Speaking of Psychology - What is borderline personality disorder? With Carla Sharp, PhD

Episode Date: July 27, 2022

Borderline personality disorder is one of the most frequently diagnosed personality disorders, and one of the most misunderstood. Carla Sharp, PhD, of the University of Houston, discusses how BPD is diagnosed, defined and treated, how family members can help children and adults with BPD, and how the disorder fits in with researchers’ evolving understanding of personality disorders in general.   Links Carla Sharp, PhD   Speaking of Psychology Home Page Learn more about your ad choices. Visit megaphone.fm/adchoices

Today we're going to talk about the most frequently diagnosed personality disorder that many of you may never have heard of. But if you have, you might not really understand what it is because even its name is somewhat enigmatic. Borderline personality disorder is a condition marked by intense emotions that are typically hostile, angry, or depressive in nature. People with BPD may have a history of impulsive behavior and chaotic relationships. Many fear being abandoned and may tend to see the world as purely black or white. Some engage in self-harm or suicidal ideation, and what may be the most challenging about this disorder is that many people with BPD are able to project an appearance of total normalcy.

So what makes borderline personality disorder its own diagnosis? How does it affect people's trajectory in life? How is it different from other personality disorders? How might you tell if someone you know has, it or if you yourself might have it. And if people with BPD are high functioning and appear quote unquote normal, how can the disorder be diagnosed and treated? Is it really a discrete mental illness? And what makes BPD controversial among mental health researchers and practitioners? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association

that examines the links between psychological science and everyday life. I'm Kim, Mills. My guest today is Dr. Carla Sharp, Professor and Associate Dean for Faculty and Research at the University of Houston. She is also director of the University's Adolescent Diagnosis Assessment Prevention and Treatment Center and the Developmental Psychopathology Lab. She holds adjunct positions at the University of Texas, Baylor College of Medicine, University College London, and the University of the Free State in South Africa. Dr. Sharp has a longstanding interest in social cognition as a cause and correlate of psychiatric disorders across the lifespan with a special focus on youth. She has published over 300 peer-reviewed articles, numerous chapters, and eight books. A large

proportion of her research uses borderline personality disorder and other personality pathology to study where social cognitive function goes awry. Thank you for joining me today, Dr. Sharp. Thank you so much, Kim. I'm so glad to be here with you talking about this topic that's very clear. close to my heart. Well, let's start by talking about personality disorders in general. How does psychology categorize and define personality and personality disorders? And how is this area of psychology evolving? Well, that is a very big question, and I'm going to try and keep it succinct. The diagnosis of personality disorder is a disorder or a diagnosis in transition. For the last 20 to 30 years, since the publication of the DSM 3, we have been ascribing to a system of diagnosing

personality disorder that we call the categorical system. It is based on a medical model in the sense that we see disorder as something that a person has or does not have. You can think a little bit about pregnancy as an example. You know, you can't be halfway pregnant. You're either pregnant or you're not pregnant. And in the same way in the categorical system, diagnosis, we view someone as having a personality disorder or they don't have a personality disorder. Now, this has been the way we've diagnosed personality disorder since the DSM3, which was published in the 1980s. However, over the last 20 to 30 years, we have discovered that this categorical system has some limitations to fully understanding and treating personality disorder.

So one of the important data points in this regard is that when we take all of the personality disorder symptoms, and I should just explain first that there are in the categorical system, there are 10 personality disorder, 10 categories of personality disorder. And one of them is, for instance, BPD that you mentioned, borderline personality disorder. Another one is narcissistic personality disorder. A third one is antisocial personality disorder. So there's 10 of these personality disorders in the current system of diagnosing personality disorders.

When you take all of the symptoms of those 10 personal disorders and you put them together into a big factor analysis, you would expect you will get 10 factors pushed out by the factor analysis. This is how factor analysis work. If we want to understand a particular phenomenon, we put the signs and symptoms. of that phenomena into a factor analysis and we get one dimension out that explains that phenomenon. In the case of personality disorder, we want to be able to see if they really exist in nature, like the DSM would suggest, we want to be able to see 10 personality disorders come out

of a factor analysis. So we want to see the symptoms of BPD hang together to form borderline personality disorder. We want to see the symptoms of narcissistic personality disorder to hang together to form narcissistic personality disorder. Same with antisocial, same with avoidance, same with histrionic, all of those 10 personality disorders. What happens in actual fact when you put all of those symptoms into a factor analysis, it's a big mishmash of dimensions and none of these categories come out very clearly. And so this has been one of the first and most important signs that these categories don't exist in nature as we have always thought they did. In fact, when you do meet criteria for something like BPD, you probably also meet criteria for two or three

