Psychiatry & Psychotherapy Podcast - Borderline Personality Disorder: History, Symptoms, Environment, Genetics & Brain Science

Episode Date: May 13, 2021

In this episode of the podcast, we introduce borderline personality disorder (BPD). We discuss its history, nomenclature, epidemiology, etiology, and diagnosis while providing perspectives from clinicians regarding the treatment of individuals with BPD. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. All right, welcome back to the podcast. This is the first in a series I want to put together on borderline personality disorder. I thought I would start with a dialogue with two experts, Dr. Pro and Dr. Cummings.

They bring decades of wisdom from working with this population. Dr. Pro runs a partial in IOP for men called courage and women called innovations at Loma Linda University, which treats trauma and has a bedrock of dialectical behavioral therapy. This program has a high percentage of people with borderline personality disorder who go through it. She is also the assistant program director of our residency and also runs the third-year psychiatry elective for students. She is known for her almost unstoppable energy, wizard-like intellect and knowledge and mother-like love for all medical students in residence, which she's really dedicated.

her life too. Dr. Cummings, you probably know well from a multiplicity of episodes, is someone I consider one of the top five psychopharmacologists in the world. He has a new book coming out treating severe mental illness, and I myself have greatly benefited from his mentorship over the years. So for this episode, I'd like to also give a shout out to two medical students who worked tirelessly to do some prep before the episode was recorded, and then they put together with me an amazing handout, along with Dr. Cummings and Dr. Pro. This is Bryce Thomas, who's an MS3,

and Ben Robinson, who's an MS4. For this particular episode, they probably put in a couple hundred hours of work just to give you an idea. So please check out the 14-page PDF on our website, Psychiatrypodcast.com. This is a free thing that you can get in the resource library. All right, here we go.

Welcome back to the podcast. I am joined today with Dr. Michael Cummings and Dr. Melissa Pro. You guys know Dr. Cummings well. He is a psychopharmacological expert that comes on to the show. And Dr. Melissa Proe is also one of, I don't know, my mentors, someone who I look to for Psycho Farm Wisdom. She also runs an eating disorder and a borderline personality disorder track

in a partial IOP program at the University of Loma Linda. And so it was my thought to have her join us, especially for this talk on borderline personality disorder that we're going to have today. So welcome to the podcast. Thank you very much. Thanks.

Dr. Pro, just so my audience can further know, like what exactly does your track entail just kind of who is it for specifically? We have a, we actually have two different tracks, a women's trauma program and a men's trauma program. The men's trauma program is called courage and the women's trauma program is called innovations. They're both partial hospital program day treatment that steps down to intense outpatient program day treatment. Both programs run anywhere from six to eight. weeks and they are highly based in dialectical behavioral therapy but also have other components built in based on the patient's individual needs including management of substance use comorbidities

and eating disorders comorbidities awesome and you've been doing this for how many years uh we built the program in 2011 so it's been a little while that's awesome so 10 years so dr pro is someone who sees them weekly, gets them into the program, keeps them in the program, oversees the program, Trem Team Meeting, and someone who I learned under when I was a resident. So it's good to have you on. Thank you. Yeah. So I wanted to start today, and maybe Dr. Cummings, you can start and we'll kind of join in.

Since we're talking about borderline personality disorder, maybe start with like the history from your perspective of borderline precise. Let me start with, first off, a personal bias on my part. I keep hoping the DSM committee in this area will eventually update the nomenclature. The concept of borderline personality disorder dates back to the days when psychiatry was largely psychoanalytically oriented. And at first, indeed, because people with this disorder are prone to, to micro psychotic events, that is, distortions of reality when emotionally distressed, they were originally theorized to be quotes on the border of schizophrenia. Well, that turned out not to be true.

These individuals don't, by and large, go on to develop schizophrenia spectrum disorders. I think the ICD10 has the nomenclature a bit more correct at this point. In ICD-10, it is termed affective discontrolled disorder, and that seems to be at the heart of this disorder. These are individuals who experience intense, often very negative, affective states, which appears to then cause disturbances in interpersonal relationships, internal feelings of emptiness and fears of abandonment as well as proneness. to suicidality, impulsivity, a whole range of things. The best research I've read was from some of the early psychology studies done back when behavioral psychology was in its ascendancy under B.F. Skinner. At that time, of course, people were theorized initially to be tabula rosa that is blank slates at birth. That subsequently turned out not to be true.

And one of the studies that looked at that issue was a psychological study done by Strong and Chess, who evaluated infants at six hours of age and broadly characterized them into three categories. There were the easies. These were infants that in response to novel stimuli were basically approach, not much affective arousal. There were the slow to warm-ups, which were far and away the majority of infants, who would be somewhat hesitant with a novel stimulus, but then approach it. And lastly, we're the ones they call Difficults. This was about 10% of their sample.

Interestingly, they studied these individuals over a prolonged period of time, and for the most part, all of the people later diagnosed as suffering from borderline personality disorder came out of that group with intense affective arousal. This is a disorder of which occurs in about 1 to 2% of the population. The ratio is 3 to 1 female. It took a major step forward due to the work of Professor Marsha Linehan at the University of Washington in 1983 when she published the original treatment manuals for dialectical behavioral therapy, which focused on learning skills to deal with and take responsibility for labile, often intense affective states, and also taught people a variety of skills in terms of being able to manage their interpersonal relationships

and tolerate their own distressing affect. Okay. Yeah, that's a good little history. I'm just happy to listen to him talk. He can just talk the whole time, and I'm thrilled. This is my favorite thing. and he's awesome. Yeah. You know, when I think about the history of Borderline Persiazai, I think about, well, a comment

on what you were saying about the psychoanalytic tradition. There's the psychotic and the neurotic, and they thought that the borderline was kind of in between the psychotic and neurotic. And psychotic doesn't, it's like a level of functioning as well. It's not just purely like schizophrenic. It's like a level of the way that someone is internally organized. So someone could be a psychotic, really depressed person, or they could be, you know, so it's kind of like this in-between place is the way that I understood that. Would you say differently, or is your understanding that different?

