ADVICE ON MENTAL HEALTH: Understanding Borderline Personality Disorder

advice on mental health – from brain & behavior magazine, may 2022 issue

q&a with anthony c. ruocco, ph.d., c. ψ-ch.
university of toronto professor,
interim graduate chair and director of clinical training,
deptment of ψ-chological clinical sci
2014 bbrf young investigator
families for borderline personality disorder research investigator

dr. ruocco conducts research atta ∩ion of clinical ψ-chology, neuroψ-chology, and cogg-affective neurosci. his focus s'on externalizing ψ-chopathology (disinhibited behaviors, personality disorder diagnoses and traits, substance use disorders), suicidal thinking and behaviors, and depression, with pticular emphasis on executive functions, espeshly cogg control.

dr. ruocco, personality disorders (pds) are remarkably common inna pop, perhaps affecting as many as 9% of adults, according to the national institute of mental health. bout 1.4% of u.s. adults (over 3 million) experience borderline personality disorder in a typical yr, the nimh says, making it the most common pd. but you don’t hear very much bout bpd or other pds. is this due to stigma?

inna current dsm classification system, there are 10 distinct personality disorders. i study borderline personality disorder, in pticular. regarding bpd, i ‘d say, yes, thris a stigma, but i ‘d say we’re starting to see change. we’re starting to see + pplz talking bout it. although not as much, perhaps, as bipolar disorder, or autism, or depression, or schizophrenia.

one problem associated w'da diagnosis s'dat many med professionals don’t know enough bout personality disorders or how to treat them. you hear the story of the parent who goes to a local clinic and tells the dr, “i think my child has borderline personality disorder.” na dr replies, “well, we don’t actually treat pplz with that diagnosis at this clinic.”

not cause they don’t wanna, i assume, but cause they don’t know how?

yes. the honest answer in such a case mite be: “we don’t ‘ve the expertise.” generally speaking, treatment for bpd does nd'2 be speshized to be effective. cause of this issue, many parents are bein’ turned away and their children—often in their l8 teens and early 20s—are aint receiving the care they need. this can ‘ve real life and death consequences.

let’s start with some basics. wha’ does it mean, exactly, to say some1 has a personality disorder? it somehow sounds primordially ≠ from saying a'pers has depression or schizophrenia.

inna way they ‘ve traditionally been defined, personality disorders can involve disturbances in up to 4 zones. one zone is identity: how you perceive yrself, and yrself in relation to other pplz. a 2nd zone is disruption in interpersonal functioning—how you rel8 to other pplz. those two zones are titely rel8d. a third zone of potential disruption inna classical definition of pds is inna zone of impulse control. finally, one can see disruptions inna regulation of emotions, or wha’ we sometimes call affective stability.

there ‘ve been proposals in recent yrs to revise the way we clinically define pds. the l8st research suggests that while problems with impulse control and emotion regulation can be pt of the clinical picture, it’s likely that disturbances in one’s identity and how one rel8s to others that forms the core offa personality disorder.

in this discussion, you and i will focus on 1-odda pds, borderline personality disorder. i ‘ve to ask bout the term “borderline.” wha’ does it mean?

some pplz ask me, “does it mean i’m atta borderline of having a personality disorder? or does it mean something else?” in fact, when ur diagnosed with bpd t'does mean you ‘ve a personality disorder. but'a term “borderline” is a legacy of the original notion of the illness, from decades ago, when clinicians were unclear as to whether some1 had ψ-chosis, or whether they had some form of wha’ was then called neurosis.