other personality disorders. When you do meet criteria for BPD, you probably also meet criteria, this makes a picture even more complex, for depression and anxiety and substance use disorder. We are now at a point in our history in the field where we have decided to move away from this categorical system of personality disorder diagnosis. to what we call a more dimensional system. And so when you open the diagnostic and statistical manual for mental disorders, the DSM, the fifth edition was published in 2013. When you open the DSM, you will actually find two parallel systems for diagnosing personality disorder. In section two of the DSM, you will find the old 10 categories. BPD will be there, narcissism will be there,

antisocial and so forth. They will all be there. But when you page, forward, you will find in Section 3, the alternative model for personality disorder. And this is the dimensional model for personality disorder. And that is where we are moving towards in the future. And I could tell you a little bit more about what that means and why that is important that we are moving towards this dimension. But I'll stop therefore now and see if you have any follow-up questions about just the categories to start with. Well, it's very complex. and it's got to be a challenge then for clinicians who are trying to come up with a diagnosis. I mean, how could you actually say somebody has BPD if it overlaps with so many other things?

Or there are a certain number of traits, a kind of formula that says this person has BPD or has a different disorder? Well, at the moment, at present, when we use Section 2 of the DSM, which is what most clinicians still use, clinicians find it relatively straightforward to diagnose someone with BPD in the sense that there are nine criteria. So, you know, those criteria are affective instability, so mood instability, anger, suicidality, emptiness, identity disturbance, abandonment fears, relationship problems, and impulsivity. And so when a clinician meets someone and the person tells them that, you know, they don't know what's going on with them. They have a lot of relationship difficulties. They've been on an SSRI for a long time, doesn't seem to be helping.

They've tried all kinds of therapy. Doesn't seem to be helping. They still have lots of relationship difficulties. They're self-harm. They're suicidal. The clinician will start thinking this may be personality. disorder because the person is not responding to traditional treatment approaches for depression, anxiety, substance abuse. Usually that tells us that there's something extra going on in the

personality functioning domain. And so the clinician can then go through those nine criteria, and if the person meets five or more of those nine borderline criteria, then the person is deemed to be meeting criteria, clinical threshold for borderline personality disorder. And that's all fine and the clinician will then simply do what they do currently, which is diagnose BPD, diagnose depression, anxiety, substance use disorder, which usually hang together. If they explore a different personality disorder, a person may then meet criteria for another personality disorder as well. And all of that information goes into the person's chart and the clinician has the job to treat all of this co-occurring disorders at the same time.

And I think that is okay. That's how we've been functioning for the last 30 years. And we have moderate success with that. Once a person's been diagnosed with BPD, they usually get one of the frontline treatments for BPD, which is either dialectical behavior therapy, which is most common in the US, or they would get mentalization-based therapy,

which is more common in Europe. There are some other treatment approaches, too, that are evidence-based, like transference-focused therapy, schemer-focused therapy. And actually there's good evidence showing that good old CBT can actually be helpful for people with BPD as well. So there are ways in which we, that's right, cognitive behavioral therapy. So there are ways that this system has worked well enough, but we think we can do better.

We think with a new system of diagnosis, we can actually be more precise, in diagnosing people with personality disorder more generally. But we can also just make it a little less complex than having this co-occurring mismatch of disorders that each require their own manualized treatment. So the field has been looking for common factors, common dimensions that is shared by all of the personality pathology so that we can simplify this very complex process

that I've so far outlined. So how debilitating is BPD among the constellation of personality disorders? I think it is the most diagnosed personality disorder, and that is partly due to the fact that BPD appears to capture something that is common among all of the personality disorders. And I do want to talk a little bit about this dimension that I've been mentioning that is shared by all of the personality disorder.