I think that is accurate for psychoanalytic theory. I think the objection was, to the original hypothesis, was these people were not on their way to becoming more psychotic. and in fact most of them only briefly exhibit psychotic symptoms in terms of either overt symptoms or functionality. They certainly have a great deal of difficulty with interpersonal relationships and with functioning. They often do have a core lack of coherent identity. They don't have a good sense of who they are. And often I think that is their source of distress as well as dysphoria. Yeah.

One thing I pondered and thinking about the history of psychiatry is this diagnosis of hysteria, which was spoken about by the, you know, ancient Greeks and this idea of hysteria being something that might have some overlap. I don't know. Yes. Hysteria, actually, interestingly, by the Greeks, was conceptualized to be related to the uterus and indeed most mostly as women who were diagnosed suffering from hysteria. Essentially, these were individuals who indeed were prone to anxiety,

in particular in the 19th century when Sigmund Freud came along and was looking at individuals who were suffering from a variety of emergent symptoms and intense anxiety. hysteria was a fairly common diagnostic term. That certainly blends into the idea of indeed people suffering from borderline personality disorder in the sense that they do suffer from intense affective states, including dysphoria and anxiety. They also, based on those affective states, do suffer from deficits in reality testing in terms of misinterpretation of the environment and of the motivations of others,

either idealizing others or degrading them. One of my most articulate patients in this area was a woman who had undergone a great deal of psychotherapy. And at the time I met her was middle-aged and had largely recovered in terms of exhibiting behavioral discontrol. she was a university professor and told me that when she was growing up and was a child, someone asking her to pass the bread at the dinner table would set off in her a feeling of rejection, negative thoughts that they wanted her to starve to death, and consequently occasionally she would just blow up and stalk out of the room, mystifying, no doubt, the other people at the dinner table. And it's that sort of interaction that often gives rise to a huge range of difficulty in these individuals' lives.

When I think about the different symptoms, I think about Gundersen's approach, like the PISA, the P for psychotic, quasi-psychotic episodes, I for impulsivity, S for social adaptation, I for interpersonal relationships, and A for affect. And I was thinking we could go one by one through these and get Dr. Pro to tell some, like, what this actually means in real life. And then maybe Dr. Cummys, you can chime in if you have anything to add specifically. Sure. So P quasi-psychotic episodes, transient fleeting, brief episodes persisting over the patient's lifetime, depersonization, de-realization. So I think about dissociation, rage reactions, paranoia. and yeah, Dr. Pro, any thoughts on how you see this? Yeah, I think that oftentimes it's difficult to tell the difference between dissociation and psychosis.

And as a result, patients get labeled as being psychotic when in actuality, this is a dissociative state. And in a dissociative state, the patient is often not fully aware of the environment around them. to the same way where I might drive to work and not realize how I'm all of a sudden parked at work. And I know that my eight-minute commute happened. I know I didn't hit a person. I know that I stopped at all the stoplights. And if you asked me, what color were the car is next to you, I would not be able to tell you that, but I made it to work.

And a dissociative state is something that we all can get into at any point in time, but it's not to the point where it's pathologic. And a person with borderline personality disorder, when stressed, when triggered, oftentimes for no reason at all can get into a dissociative state like that, except they also have emotional distress. And I've seen a patient with borderline personality disorder who was actually on clasopine for management because these episodes were so frequent and so intense on the inpatient unit at the BMC, the behavioral hospital take her forehead and slam it into very thick glass

to the point where the glass broke. and in that episode, not even being fully aware of her surroundings or what was happening. And to the casual observer, this looks like psychosis. This is a person who is paranoid, responding to internal stimuli, etc. But more than anything, I think that this is really more of a dissociative state where this person is more closely in trance, not fully connected with all of their personhood, the same type of things that you see across cultures that have different presentations. Yeah, that's good. That's good. So Cummings, how do you differentiate dissociation from psychosis?

Most of the psychotic illnesses, now certainly not all of them. A good example, brief psychotic disorder, of course, can occur in people with perfectly normal brains under intense duress. People can also become psychotic in response to psychotogenic compounds like amphetamines or fincylidine. But in the case of most psychotic illness, and certainly the far and away the most common psychotic illness or schizophrenia spectrum disorders, you're looking at an ongoing disturbance in reality testing associated with positive psychotic symptoms like auditory visual hallucinations, paranoid delusions, grandiose delusions, bizarre delusions, ideas of thought insertion, thought withdrawal, thought control, along with negative symptoms, blunting of affect, inappropriate affect, and cognitive deficits. That's an ongoing chronic condition that is more akin to a developmental dementia,

whereas these people function normally much of the time, but indeed when emotionally distressed, it causes a disturbance in their reality testing and their perception of reality, as Dr. Perrault was saying, rather than the more schizophrenia-like loss of reality testing, this is much more a dissociative state where the person may either feel that they're not real or that their surroundings are not real, cartoon-like. And once the affective storm, if you will, dies down, their reality testing fairly quickly returns to normal. In the more severe cases, indeed, second-generation antipsychotics over the last decade have become more commonly used in people with this diagnosis,

including clospine, for which there is good evidence that it can be quite effective, both in reducing the number and intensity of quasi-psychotic episodes, but also actually can help with modulation of affect, probably by enhancing glutamate signaling in the frontal lobe.

Yeah, Dr. Perra, this is like one of those questions that I'm like, how do you treat this? Like is it acutely, I know in the psychiatric hospital, which you also spend half your urine, is it really the antipsychotics that you see working for the dissociation? Or what is that pulls someone out of the dissociation state? So if we're going with dissociation occurs as the result of affective dysregulation. The person gets triggered.

They go from I feel an emotion to I am distressed. in seconds or microseconds, and then from that to a dissociative state, a lot of times, similar to the management of a person that has acute psychosis that is in a fighter flight and trying to escape and more likely to be combative secondary to not having perceptual awareness that's based in reality, you will do what you can to reduce that reactivity. And so if you can reduce the anxiety state to begin with, if you make it so that, you that the person is less likely to be anxious to get overwhelmed and to respond that quickly to a trauma. You can see, you can see reduction in the severity and in the frequency of these episodes.