“borderline” came inna'da picture cause some pplz with bpd can appear “ψ-chotic-like,” and atta same time, ‘ve a severely unstable mood. when they’re experiencing high lvls of sufferation, they can experience difficulties with testing “reality.” they mite feel strongly that some1 is out t'get them, or they may ‘ve dissociative experiences in which they may feel they’re floating above their body—or, that the realm has sloed down; or, they ‘ve disruptions in their memory and time lapses they can’t account for. atta same time, patients with bpd were described as having a very unstable mood, which ‘d exacerbate their ψ-chotic-like experiences. these are somd' reasons why the terms “borderline” was originally used and t'has remained pt of the terminology.

but to be clear: tody, bpd is + strongly associated w'da emotional components of the original conceptualization— it’s largely thought of as a disorder centering on emotional dysregulation, and to some extent, impulsive behaviors.

onna other hand, that aint all that is involved, rite?

exactly. there are other types of symptoms. but'a way many major theorists think bout it these dys s'dat emotion dysregulation mite actually be the reason that pplz with bpd, for ex, ‘ve problems having a stable sense of identity— cause their emotions are so up and down, it’s hard to ‘ve a sense of who ur. wolso' think they ‘ve difficulties with controlling their impulses cause their emotions mite be so intense t'they do things tha're out of toon 4'em.

why not, then, call it “impulse control disorder”? perhaps that ‘d carry less offa stigma?

ur not the 1st person to suggest something like this. dr. marsha linehan, who is 1-odda main figs inna field of borderline personality disorder and developed dialectical behavior therapy (dbt) to treat it, proposed the term “emotion regulation disorder.” that bein’ said, bpd can be expressed in a range of additional ways. it’s primordial to try to capture those, too.

if i hear you rite, the aspect of the disorder that has to do with uncertainty bout one’s identity and/or a shifting perception of the self and one’s relation to others, maybe but isn’t necessarily rel8d to “emotion dysregulation”—and these other common aspects of bpd are primordial to keep in focus?

yes. another thing s'dat the disorder really differs from one person to another. one can be highly emotionally dysregul8d and highly impulsive, b'that doesn’t necessarily capture whether the person has + of an identity or interpersonal problem. often pplz with bpd ‘ve a really unstable sense of who they are. they’re very fearful of pplz abandoning them. they ‘ve really chaotic interpersonal relationships. they may ‘ve anger difficulties. these are all aspects that can also be pt of the picture.

let us now turn to bpd as tis defined inna current 5th edition of the dsm. wha’ kinds of traits are mentioned in dsm-5 and how many o'em do you nd'2 receive a diagnosis?

anybody who’s goin to receive a diagnosis needo meet wha’ we call the general diagnostic criteria for a personality disorder. that’s inna dsm, n'it includes having a disturbance in at least two of 4 domains, as i mentioned earlier: identity, interpersonal functioning, impulse control and emotion regulation. that’s the starting point. for bpd specifically, you nd'2 meet any combination of 5 of 9 potential symptoms. impulse control symptoms involve things like substance abuse, binge eating, reckless driving, etc. these in turn often go hand in hand with suicidal behavior. the latter can include self-harm without the intent to die and self- harm w'da intent to die, which are often rel8d to pplz’s emotion regulation abilities and impulse control. pplz with bpd can be set off easily in terms o'their emotions and ‘ve a difficult time gettin back to their baseline emotion, cause they tend to be so highly reactive. they find it difficult to control their emotions. acute episodes like this can last several hrs. often wha’ pplz talk bout as bein’ 1-odda most impairing aspects of bpd is feeling out of control of one’s emotions and feeling like they’re experiencing their emotions very intensely. in addition to this, patients sometimes express fears of abandonment. this is one od’oda interpersonally relevant symptoms. another symptom that’s relevant to interpersonal functioning, as i said earlier, is chaotic, turbulent, up-anddown relationships, where pplz with bpd will view others in an “all or nothing” way.

this is splitting tween “all good” and “all bad,” n'it can shift— the view offa'pers can go from +, maybe unrealistically so, to unrealistically neg, and rather rapidly, rite?

exactly. it can be a really rapid shift, and we think this can contribute to chaotic relationships and having a really hard time maintaining relationships. this often comes out in a familial context swell. so many of the pplz that we’ve studied aren’t in contact with family members cause of this history of chaotic relationships.

another trait often seen in bpd is outward displays of anger, where pplz are breaking things, or constantly experiencing feelings of anger, and really having a hard time regulating it and having that anger subside.

