear, the disappointment, the anger in all of my relationships. And then what

I start to do is I start to react when people are 70% happy. Even though they're still happy, I'm like, oh my God, this person is upset with me. And then I'll start to ask them, hey, why are you mad at me? But the person's like, I'm not mad at you. I feel okay. Like I'm a little bit frustrated, but it's not that big of a deal. Oh, my God. Why are you frustrated? What did I do wrong? And then what they'll sort of do

is create these frustrating dynamics with the relationships that they're in. So now we're going to talk a little bit about what do we understand about the development of BPD? So we know that there's a high correlation between trauma and BPD, but my favorite theory of this actually comes from Marshall Linahan,

who is the developer of something called dialectical behavioral therapy, brilliant psychologist who, if memory serves correctly, I could be wrong here, but I think she herself has BPD and kind of talks about that. And so what she sort of believes is that we have, in order to develop BPD, what we need

is a neuroscientific vulnerability, i.e. a brain that is sensitive to negative emotion, plus an invalidating environment. So you can have a brain that's sensitive to negative emotion, but if you grow up in the right environment, what that sort of means is that you'll get enough emotional reassurance to where you'll learn that like over time, like when you're four years old, five years old, that even though I feel really angry, my parents are there to kind of create a safe space for me so I can kind of calm down and I can develop some security. I can start to feel good about myself,

even though I was feeling bad a little while ago. And on the flip side, what we kind of see is if you have that neurological vulnerability to intense negative emotions and you are in an invalidating environment, what that sort of does is like, then when those negative emotions arise, like they get amplified and they don't get toned down by your environment.

So what this also means is that if you have a neurotypical brain, in an invalidating environment, but if you aren't neurologically sensitive to that negative emotion, even if the environment is somewhat invalidating, it's not that big of a deal because your brain is able to sort of like regulate its own emotions internally.

So this is why there's a correlation with trauma, but what we tend to see is that some people with BPD don't grow up in necessarily traumatic households. Some of them will really grow up in invalidating environments. And then you'll have like invalidating environments. Let's say your mom is invalidating, but you've got three kids in the household, and only one of them will grow up with BPD,

even though they all have the same invalidating an environment. What's the reason for that? It's because the other two kids have brains that are not sort of like have an itchy trigger finger when it comes to negative emotion. So I really like this theory. I think it's very explanatory where there's a neurological vulnerability plus an environmental factor. So a key thing that people sort of think about,

especially when we talk about personality disorders, is does this mean I'm screwed? Because this is a personality disorder, right? You're telling me, Dr. Kay, that my brain is, I have a small amygdala. And like, if I've got a small amygdala and I don't know who I am on the inside, does that mean I'm essentially screwed because I engage in all these manipulative behaviors and I'm screwed, I'm screwed, I'm screwed, I'm screwed, I'm screwed. The answer is actually shockingly, no. Actually, BPD is, I know it sounds kind of bizarre, but actually has one of the best

prognoses of personality disorders. So the first thing to understand is that there are very good treatments for BPD. One of my favorite treatments for BPD is something called dialectical behavioral therapy, which is essentially cognitive behavioral therapy, with this mindfulness component added to it. So the mindfulness helps us do things like regulate our emotions, right? Gives us healthy alternative coping strategies to things like substance use or cutting. And then the other cool thing is like this Eastern yoga meditation stuff helps us discover who we are as people. And so in my experience of working with BPD patients, like they actually end up doing really well because we sort of do this weird like yogic, find yourself inner journey thing. And it actually

works really well. So in terms of statistics, this is really shocking. But if you take patients who are hospitalized due to borderline personality disorder, so these are people who are in such a crisis where they get hospitalized potentially involuntarily, they get locked into a psychiatric ward. Two years after hospitalization, 34% of them are in remission. Four years after hospitalization, 49% of them are in remission. Six years after hospitalization, 68% of them are in remission. And a decade after hospitalization, 86% are in remission, which is kind of staggering, right? So what we're saying is that you can be so sick that you get hospitalized. And 10 years out, if we take 1,000 people with BPD and we just measure them 10 years out,

we're not really sure who engaged in what level of treatment, by the way. But we just look at the statistics, the odds of that 860 out of 1,000 people will be in remission. Now, what does remission mean? that means that not having significant symptoms for a two-year period. Only about 6% of people who are in remission will have recurrences. So are we kind of catching people on a good day? And that's why these statistics are so good. But actually the prognosis for BPD is like actually really, really good.

And we have very, very good treatments for it. There's also a lot of evidence that shows that having stable relationships can rapidly improve BPD. So all you need is really like one person. who's kind of a stable source in your life to really improve things. So one study that I looked at suggested that there was somewhere around a 50% remission rate at two years if you have a stable relationship. But remember that you don't necessarily have to have a stable relationship. People find remission in all kinds of other ways. And when people sort of wonder about that, this is kind of my experience of it as a clinician.

Is that remember that the key thing here is that you don't really know who you are, right? So you sort of define yourself based on how other people treat you. If you take people who are really confused about their identity, let's say a 21-year-old who's been hospitalized, if you look at the difference between a 21-year-old and a 31-year-old, a lot has changed between a 21-year-old and a 31-year-old. The first thing that's happened is their brain has fully matured. And what we sort of know is that strong frontal lobe development mediates or reduces the symptoms of BPD. So just literally like your brain maturing can reduce the symptoms of BPD, just aging. So every year that goes by, like could be better for you.

The other thing that tends to happen is we don't really know who we are at the age of 21. And by the age of 31, a lot of us have it more figured out, right? We sort of have figured out a little bit more about who we are. And so as we sort of develop the sense of identity over time, as we sort of discover who we are, hopefully we can find some good supportive relationships. Hopefully our brain develops a little bit. Hopefully we learn how to regulate our emotions. Hopefully we actually engage in treatment like dialectical behavioral therapy or learn mindfulness or meditation.

As we kind of do all those things, BPD can actually get. better. So borderline personality disorder is one of the most misunderstood diagnoses out there. I think it gets a really, really, really bad rap, especially because if you know people who have BPD, it can be really hard to engage in relationships with them, whether they be family relationships, platonic relationships, you know, all kinds of stuff, this can be hard. But the good news is that with the right kind of treatment and even maybe just getting older, a lot of this stuff kind of resolves on its own. We're not really sure about too much there. But we do know that the prognosis this is actually pretty good.

So if you have BPD, if you suspect that you have BPD, I strongly encourage you to get evaluated, get treatment, and most importantly, don't lose hope.