So more often than not, in the inpatient setting, we will start something that's going to enhance GABA. So something that is going to be calming while at the same time not necessarily cloud the sensorium. with these patients, we're never going to want to use a benzodiazepine if we can avoid it. That would be helpful just because of the huge comorbidity with substance use disorders. And so something like gabapentin, oxcarbazepine, these medications will use while we're starting other medications. And this at least helps the person to not get to a distress date so quickly. You can use PRN medications as well. And generally for PRN medications, there are a number of things.

again, trying to avoid benzodiazepines, and we might use hydroxazine, quittapine. Really, all you're doing in those cases really is anticholinergic sedating type of medications while you are managing them acutely. The goal is not to continue those medications long term at all. But I think when it comes to the acute setting, management of these trans-type episodes, these associative episodes, is to lower the overall state of anxiety on a minute-to-minute basis so that you're able to use other interventions and they can be successful. So being able to take a person that has tidal waves of emotion that come in and using something

that's overall calming so that when those emotions coming on, they're smaller waves. Yeah. Yeah, I see in psychotherapy, I see two things very important. One is the mindfulness stuff that you guys teach in TBT to get someone to come into the here and now present moment. and also I would say the mentalization of mentalizing their own emotional states and then that of their provider and then using a lot of empathy. Some patients respond to pure empathy, I've noticed.

Someone comes in with dissociation. You give them half an hour of empathy and they're completely back out of the dissociation. And I've had patients who I've tried some of the mindfulness stuff and they're like, Dr. Peter, don't do the mindfulness stuff. just be present with me. And I'm like, okay, I'll just try to do that. I think for many of these patients that, you know, the empathetic support is highly valuable

because of their difficulty with interpersonal relationships and they're often intensely odd interactions with other people that's rather off-putting for people around them, and they often feel very invalidated by their environment. So a little bit of validation often goes a long way. The other comment I wanted to make is that one of the things I want to be sure we underscore in this is that while a number of medications have been used as adjuncts in this context, there is no medication per se for borderline.

personality disorder. In the early 2000s, the SSRIs were popular because these individuals are prone to impulsive behavior. More recently, over the last decade, medications have shifted much more toward mood stabilizers and second generation antipsychotics as adjunctive treatments. I think an important message for both clinicians and patients, though, is the answer to improving with this disorder does not come out of a pill. Yeah, and in regards to that, I wanted to get to later, but what I've found in some of the big longitudinal studies of mentalization-based therapy, for example,

is most of the people are actually getting off of meds who get effective partial and who get effective long-term treatment much more than treatment as usual. And so I highly, highly recommend for someone, one with this diagnosis to get into a good partial program. And that's why I think, like, the work that Dr. Pro is doing is so important because not everywhere do they have a good partial program. Not everywhere they do the necessary, you know, training to learn one of the specialized

therapies that works. And we'll get to later, maybe in this episode or a subsequent one, we'll go through all the different therapies that work. And it's, I'm not, I'm not sure that there's one that works better than, Another, one of the, you know, there's a bunch of specialized therapies, mentalization, transference focus, dialectical behavioral therapy, schema focus therapy, all of them work very well. And when you compare them against each other, it's not like one is really standing out as the huge winner, to me at least.

I agree completely. I think that in the partial hospital setting, the goal in that setting is to not even, at least from my experience is not even to be focusing on the medication management. and if anything, to minimize the use of medications because the actual treatment is going to be done in the therapy and in the continued therapeutic response. And I think the acute inpatient setting can have a different presentation, certainly, but the goal, I think, even over time, really is to reduce those inpatient hospitalizations by any means possible so that you're not in that situation to begin with where you're managing a patient

with borderline personality disorder who's distressed in an inpatient setting. Yeah. In general, hospitalization for these patients is at best a two-edged sword. It often is detrimental to them in the sense that hospitals are inherently a somewhat infantilizing environment and can, frankly, in individuals who have a somewhat unstable personality structure to begin with, can induce an excessive amount of regression. I've treated a number of borderline patients who, while, yes, they were impulsive,

they had psychotic episodes, they had very troubled lives. At the beginning of their introduction to psychiatry, they were nevertheless functional. They were working. They had a family. If they were hospitalized frequently, they often regressed to the point where they became non-functional.

because and frankly this is a characteristic of hospitals in general we too often make people dependent and more infantile when we hospitalize them yeah okay i do want to get through this piece of thing so let me go to the second one for the eye impulsivity so you'll see a long-standing behaviors that may undergo symptom substitution such impulsive things self-regulation issues such as eating, drugs, money, gambling, promiscuity, mood regulation, chronic pain syndromes, somatic preoccupations. You have the self-destructive behaviors such as the self-mutilation, suicidality, sadomasochistic relationships, high-risk hobbies, high-risk behaviors, inattentiveness to care, to self-care, sabotaging relationships and academic success. As I list off those things,

Dr. Pro, does anything jump out as you as like, yes, I'm seeing this all the time. this is the secondary issue that we're trying to maybe not directly approach, but that improves. Are you approaching it directly? Are you hoping that some of the affect regulation leads to these things going down? Like, what's your general approach and what do you see? So I'm a huge fan of good psychiatric management for Borland Personality Disorder, which was Gunderson's work. And I was lucky enough to go to a conference at UCLA only a couple of years before he died.

where he was there going through it with us, you know, piece by piece. And I really have seen a lot when it comes to maybe, yes, there's an underlying neurobiologic reason why these things are happening. There's circuitry in the brain that is not functioning the way that it's supposed to. But I think even more so looking at this from a clinician's perspective, psychoanalytically, you have a person that is seeking a secure and connected space. And GPM looks at this is a person. who looks to be secure and connected with others. And when they feel disconnected from others, when they feel insecure, when they feel invalidated,

they move into a place that becomes chaotic and then a place which becomes alone and desperate. And as a means of trying to get back to that connected place, they often engage in those behaviors. And whether those behaviors are dopamine seeking, whether those behaviors are seeking connection and attention from others, their brain is looking to feel connected and to feel safe. And these are the behaviors in some ways that are loopholes, where they're not going about it in a way that's healthy to get the connection that they need. They found a loophole to feel connected in the moment. But the downstream effects are further disconnection.