So what is this dimensional approach that the field is moving towards that helps us better define personality disorder? So if you, I'm going to go back to factor analysis, which I introduced a little bit earlier, as a way of legitimizing disorders, right? If you actually do factor analyze all of the symptoms of personality disorder, what you do get out of that factor analysis in more recent studies is what we call a general factor, a general factor of personality functioning. Now, if your listeners have been hearing about how IQ works in the past, they will know that when we think about IQ, we think about a person with an IQ of 100 as having

average IQ. And we think about a person as having an IQ of 120 as above average. And a person with 140 as superior, right? And we would also think about someone at 70 as someone who is lower in IQ. So there's a common dimension, a general factor of intelligence. Now, within that general factor of intelligence, we can think about people that are very good at math, but not so good at language, or people that are very fast at processing speed, but they're not so good at math. So we can think about specific ways in which people differ on specific aspects of intelligence, even though their average, their general IQ, can be at a certain level. The field of personality has moved in that same direction, where we, rather than thinking

about the 10 categories, we are now thinking about a general personality functioning, a sort of personality quotient, if you will, rather than an intelligence quotient. Rather than IQ, we can think about personality quotient. And what we want to talk about when we think about your personality functioning is how good are you at managing yourself in the context of interpersonal interactions? How good are you at reading other people's interactions, reading their minds, and managing yourself when you are busy interacting with other people? So the shorthand version of this is adaptive or maladaptive self.

and interpersonal functioning. And that appears to be the general factor of personality functioning. How good are we at managing the self in the context of our attachment relationships? How good are we at managing the self in the context of interpersonal relationships? If you're good at that, then you have a high personality quotient. You're doing pretty good on your personality functioning. If you're poor at that and you get dysregulated really easily, you get defensive really easily, you start compensating in the interpersonal interactions, you get confused about what's in your mind and what's in the mind of other people. You start projecting what's in your mind onto other people. You start blaming people and not owning what's going on for you rather than taking

responsibility for your contribution to the breakdown in a relationship. When we are in that domain, we are saying you've got low personality quotient. You're not doing so well in the personality functioning domain. And it seems that all that this dimension is the common factor for all personality disorder, whether you've got BPD or narcissistic personality or antisocial. All people who have problems in personality functioning struggle to manage themselves, to regulate their self in the context of interpersonal interactions. So to get back to your question, you know, how debilitating is BPD? BPD is debilitating, but I would, I think we, we're at time where we want to move away from the concept of BPD per se and just think about the general

factor of personality functioning as maladaptive self and interpersonal functioning and that we all lie on a continuum there. You know, I have good personality days where I'm well regulated and I have bad personality days where I'm not so well regulated. We all can identify with that. The question is do I get over, you know, average on most days in terms of of my ability to regulate myself in the context of interpersonal interactions. And if I do, then I need to seek help because then I probably have problems in the relational domain that needs a specific kind of treatment in order for it to get better. Right, right. So if it's interfering with your everyday life, then you should seek some treatment. I was going to just say,

if you're struggling at work to get on with people, and if you're struggling in your personal life to get on with people, then you know you're probably someone that struggles with personality functioning and you need to seek help from an expert or people that understand personality. So I wanted to ask a really basic question, which is what is the meaning of the term borderline in the context of BPD? What's the border between? That's a really good question. And it is a very interesting question as well because originally when the term was coined by Spitzer, he actually tried to articulate the border between psychosis and neurosis. And this was, you know, 60 years ago, more than 60 years ago. And at that time,

we thought about mental illness either as psychotic or neurotic. The neurotic disorders are, you know, the depression, anxiety disorders where there's not a real break with reality occurring. The psychotic disorders are the ones where there is a break with reality occurring like in schizophrenia. What makes personality pathology so interesting is that it really is neither, it's a little bit more than neuroticism, but a little bit less than psychoticism. So people with BPD or personality pathology, they don't experience a true break with reality. But sometimes they appear a bit psychotic because they seem so fixed and really, it in their view on what's going on. They could almost come across as being a bit delusional in what they think someone else is thinking about them in the absence of any good evidence. And so

that has made people think this looks like psychosis, but it isn't really psychosis. And it certainly doesn't respond to antipsychotics like schizophrenia word. But it's not as mild as neurosis, where there is a good sort of reality testing and a person can be easily, you know, reasoned with. It's very difficult sometimes with a person with BPD or personality disorder to reason with them because they get very, very fixed in their view of reality. And we call that in mentalization-based therapy, we call that psychic equivalence. What is in my mind is true. and to help they move away from this very fixed idea that what's actually in your mind is a

representation of reality. It doesn't necessarily map onto reality perfectly. It's a representation of reality that we can test and explore and put to the test to see how true it actually is. So that was what border originally meant. So one of the areas where you have done some groundbreaking work is around diagnosing BPD in younger people in adolescence. Can you talk about that? I mean, adolescence is a time of stormy emotions, moodiness, confusion. I mean, how could you diagnose a kid as having BPD when,

you know, he or she is still going through all of this developmental turmoil? Oh, absolutely. So you're right. We, up until about 10, 15 years ago, even though it was allowed in the DSA to diagnose BPD, and a young person and a person below 18 years of age, we really did it. Because there were these myths about personality and personality functioning in young people, one of the things that we thought was that personality wasn't stable until people reached the age of 18. And, you know, when you wake up with your 19th year after your 18th birthday, people thought, you know, suddenly you had a stable personality and yesterday you didn't.