in contrast w'da symptoms i’ve sfar mentioned are two contrasting traits of the 9 mentioned inna dsm. the 1st is a pervasive sense of emptiness. and, as i mentioned earlier, pplz with bpd may also ‘ve sufferation rel8d to dissociative experiences, i.e., disturbances in one’s sense of reality that occur under sufferation. also, pplz with bpd ‘d, when they’re under sufferation, experience suspiciousness and paranoia round pplz they normally trust. so u can see it’s a'bitto a mixed bag, but at least 5 of these symptoms in combination is wha’ leads to a bpd diagnosis.

and bpd is often comorbid or co-occurs witha № of other ψ-chiatric diagnoses?

yes, bpd is comorbid witha wide range of diagnoses. most comm1-ly, these include depression, espeshly chronic, long-standing depression. it can also be co-diagnosed with post-traumatic sufferation disorder (some ‘ve proposed that bpd mite be a form of complex ptsd). bpd is also comorbid with substance-use disorders, whether it’s alcohol or other substances. occasionally bpd overlaps with bipolar disorder, but i think of this mainly inna zone of mood instability. the two can sometimes be confused n'it’s primordial for patients t'work witha ψ-chologist or ψ-chiatrist with expertise in bpd to cogg whether one or both of these disorders mite be diagnosed for a given person.

and wha’ bout adhd?

yes, we see high lvls of comorbidity with adhd, which is interesting to me cause i study cogg, and a lotta pplz with bpd reprt difficulties with attention and memory. interestingly, adhd is also associated with impulsivity. so there’s a lotta overlap inna symptoms of these disorders. the other piece that i think is really primordial to note is bpd’s co-occurrence with social anxiety disorder. social anxiety is often 1-odda + impairing aspects of bpd.

is there a common element of social avoidance inna two?

there can be. in bpd, as we’ve discussed there can be a fear of rejection. cause of interpersonal problems, and how easily a'pers with bpd can be emotionally triggered, some pplz tend to avoid social contacts and they can become isol8d. fear of rejection is such a painful experience, and avoidance maybe an adaptive thing to do inna shortrun. but this has consequences ‘oer the longer term for feeling connected to other pplz, feeling that you ‘ve a social support network, bein’ able to rely on other pplz for support.

is it true that + ♀s than ♂s ‘ve bpd? or s'dat + offa myth than reality?

wha’ i think can be a bit deceiving s'dat when you read research on bpd, often the pplz who are studied are women. i think the reason s'dat women tend to be + likely to seek treatment. and often, when pplz are doin’ research, they’re recruiting from a clinic. and so we see treatment-seeking samples often bein’ highly skewed toward women. however, if you study pplz at a pop lvl, you start to see a gr8r balance in how many pplz of each gender are affected.

dr. ruocco, yr field is clinical neuroψ-chology. please explain the relation of yr experience with patients with yr work in research to discover wha’ maybe driving the symptoms of bpd.

my training was atta ∩ion of ψ-chology, ψ-chiatry, and to an extent neurology. integrating them s'been one theme of my career. as a clinician, i’ve seen a lotta pplz with personality disorders, and ‘ve been involved, i ‘d think, in diagnosing hundreds o'em. wha’ i ♥ bout wha’ i do is trying to apply wha’ we're learning bout the biology of the brain to a disorder like bpd.

inna titles offa № of yr papers on bpd there are references to the frontal and limbic regions of the brain. tell us bout the significance of those regions.

we often refer to regions deep within the brain, s'as the amygdala—1-odda brain zones central in processing fear and emotion—as pts of the limbic system. we tend to think bout the limbic region as a somewha’ + primitive pt of the brain that is reacting to some type of an event—tis engaged n'our response to stimuli.

in contrast, we ‘ve “higher,” regulatory regions of the brain that come online, as the name implies, to regul8 the emotion centers. the regulatory regions can be called frontal regulatory regions. the frontal, functionally + advanced regions of the brain evolved to presumably impose control over those + primitive systems.