And we're going to include a link for Dr. Darcy Trinkle, who goes through the cycle that patients have. between connection, chaos, and feeling alone. And I think it's really helpful. I have every patient with borderline personality disorder that I treat, watch this video. I have my trainees watch it. It's a really good overview of Gunderson's work, and it really does look at how to educate patients on this,

because the majority of these behaviors oftentimes are occurring because this individual is seeking connection one way or another, seeking to feel attached. And these behaviors generally will get it done, which is why they continue to repeat this process, because it's been rewarded in one shape or another. And yet it is leading to the pathology just being furthered. Yeah. I wanted to comment that indeed in Lenehan's dialectical behavioral therapy, one of the major components of that was first in therapy, first in therapy groups teaching individual skills for dealing with distress in terms of social situations. And then often those groups involve coaching so that when the person's out in the real world and runs into a difficult situation, they often had resources they could call and very briefly ask their coach, this is the situation, what should I do?

And that was a very pragmatic way of avoiding some of these loopholes and impulsive behavior. The other comment I would make is this is one of the strongest reasons not to use a benzodiazepine in a borderline individual. Yes, acutely it will calm them down, but at the price of worsening impulsivity. Yeah, two things, or one thing from that, is when you think about Marshall Anaham's DBT, one of the things she does is actually gives out to each patient has a way of contact. the therapist. And when I was at a conference, she was speaking at, she was said, this was so important because she would have people call her and she wouldn't have lengthy, you know, half an hour conversations with people. It would be very short, like five minute, 10 minute. Okay, what skills

are you using? Okay, I'll talk to you more about this in group tomorrow. But it's that, like, that connection that seemed to be really important. And I see that in all of the therapies that seem to have worked is that there's quite, there's an intense connection going on multiple times a week in these groups, in these relationships with these therapists, and mentalization, they trained nurses actually to perform a lot of the therapy. And it's that intense connection over time that seems to, in my mind, really help these clients get better. Okay, let's move on to social adaptation. So we have PISA PIS is social adaptation. And Dr. Cummings already talked about this, how there's this ability to bring together their life in such a way that they

can look normal to a lot of people. So they have this superficially intact social veneer, and their high performance may be only what their colleagues see, right? So this is kind of like, you could have someone who maybe is struggling with this, and you just have no clue, because outwardly they just seem to have it together. This seems to be. This seems to be. to erode with high stress, comorbid axis 1, illicit drug use. In higher functioning patients, it seems to be that if you are an authority figure, they will pull it together for you in particular. So some of my front staff used to tell me this person is like belligerent, and when they get in my office, it's like I would have never known, you know? So Dr. Pro,

any comments on this, anything that you've seen? Because I know you've treat a lot of physicians. I mean, Dr. Pro treats probably a hundred, would you say 100 physicians at this point? Okay. So, yeah, what do you see? Social veneer. And 100%. I was literally, as you were saying that, I was thinking about a few physicians that I treat that very strongly have borderline personality disorder and yet are very successful. And, you know, some of this just has to do with the chronic nature of the disorder and the fact that you have a person that, you have a person that, you know, that that has a brain that is not functioning in a normal way necessarily, where there is heightened distress and their ability to manage that distress is poor.

And yet at the same time, this can be a person that is very adaptable, that can easily sublimate, that can connect with other people, that is able to take a lot of the things that may come with the condition and use them for good. When I talk with patients about borderline personality disorder, I will often explain there is a lot of good things potentially that come with a person with borderline personality disorder. You can take a person like this, leave them in Detroit or somewhere that they've never been before in their entire life and say, I'll see it tomorrow. And by the next day, they will have a place to stay. They will have found people to help them out.

They will have been able to make their needs known. They are adaptable. They are quick. They are able to bond with other. they can read others very well. There's components of this that over the course of time, just being able to adapt and deal with this brain, they've been able to pick up additional skills.

And if you can highlight those things and subtract out some of the more detrimental aspects, you end up with a person that's very capable. And having treated a number of physicians with borderline personality disorder, it's very clear that you can see evidence of these behaviors there. And yet at the same time, they still have a beautiful, and tax monologue that plenty of the time is able to, you know, use other processes rather than simply respond in distress. But it comes down to, you know, what has been, what has been the reward for that. And in some settings, in some patients, the greatest reward has been, you know,

being in a state that was dependent. But you can definitely see people that are very, very high functioning and have this disorder and yet be able to control it most of the time. Yeah. Dr. Cummins, any thoughts? Social adaptation, social veneer? I would agree. Many of these individuals do manage to maintain a social veneer, often at very large degrees of effort on their part. And, you know, we see them, of course, when these things break down. I think one of the things that's important to address here is that many clinicians in the community in general are quite pessimistic about this disdiscuous. order, and that's frankly one of the reasons I would like to see the name changed. Somehow, oh, their borderline has become, for many, a pejorative statement. These individuals, contrary to those who have been kind of exhausted by treating some of these

individuals, the recovery rate's actually pretty good. Now, in part, that's influenced by the fact that this has one of the highest suicide rates around about 10%. But by the time these people reach middle age, about half of them no longer meet the criteria for borderline personality disorder. Yeah. I actually, I often don't tell clients when I think they're borderline or have borderline traits unless I feel like it's going to help them engage treatment in a way that would be helpful. So if I'm trying to convince a person why they shouldn't smoke weed and why they shouldn't be on benzos, you know, then I might pull out the diagnosis or why they need to go to a partial program or why therapy is going to be helpful more than medications long term. Then I really, I think actually having the diagnosis gives them a sense of power and like, okay, I could actually make some choices here that will make this not something that's like forever diagnosis and forever disease, you know?