Of course, that's not true. We now know from temperamental research in children that actually little babies coming to the world with very, quite stable patterns of approach and avoidance behavior. Some babies are smiley, open babies, and they like new experiences. And some babies are avoidance babies. And they just need a little bit more from the environment to help them feel calm. And so those are temperamental traits that become personality traits as they begin to interact. with the environment. And so these stability coefficients turn out to be as stable in children, adolescents, as they are in adults. So the idea that personality isn't stable in adolescence

was pretty much debunked a few years ago already. The other idea that people had was that, you know, there is this normative increase in personality. flavored disorder, you know, all adolescents, like you said, are a bit more emotional. They do get more impulsive. They are a little bit more self-centered, all of them. And that is normative. So how do we know whether a 15-year-old who is impulsive and emotional and egocentric have narcissistic personality disorder or whether they have BPD?

And so that was the other, one of the other myths that people had and made them reluctant to to diagnose BPD in young people, they thought, well, they'll grow out of it. Turns out that a good proportion of young people who show that normative increase in borderline traits during adolescence do not grow out of it. And so it still is an important clinical decision to make whether this young person, are they on a trajectory to stay high in terms of borderline traits through adolescence and never really go down again like their peers, because what the normative increase eventually shows a normative decrease again

in borderline traits by about 25 years of age, most young people normalize, and they don't show this sort of upheaval in terms of emotion dysregulation that they showed when they were 15 and 16. But a proportion of young people get stuck. And so the clinician's job becomes to be able to predict who's going to be stuck and who's not going to be stuck. When I see young people in our clinic, who's 15, who meet criteria for BPD,

I usually look at some of the protective factors in order to decide, is this a young person who's going to be stuck, or is this the young person who is going to show the normative decrease? And so I would say to a parent, you know, your child meets five criteria for BPD right now, but I don't think it's going to stay because I can see that, the child is getting a lot of scaffolding at home. You're slowing down a lot around emotional content. You're patient with her. You stay with her. You validate her emotions. You're here seeking help from us. That's a good sign. We need to make sure that she has a life, that she continues to do sports and cultural activities so that she continues to feel engaged. Here are all the things

that we can do to scaffold the personality consolidation. But sometimes I see a young person who doesn't have that protective factors. And then I would tell the parent, you know, I do think there is some risk here that she can get stuck and that she can't, she won't sort of get relief from these symptoms as she age out of adolescence. But here's what I think we need to do in order to make sure that she shows the normative decrease that her peers would. So I think that becomes the clinician's decision point, you know, is what other protective factors are in the environment to help a young person follow her peers down the normative trend versus get stuck and continue to have this elevation of borderline traits through through adolescence and young adulthood.

So I want to talk a little bit more about parental involvement here. and I'm wondering about the theories around the causes of BPD. So is it, if you happen to be the child of, say, a parent who is borderline, might you learn those behaviors and begin to exhibit them yourself as a young person, or is it the result of trauma, or do we not even know? You know, I think there is a relatively good evidence to suggest a 55% heritability for BPD and for personality disorder in general. So these traits of impulsivity, of emotion dysregulation, you know, most young people who, and people with BPD are described as people who have a

sensitive temperament. From the time they were young, they evidenced what we always refer to as thin skin, you know, their feelings are hurt easily and they feel slighted easily by others. And so I do think there is a temperamental biological component. Marsha Linehan's theory, Marsha Linehan developed dialectical behavior therapy, which is one of the main therapy approaches for BPD. And Marsha Linehan's theory is called a bio-psychosocial theory for BPD. And she acknowledged that there's a strong biological component to BPD,

which I think the data has borne out. But there are plenty of people who come into the world with a sensitive temperament who don't turn out to have BPD. And those are usually folks who have had a caregiving environment where the parents somehow found the patients and the reserve to meet that temperament halfway. You know, there used to be a time when parents were blamed for personality disorder and I'm so glad we passed that. I still see that sometimes among clinicians and wherever I go, I try to promote the idea that parents are not to blame for the development of personality disorder because it's very difficult to parent a child with a highly sensitive temperament.

