Borderline Personality Disorder

It hit me like a rock in the back of the head: a vicious complaint from a patient that had me reeling. What could I have possibly done to deserve such harsh criticism? I don't want to play the victim here, but even to the casual observer, it would be obvious that the complaint was excessive, cruel and unmerited. I'm not the best doctor, not always in the best mood, not always as respectful of people as I should be, so I took it in stride. Then I reviewed the patient's chart and saw the diagnosis. Aha. That explains a lot.

Bordeline Personality Disorder is a mystery. I'm writing this blog post in the spirit of seeking understanding, because I imagine that there are many people in all walks of life that have been the victim of this behavior, and I thought it might be cleansing to share my thoughts and have others share theirs.

I remember this feeling of being attacked, from years ago, when I was on the speaker circuit. Reading the audience reviews, after the talk, I sat bolt-upright and started sweating. Did I really say that? Did I use that tone? The scariest part was that, yes, I may have.

So, it occurred to me that people with Borderline Personality Disorder are not wrong. There is always an element of truth to their complaint. It's just that it they are so harsh, so lacking empathy. Why are they like that?

Why are they so quick to attack others, self-rightiously, without any reflection on themselves? 2) Why are they so primed for injury? 3) Why do they lash out with vengeance? 4) Why do they have no awareness of how the recipient of their wrath might be affected?

Basic Facts About Borderline Personality Disorder

• Definition: Borderline Personality Disorder is a mental health condition characterized by pervasive instability in moods, behavior, self-image, and functioning.

• Prevalence: BPD affects approximately 1.6% of the adult population, though some studies suggest it may be as high as 5.9%.

• Diagnosis: The diagnosis is made based on criteria outlined in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), which includes patterns of instability in interpersonal relationships, self-image, and affects, along with marked impulsivity.

• Causes: The etiology of BPD is believed to be a combination of genetic, environmental, and social factors. Childhood trauma, particularly emotional or physical abuse, is a significant risk factor.

• Treatment: Treatment options include psychotherapy (such as Dialectical Behavior Therapy), medications (like mood stabilizers or antidepressants), and support groups.

  
  

Characteristic Behaviors of Individuals with BPD

• Emotional Instability: Individuals often experience intense emotions that can change rapidly, leading to mood swings.

• Fear of Abandonment: There is often an overwhelming fear of being abandoned or rejected, which can lead to frantic efforts to avoid real or imagined separation.

• Impulsivity: Individuals may engage in impulsive behaviors such as spending sprees, substance abuse, or reckless driving, often as a way to cope with emotional distress.

• Interpersonal Relationships: Relationships can be intense and unstable, with individuals oscillating between idealizing and devaluing their partners.

• Self-Image Issues: Many individuals with BPD struggle with a distorted or unstable self-image, which can contribute to feelings of emptiness or lack of identity.

• Self-Harm: Self-injurious behaviors or suicidal ideation can occur as a means of coping with emotional pain.

• Chronic Feelings of Emptiness: Many report feeling empty or bored, leading to a search for fulfillment through relationships or activities.

People with Borderline Personality are especially badly treated by the medical profession. We just don't get them. We treat them as a threat and we ice them out of the therapeutic process. They are often at the sharp end of the exclamation: Get Out of My Emergency Room!

First, to be fair, we have to agree that there is a certain dysfunction there. We're not being defensive for nothing. But we have to admit that our track record for helping people with BPD is not good, and we have not created a way to understand them without attacking them.

I don't pretent to understand BPD, but from what I have read, and heard at conferences, it has a lot to do with trauma. The trauma sets them up to be a) sensitive to the emotional environment, to prepare for trauma should it be in the air. b) defensive as a coping mechanism to being frequently attacked. c) vicious, because that's how they have been treated and d) in the early stages of the relationship, be inclined to either side with their attacker (Stockholm Syndrome) or become the attacker. That's the hot-cold, love them-hate them, black-white nature of their disorder.

It's taken me decades to even come close to appreciating how to talk to a patient with BPD without getting defensive. It's hard not to dislike someone who is being difficult.

If I pay attention, I can notice this dynamic creeping into the conversation. That helps me find the empathy to recognize that they are not aware of how they are behaving. That's the best that I can do.

Understanding the BPD-provider relationship

If I dig into the essence of BPD, I understand why it's so difficult to help. People with BPD struggle with the reptilian reflex of assumng that they are being attacked. Can you blame them? They have been attacked, more than you or I could ever imagine. They are as sensitive and untrusting and as afraid of abandonment as anybody would be given the lack of safety, lack of validation, lack of care that they would have likely experienced.

They say that people with BPD lack an attachment object. That's someone who reflects your best traits back to you, accepts you as you are, and earns your trust. Well, if you listen to the history of childhood adversity that many people with BPD recount, you can imagine how they might never have had such a person in their life.

The scary part is that not having had that kind of acceptance, they don't let people get close, what we called avoidant attachment, and so they unwittingly perpetuate the scenario of not having anyone close, who would help them get some practice at the challenges of human attachment.

Then it's not hard to understand how a person with BPD would not vibe with the typical rushed MD who just wants the facts and reminds them of someone who would in the past have invalidated them. That triggers the push-back behavior which results in another fractured relationship, pronpting the person with BPD to say, 'You see, nobody loves me'. And they'd be right.

Another observation is what I call: misperceive-overreact. People who have experienced even moderate trauma, have their danger radar on high. That means they are right, some of the time, but most often misperceive danger when there is none and react as if there is more danger than is really the case. It's a bit of a lose-lose trait because the real danger, likley was in childhood. People with Borderline Personality Disorder are acting unwittingly as if the danger is right now. If you're in the same family, a relationship or a workplace with them, it's not subtle. You are going to feel them.

So how to solve this impasse? To be honest, I don't think the solution is going to come from the traditional medical model. for starters, people with BPD need longer relationships to get them close enough to trusting someone to be able to resist their typical reptilial reaction. Our current EAP counseling model is often also too rushed, leaving the person with BPD with precious few opportunities to bond within a therapeutic relationship.

Treating BPD

That's why it is my humble opinon that psychedelic assisted psychotherapy might be a good fit. If we can show that psychedelics can allow people with BPD to review their past in a less blameful light and slow doown their automatic reaction to push people away, then they may be able to generate the kinds of supportive relationships that will allow them to put a toe in the water and slowly make their way into the more fulfilling relationships that allow them to unblame themselves and unblame others. remember Good Will Hunting?

If you had a therapist as patient as Robin Williams, maybe you'd be in luck, but it does not often turn out that way. Psychedelics have a way of adding a turbo boost to therapy which allows patients to move towards healthier thoughts faster.

The world of psychedelic research is moving steadily towards newer molecules, better data and more permissive regulation. Hopefully someday we'll have enough good data to convince the insurance industry to fund psychedelic assisted psychotherapy as a cost-effective way to address the massive carnage associated with the common and costly problems caused by early childhood adversity.