Yes. Well, that's where I think, frankly, my own opinion is that the term personality disorder in this context is wrong. I think this is an affective disorder, an affective dysregulation disorder from which people can recover. It's not a sentence to a lifelong maladaptive personality structure. And I think that the neurobiologic basis of the disorder is something important to highlight with patients that, But this is not simply a problem with your personhood or personality. Many patients with borderline personality disorder will carry and hold very strongly to a bipolar disorder diagnosis. And when you talk with them and try to gain more insight into why they're holding tightly to the bipolar disorder diagnosis. When once you've assessed them and had time treating them, you realize, no, this is not bipolar disorder in this individual. looking at a diagnosis like bipolar disorder can help them understand why episodes come on without any kind of warning, why they may behave in ways that don't make sense to them, why their brain does things that are strange or bizarre or nonsensical when it's not aligned with their values.

And I think being able to describe this with patients and to be able to go through with them and say, this is a disease that is in the brain. This is something that is that is heritable. This is something that you can see has structural, functional abnormalities and is something that is very, very treatable. I think being able to provide some of that education for patients ends up being really important because then it doesn't just sound like you are inherently as a person broken and instead gives them some of what they're looking for in there is something wrong in my brain in the way that I'm interacting in the way that I'm acting in the way that I'm behaving and I can't put my finger on it. So it must be this thing and being able to convert it into this is a different

disorder that can be very disabling. And at the same time is something that has a neurologic basis. It makes sense why this is happening and there are options for care. Yeah. Very good. And yeah, with the social adaptation, I think one thing I would add is it's helpful in the diagnosis of this because someone who's psychotic will be psychotic around a multiplicity of people in situations or someone who's truly manic it's not like they can pull themselves out of the mania and then appear normal to one person and then the next moment they're back to being manic so i think it's helpful to sort of see the social adaptation for social veneer as like part of the piece of the diagnosis which can help you make sense of it i hope you make sense of

Okay, P-I-S-I, so I is for interpersonal relationships. So these are often chaotic, unsatisfying relationships with others, sometimes socially superficial, aloof, detached, but close relationships are often extremely intense. There can be some dependency in them. They can have some intense fears about being alone and rage with the primary care. caretaker. There's this feeling sense of pervasive aloneness and they can find themselves victims in certain relationships being preyed upon by predators. So yeah, any thoughts, Dr. Perrault on how you see this and how you coach people to be more maybe healthy or how do you approach this without someone feeling shame, I guess is one of my questions. I think for me in this tree,

is being able to highlight that intense need for feeling connected, for feeling attached and feeling safe. And exactly as you were noting with patients, that empathy between the treatment provider and the patient is so valuable. And oftentimes, a very easy thing. When I'm talking with residents about how to work with these patients, how to help them toward insight, I start by asking the resident, do you like this? person, is there anything about them that you can see and value or do you just clearly want to

run away from them? And if the residence says, I want to run away from them, I said, then this is never going to work because if you're not able to highlight something about them that you care about or you want good for them, they will feel that in you. And you will not be able to bond them or connect them. But if you can bring forward the parts that really do want to help protect and empower this person, they will detect that. They will bond with you. And then you can bring them toward that insight of This is what connection looks like. And the reason why things went terribly wrong yesterday afternoon, where you overdosed on all of your medications after your partner told you that they liked what you were wearing that morning and you had no idea why that led to that action, this is because you have issues with those connections. And sometimes feeling too close of a connection with another person can lead to them becoming disregulated.

Sometimes feeling a person pulling away can make them feel dysregulated. They have very, very highly attuned systems to that feeling of connection. And the connection is vital to them on a day-to-day basis. And many of their behaviors are happening unconsciously when they feel that connection shift, especially if somebody's pulling away from them. And many of those behaviors that are maladaptive are occurring to try to get that connection back. And I think that being able to show

how many of their behaviors are the product of that lack of connection is important, which is where some of the DBT skills work is valuable, being able to do chain analysis, looking at here are all the pieces that led up to this thing that happened yesterday, and here are the places where feeling disconnected led to additional behaviors.

Very good. Dr. Cummings, any comments? Any thoughts? Yeah, I think one of the things that it's important for someone working with these patients to realize is that when we talk about them having intense fears of abandonment from their perspective, because they have sort of an incomplete sense of themselves, That often means that if the other draws away or threatens to abandon them, they're faced with intense feelings of emptiness, which is frankly a very scary place for any human being to be. And if people can get sort of past the chaos that sometimes comes with these patients, I think a good rule of interaction is the more chaotic the patient becomes the calmer, the therapist, needs to be and responding to that empathetically.

Yeah. Yeah. I think if you look at a lot of the therapies that work, it's like relationships are part of the cure, probably a majority in my mind of the cure. Despite, you know, there's these brain circuits that we've identified. We'll talk about later. There's a heritability to this. There is a relationship cure to it, which is, it's a little bit confusing to some

people because they think, oh, if there are brain aspects, then isn't the, you know, how does the therapy interact with the brain? And, well, our brains form in relationship, right? And our brains form in attachment. So it's, it's, it's, it's, it's sometimes takes a little bit of skill to work with this population. Part of what I can see in DBT and in mentalization, transfer focused, a lot of it's like, how do you understand them to a point where you're not feeling critical towards them in the midst of the different things that come up in the work that you do? And I think one of the big things that I see for success as a therapist is how do you deal with your own reaction, your own countertransference?

That's like something I keep coming back to is like it's fundamental, it's important. Indeed, one of the elements in almost all of the therapy. designed for this disorder have been that the therapists in turn need a support system to an including formal meetings among the therapists to support each other to decrease burnout. Working with these patients can be affectively intense, can essentially require the therapist to be on their toes and thinking. and frankly it can be difficult work at times. Okay, the last one is affect.

So PISA ends with an A, so affect chronically dysphoric and or labile. So one question is since adolescence, what percent of the time have you experienced a normal mood? By that, I mean no anger, emptiness, anxiety, or depression, for which they often answer somewhere below 20 percent. there's also chronic passive suicidality dating back to adolescence that we often see, which if you want to ask one question, have you felt this chronic passive suicidality? When did that start? And they usually say somewhere around 12, 13, 14. Dr. Pro, what would you add to this?