They do ask more of a parent. And, you know, I remember so clearly one mother once told me she had a young person with BPD and she said, you know, when I asked her to put her shoes away, she would find that invalidating. And so a parent has to work so much harder when they have a child with very, very thin skin, with very, very sensitive temperament to really slow down. And that's if your audience can take away any nugget of truth that I've learned over the years, it's slowing down. So how do you ask a child with a sensitive temperament to put their shoes away?

Most parents, including me, will just say put your shoes away. but if you're aware that you have a child with sensitive temperament, then you are going to have to say, you know, I can see that you're busy with your iPad right now. We're going to have guests coming over in a few moments. Can I ask you that you put your shoes away? So you can see that took longer, 100% longer than can you please put your shoes away. But when you're dealing with a child with a sensitive temperament,

you're going to have to slow down and you're going to have to build into your schedule, time to create an environment that doesn't feel invalidating to the young person. Of course, with the necessary balance as well, you can't have a laissez-faire environment either where anything goes. You'll have to just work really hard as a parent to get the balance right between I'm validating where you might be coming from, but I also have needs as a parent and our environment has needs and rules that need to be followed. But slow, Down is the main advice that I have for parents with children with sensitive temperament. The time that you take to slow down in the moment today, you're going to save 100-fold over

in years to come when you're avoiding inpatient treatment and all the kind of crises that go with a young person with BPD. Does that same approach work with an adult who has BPD? I mean, let's say you're in a relationship with somebody who has a lot of these characteristics. characteristics, do you have to behave in that way in order to accommodate the way that they react? Absolutely, absolutely. So in the therapy approach that I use most often is called mentalization-based therapy. And this slowing down is really what we call the mentalizing stance. And the mentalizing stance is the stance that we take in order to help another person feel understood or

validated. If you use DBT language, you would say you make another person feel validated. In MBT language, mentalization-based therapy language, we say we make a person feel understood. People with BPD have almost an existential feeling of being misunderstood. They feel very alienated, not only from society, from their family members, but also from themselves. They don't feel homie in their own bodies. They don't feel comfortable in their own bodies and it's a very, very lonely existence. And so what family members can do and therapists for people with BPD is to help them feel understood. And we only help people feel understood when we slow down. And when we put our mind on the table and say, you know, this is a dilemma for me. On the one hand, I feel I want to help you with this.

on the other hand, I feel I don't want to interfere with what you're busy with. Where does that leave us? In putting your mind on the table like that, in explaining rather than jumping to conclusions or taking shortcuts, you instill in the recipient of your communication a feeling of being understood. So absolutely, you're absolutely right, Kim, for both for children, but also for adults in our lives, but also therapists. We slow down. it's the only way to go with people with with BPD.

Last big question, what are the next areas of critical research for BPD? We absolutely have to move the field to the dimensional system. So we have to get away from the categories. And I hope the next time I speak with you, I don't even talk about BPD anymore. And I talk about personality problems writ large or personal. personality difficulties or personality challenges or maladaptive self and interpersonal functioning rather than talking about BPD. I think BPD has become so stigmatized.

We have so many wrong ideas about BPD and people with BPD that and to understand that all of us have bad self and interpersonal days. None of us can always be perfect in our management of interpersonal relationships. It's our biggest challenge every day. And yes, people will. with BPD or with personality disorder will have more occasions when they lose it with people, but we all can relate to that and to put that on the same dimension and to acknowledge the continuum between typical and atypical personality functioning is where we need to go.

So I think there's a lot of empirical research in support of these ideas. What we now need is the treatment research that shows that when we use the dimension to identify people into our randomized control trials for personality pathology treatment. We have the same effects as when we categorize people into BPD and we enroll them into our treatment trials. So I think the next big step for us is to do randomized controlled trials with alternative model defined personality disorder and not the old categories. That's definitely the biggest new challenge for us. Well, Dr. Sharp, this has been really interesting. I appreciate you're taking the time to talk to me today and to explain this really complicated disorder. Really, thank you so much.

Thank you. It was my pleasure. You can find previous episodes of Speaking of Psychology on our website at www.spokenof psychology.org or on Apple, Stitcher, or wherever you get your podcasts. And if you like what you heard, please leave us a review. If you have comments or ideas for future podcasts, you can email us at speaking of psychology at APA.org. Speaking of Psychology is produced by Lee Wynerman. Our sound editor is Chris Kondyin. Thank you for listening. The American Psychological Association, I'm Kim Mills.