Or how would you sort of bring this to life a little bit? I think that this is a perfect segue into those. abnormal circuits in the brain when talking about the affect and the effective dysregulation. So often it's easy to see patients with borderline personality disorder and their behaviors as manipulative as being done intentionally. And while yes, I'm not going to take away a person's agency at the same time, if you think about any of our brains when dysregulated. So if all of a sudden I received a text from a colleague and it said, guess what, I'm not going to cover your vacation. next week, like I said, I was going to.

What my brain is going to do is going to go into a sequence of I'm feeling upset, I'm disappointed, I'm angry, I might want to text them back and say something rude, I might want to text a colleague and complain to them in that state. My brain is effectively dysregulated. I'm not in charge of what's happening in that minute. I can decide how I want my actions to go next, but I have a brain that is more. under my control in a lot of ways than those with patients with borderline personality disorder. Not to say that their brains cannot be rehabilitated and trained in that way, but at baseline,

especially earlier in the illness, you can see that effective dysregulation occurring often frequently and over much, much smaller things, not somebody saying your vacation is canceled, but somebody simply didn't respond to the text as quickly as you would want them to. and there becomes a sequence of effective dysregulation that occurs, that it really is outside their control. And so what they do and their behavior certainly is within their control. But that affect, those feelings that become not just emotions but distress so quickly is not within their control. And that's something that's very important, in my opinion, to highlight. Yeah, I want to add to that in this one meta-analysis where they looked at that the brain,

of people with borderline precise order, what they found was that they had heightened activation during process of negative emotional stimuli in the left amygdala, left hippocampus, and posterior cingulate cortex, as well as diminished activation in the prefrontal regions. So this was shown across multiple studies, 281 people,

so that there's something going on. When they get very stimulated, their emotional centers of the brain are reacting more than the frontal lobe. The frontal lobe can be seen as kind of putting thoughts to things. So this is where in DBT they have wise mind is the combination of the emotional centers and the thought centers. If you put those both together, they try to integrate those in DBT. So that's kind of like trying to integrate this more limbic response with a more thoughtful response. You put those together, you get wise mind.

in mentalization, what they believe is that when someone gets physiologically aroused, they go into something called psychic equivalence mode, which is the reality that they believe is reality. So you can think about like when you get in an argument with your spouse, you may think this person doesn't love me in this moment, but at the same time you're usually thinking, yeah, but they do and this and I'm just having this argument. With someone with Borderline-Presagosges, or when they get in this sort of psychic equivalence mode. The reality that they think in their mind is the reality for that moment. So despite whatever

you're believing or thinking or saying, they believe that you are thinking something about them, often something very shame-inducing, something very isolating or making themselves feel very alone. They believe that that is the reality that is going on. So physiologically, they have to come down before they can start to put some new to, to start to be able to be able to be able to, able to think that you might not be thinking what they believe that you're thinking. Okay, so that's what this kind of affectively charged brain is doing in that heightened state. Dr. Cummys, I'm sure you could wax poetically about the MRIs, the functional MRIs. I don't know if you have anything to add to this.

Yes, these are individuals indeed who have an excessive amygdala response, particularly in the dominant temporal lobe. and that essentially translates into intense fear, intense anger, underscore and capitalize intense in both cases. In turn, the overactivation of the hippocampus and parahippocampal complex is related to the distortions in reality, the dissociative states that these people experience. people have actually found that the hippocampus and parahepicampal structures are smaller in people with this disorder likely due to chronic exposure to cortisol because they spend a lot of time being sympathetically aroused. The prefrontal cortex in turn is hypoactive, hypol responsive, and these individuals, consequently,

they don't have that ability to top-down, modulate their affective state as effectively as other people do. One of the interesting things that all of these therapies have in common is that they essentially appear to cause a process called initiation and adaptation in these neural circuits so that with repeated therapeutic episodes, the functioning of these areas, of the brain move back toward a more normal homeostatic status. It's an interesting thing that's been of interest to me for some time is that psychotherapy is essentially a way to perturb the functioning of the brain, just as medications are a way to perturb certain neural circuits. Essentially, I think both are hitting on the same underlying biological process. these.

Yep. Yep. There was one large scale population study done in Sweden where they looked at, you know, the full population, so they looked at 1.8 million individuals. This just came out in 2021 by Skuglund. And they had 11,000 individuals diagnosed with borderline per size or in this full population. So that's 1.1% of female. males, 0.2% of males. And they found when looking at the familial association that people who were

more related had a stronger link. So for example, monozygotic twins, the concordance rate, so if one twin was diagnosed with borderline for sciisorder, the concordance rate that the other one would also be diagnosed was 7.4%. Whereas di-zygotic twins, it was 4.2%, full siblings, 2.5%. So they put the heritability estimate at 46%. Now, I know this varies in different studies, but I think it's good to put out there that this is 46%. What does this actually mean, you know, heritability-wise? Bipolar estimates are around 60, schizophrenia around 73. Schizophrenia has a concordance rate of monosagotic twins that are at 33%. So it's very genetic. ADHD, 71% to 73%

height is around 90%. So when you think about this, Dr. Cummings, my question for you would be like any nuance that you would put here, I know we've talked a lot about genetics and biology, but it seems to be about 50-50, you know, environment, a little bit and genetics. Yeah, my reading of the data is that

as in the strong and chest study way back in the 40s. the underlying biological substrate, that is, the tendency to experience intense affect, is there largely genetically. I don't think anyone would argue that at six hours of age, the environment had yet had a major influence on most of the infants. But that genetics, of course, is born into an environment that then begins to shape the brain. And in a certain percentage of these individuals who have the underlying biology, they go on to develop a disorder, which we've either named borderline personality disorder or affective dysregulation disorder. My guess is the ones who do not gain a clinical diagnosis may still be affectively intense people, but ones who are better at modulating their affective responses. And consequently, they don't fall into some of the impulsive and socially disastrous patterns of behavior that the persons that we see have.

And can you speak at all about the epigenetic nature of the illness? We barely are beginning to understand epigenetics. In fact, everyone was somewhat dismayed, I think, in the genetic community when they figured out that not only do we have to figure out which gene folks, Osi are involved in a particular illness or in the underlying propensity toward a particular illness, but genes spend a lot of their time talking to each other, and genes will either increase or decrease the activity of other genes, which is a hugely exponential process and likely, however, underlies many of the adaptations that occur in response to the environment. One of the things that Dr. Peter was saying that is absolutely correct is we are born with a

very plastic brain. We have certain genetic propensities and epigenetic propensities, but by and large, our brain is made to interact with the environment. And there have been any number of studies suggesting that if someone with the underpinnings for this disorder

is born into a hostile, rejecting, neglectful, abusive environment, it increases the probability that they will wind up with a clinical illness. Whereas a positive, nurturing, empathetic environment,

starting with the same biology tends to decrease the pathologic outcome. Yeah. There's a study that came out in 2021. I shared with you, Dr. Pro. Arens, 2021, where they found that epigenetic alterations, more frequent in genes controlling oestrogen regulation, neurogenesis, and cell differentiation, which may be modified by early childhood trauma.

So these early childhood events, trauma, modulate the magnitude of this epigenetic alteration that we see in these genes with borderline per size disorder. So it seems like there's this change that goes on. And I think from what I was reading, there's a lot of stuff that's just not known at this point. And I'm sure this will be a place of continued research. And this type of research, I think, is pretty hard to do. because it's probably pretty expensive. Very difficult to do and frankly very difficult to understand just because of its complexity. We have about 10,000 of our genes are involved either directly or indirectly in brain development and brain function.

If you have 10,000 genes that talk to each other, we're just barely at the beginning. of being able to understand what those gene-to-gene conversations mean, basically. But it will be a rich area of research, because I think as we understand it more, we will have a better handle on what goes wrong and what influences both the adverse effects in the environment and, frankly, also makes potentially our psychotherapies more effective. Yeah. I was looking at a lot of attachment. and I'll probably do a separate episode on this, but I wanted to kind of put out some of these things

and get your perspective on this, Dr. Cummings and Dr. Pro. There was one prospective longitudinal study done by Carson in 2009 where they followed 162 infants who became adults and at 28, they looked at them again, so this is a pretty long and probably rather difficult study to do, where they found that borderline personality, borderline personality symptoms significantly related to relational experiences,

attachment disorganization at 12 months, maltreatment at 12 months, at 42 months maternal hostility had an R of 0.42, and this sort of early malevolent experience seemed to be pretty strongly associated with future. borderline per sali disorder, family disruption and related to the father's presence, family life stress, at age 12, emotional regulation, and issues with self-representation were highly linked. Any thoughts on early childhood and how this plays and what specific environments lead to people having more of these issues that we're talking about? Well, it seems clear from this and from earlier studies that childhood adversity in terms of growing up in a chaotic environment and unpredictable environment is associated with the loss of confidence in connectedness that Dr. Perrault was addressing earlier.

Many of the things that cause these people to be so desperate and to do things that are in a sense. advisable seeking connection is related to the fact that their early environment was chaotic. It was unpredictable. It was often punishing. You know, you do X and you get praise one day. You do X the next day and you get punished. If you're a young brain trying to figure out the world and what works and what doesn't, that makes that virtually an insurmountable task.

And you see that then reflected by these individuals in terms. terms of their relationships with others where they will either idealize the other, oh, you're absolutely wonderful, you're perfect, you'll take care of me, I know this will be absolutely wonderful. And then, of course, as soon as the other individual screws up or is perceived to screw up in some way, their response is, oh, you're terrible, you're awful. You know, it's a very black and white interpretation of the environment, often because their environment was very black, white, chaotic, jumbled.

you know, one of the chief things that young humans try to do is figure out how the world works. That's not very easy to do in an environment where the rules may change not only from day to day, but from minute to minute. I think, for me, a lot of looking at the new data that exists and looks at attachment and looks at how this presentation comes about, you get to see some of the myths come on done. I think there's, as mentioned already, you know, there's a huge stigma associated with the diagnosis. And I think 20, 30 years ago, there was a belief that these are people that have had some kind of trauma. There's something broken in them. And you just have to wait for it to burn out or for there to be the logical progression of the illness towards suicide.

And there was a lot of stigmatization in these individuals. and practitioners giving up and just saying there's nothing that can be done. And I think with more data that comes out with more understanding of heritability, with understanding the circuitry of the effects of therapy, you're able to see you can have an individual that had no trauma whatsoever early in life and still can manifest with these symptoms. And I think for me, treating physicians that had very clear symptoms of borderline personalities

or yet had no adverse early life experiences, made me first begin to look at that data because I was like, I looked and I looked and I looked. However, I can find through tracking, I can find a parent and or a grandparent that had substantial amounts of trauma and had very clear manifestations of this illness. And this is something that there is changes in the brain throughout the course of life that can then be passed down. And understanding that component is important not only for education of the patient, but also just as practitioners, understanding that this is something that is not cut and dry. This is not something where you just need to figure out what the trauma was. In addition to that, the knowledge that a lot of these therapies are leading to structural and functional changes in the brain that can be seen in fMRI. For me, that gives me so much hope.

and is one of the reasons why I love treating these patients because over the course of time, you can begin to see new skills emerge and new abilities to correct and new abilities to regulate, improved ability for portions of the prefrontal cortex to come online and the person says, what are my values right now? And what do I need to do about this? This is how I feel, but I don't need to act on how I feel right now. And to get to see a person's brain begin to do that over time for me is one of the most rewarding aspects of working. with these patients.

And knowing that as long as a provider, I hold these things at the same time, I can have more hope for their care and I can impart some of that in them at the same time. Yeah, I just want to give the study to that. Goodman, 2014, Dialectical Behavioral Therapy was found to attenuate amygdala hyperactivity at baseline, which correlated with changes in measures of emotional regulation and increased use of emotional regulation strategies. So the cool thing about, you know, how the brain interacts with therapy is that the therapy and the partial and this sort of like this repetitive work that's being done is actually changing the brain. It's so hopeful to me. I love that the book,

how the brain, the brain that changes itself. It's like the story of how the brain can like change over time. And it's like, it's not like this static thing that's like never changing. You know, so I don't like the idea of personality because personality seems chronic and unchanging where it's like, no, this actually can change. You can learn how to emotional regulate. It's hard. Like doing the work is hard. It is very, very hard. But knowing that there is hope is encouraging to me. And I like what you said, Dr. Pro, that it's not like a singular trauma that once you get through this singular trauma, this person is going to be different. I think that there's this sort of fantasy and maybe there's a couple cases where this happens, this one person works, there's one memory,

and then it's all better. But because it's so much attachment related and stuff, it's going to be through attachment that change occurs. Attachment takes time. Attachment is hard work. You're in the trenches. You're working through your own countertransference. You're working on staying empathic when at times it's difficult to stay empathic. Your own stuff gets stirred up. So you have to do your own work as you help people, you know? And so, it's a hopeful message that I hope we're putting out here

but also a message of the reality of like okay this is actually like something that's very difficult to do and we have to fight insurance companies which is even maybe our countertransference towards the insurance. My countertransference towards insurance companies is worse

than my countertransference towards patients at this point of my career. I don't know about you Dr. Pro I'm like watching you smile over there you're like yep. I I agree. I have to do a reframe and just remind myself that there are people in places that will abuse any system and that this exists as a result of that abuse and that I have to accept these limitations. If I don't reframe it that way, yes, I will lose my mind. And how many docks to dock do you do a week?

Probably four or five, and that's better than what it used to be. So if you're listening to this and you fantasize this idea of becoming a psychiatrist, and the sort of glory that we get to do, also know that there are thorns in our side, right? And it's often the people that we can't treat. The people who are making the decisions, like, there's a quota, and we can only allow so many days before this quota gets done. And so, like, there's certain times of the year that the quotas sort of get tightened, right? What are the worst times of the year? It's like December.

October to December. The last quarter. They're like, okay, finally we have to start saying no because we can only give so many days. Okay. Well, I want to make sure that we hit any points in this thing that you guys really wanted to hit on this. So Dr. Cummys, as we're sitting here, as we're talking about this, anything that we haven't spoken about that you really want to say, and then Dr. Perra asks you the same question. I think I just want to reiterate. something that you said that this is a disorder that requires a lot of work to improve.

However, it is not a hopeless diagnosis. It is rather hopeful. There aren't many other conditions we treat where half of the people recover and essentially no longer meet diagnostic criteria. Or like the mentalization data, which I'm probably most familiar with, it's like 86% So they did treatment for two years and then they followed them for five years. Like 86% did not meet criteria for borderline per seiz disorder. And most of those people were off medications, which is like mind-blowing if you think about being in the trenches.

The thing about if you're a resident out there and you're like, really, that just doesn't make sense. It's because you're seeing the patients who are coming back to the hospital. You don't see the patients who are doing better, which is part of the. of the problem of not being able to follow patients longitudinally until you get out of residency for years and years. It's like you don't see the good cases of like, oh, this person got the treatment and this person's doing well and they're at this other place in their life. No, as a resident when you're in the trenches or if you're an inpatient doctor, you see the people who are continually struggling, continually not getting or in the process of getting the care

that they need to overcome. You know, so I think that's another people. piece of hope I would give you out there if you're in the trenches. It's like, consider that you're part of this solution, a small part. And if you can do your role, it's to the best of your ability. It'll give the best chance that this person will have that long-term recovery. Dr. Pro closing remarks, closing thoughts. Yeah, I would definitely say, check out Dr. Trinkle's video. Check out the good psychiatric management handbook for clinicians.

the thing that I find that that's the best about this way of management is it doesn't have to pit mentalization versus DBT versus other. It says all of these things have good evidence. All of these things can work. Here's how you can incorporate them as tools in managing patients under a larger framework. And it gives a lot of really good ideas on how as a practitioner you can interact with a patient when a patient is being rude or nasty or manipulative. And so it is a modular approach for a clinician who's going to be managing these patients long term. And as a person where 30% of my patients that I work with have really, really severe borderline personality disorder,

it's something that has helped me to change the way I engage and interact with patients. And it's provided a lot of support for the way that I think about the disorder. And as Dr. Cummings was said, make sure that I've got a team working with me and not doing this on my own. because this is very, very difficult. But I think that I think having information and resources like these are good. And I think that having a team is one of the most important things to make sure that I don't get lost in this. And so even if it's just outpatient, me and the therapist being in close contact and, you know, texting or calling, you know, once a month or every few weeks, just the touch bases, then we're on the same page. But also it gives me support as the provider.

and if there's something I'm struggling with or frustrated with on the patient, I have someone to talk to who may have similar struggles, and by the time we're done discussing it, we both feel better and we're on the same page and we're ready to go after this and help this person. So I think doing this alone is one of the greatest reasons why people get burned out from the treatment. Yeah, you know, not that my program is for this population, but we often see people with medical issues with borderline per size disorder. And one of the things I've had to do is the medical director is to notice when there's some splitting going on.

And to see it in the context of, okay, this person is recreating the chaotic interpersonal world of their childhood in this treatment team. And so, you know, just like mom and dad were yelling at each other at times. Now that, you know, this therapist and the psychiatrist, they would be best yelling at each other. So they're going to try to recreate the chaos. And so to say that that might be going on and then to, empathize with how that's playing out in the team, I think it's very, very important. I think you run a really good team where you have a lot of cohesion, Dr. Pro, and that's probably been a huge point of your success.

And, you know, I just want to compliment you in that way. I've always been, I've always appreciated seeing how you create the cohesion in your teams. And I think that's just huge. I'm definitely grateful to have this as a resource in this region. A specialized DBT treatment program is not a part of every partial hospital program. It certainly requires more staffing, more time, more work. The patients are more acute. And at the same time, having the service to offer to the region, I think, is wonderful

because there are so many patients in this area that are in need. Very good. All right, guys. Well, thank you so much for taking the time to come on. I'm sure my listeners will appreciate it if you want the notes. go to the resource library and in the PDF, I'll put in the links that Dr. Pro talked about. So you could either go to Psychiatrypodcast.com or follow the show notes to that. And we'll leave it there for today.

Okay. Thank you. Thank you very much.