in pplz with bpd, my research na research of others has found gr8r activation [than typical] inna limbic regions, espeshly the amygdala. my research has also highlited h8ened activation inna insula—a brain structure that appears to be involved in how intensely somebody experiences emotion. these two limbic-rel8d regions tend to be overactive in pplz with bpd.

the frontal regions of the brain that we believe are involved in regulating the limbic regions tend to be underactive in pplz with bpd. and so u start to see, perhaps, one component of the biological basis for bpd, an imbalance tween the emotion-generating centers and an inadequacy of the controlrel8d regions. this ‘d help explain why we see emotion dysregulation in pplz with bpd.

the findings you sketch out in broad terms are based on imaging that yr team has performed while pplz with bpd ‘ve performed tasks, rite?

probably the most common way that we study emotion in pplz with bpd is by presenting “emotional faces” to them— pictures of pplz—while imaging the brain in real time. another method is to ‘ve pplz with bpd generate written scripts—to literally write down an account offa time when they were abandoned by somebody. they write that down, we ‘ve them read it, and record it, then play the tape to them when they’re inna mri scanner. we hope in this way to invoke responses tha're specific to that person’s history.

then, in terms of better cogging of impulse control, one thing we do is present pplz witha very simple task, like pressing a button every time they see a letter of the α-bet that comes up na' computer screen, except for, let’s say, an “s.” that means if an s comes up onna screen, they must withhold their response. if we ‘ve somebody do that for, say, 15 minutes, we’re building up their response tendency. whn'we infrequently present the s, they nd'2 control that. we study brain activation that occurs during those infrequent “stop, don’t press the button” moments.

and wha’ ‘ve you discovered by doin’ this?

wha’ we found n'our recent family study of those with 1st-degree relatives with bpd was that pplz with bpd show less activation inna frontal regions of the brain that we think are primordial for bringing this inhibition to the fore. interestingly, we expected that family members ‘d show a similar type offa pattern. but instead we saw an overactivation inna frontal lobes of relatives. twas unexpected; the effect was quite robust. we think this may indicate that the close relatives of pplz with bpd mite be compensating for a trait they share with their relatives with bpd. the difference bein’ t'they ‘ve a + capable regulatory system, so they can actually switch it on and maybe turn up the regulation, n'it works 4'em.

b'we went onna discover, also unexpectedly, that even if you compared relatives of pplz with bpd to controls who don’t ‘ve a family history of mental illness or a relative with bpd…the relatives of pplz with bpd still showed even + activation of control regions than the μ person. we don’t really know wha’ this means, but it ‘d mean the relatives ‘ve some unique functioning within their brains that comes online when they nd'2 control their behavior.

but regarding the bpd patients themselves. how do yr discoveries sfar bout limbic and frontal regions inform the way we approach treatment?

i think there are two potential treatment implications. if these indeed are the regions tha're activating ≠ly in bpd, maybe intervening atta lvl of the brain ll'be therapeutic and help to control or reduce symptoms. thris emerging research to suggest that using a wide range of non-invasive brain stimulation tek knicks ‘d potentially help, including transcranial magnetic stimulation (tms) and wha’ i’m studying with help from my bbrf grant, magnetic seizure therapy (mst), which is a newer form of brain stimulation treatment that’s rel8d to ect. these types of treatments seem to be not 1-ly improving symptoms in some pplz with bpd but they mite also be having an effect onna brain. at this point, it’s too early to say precisely wha’ effect. but thris some indication that the brain is changing, and that symptoms are changing. we nd'2 know +.

mst is non-invasive, but does involve inducing a therapeutic seizure?

the patient is under general anesthesia, but mst is non-invasive inna sense that nothing is surgically implanted inna brain. in mst, magnetic field pulses are directed inna'da brain through a magnetic coil and produce a seizure. mst is applied in a + targeted way compared with ect. 1-odda benefits of bein’ + focal s'dat you see fewer side effects than with ect, including cogg side effects s'as memory loss. the seizures are generated, course, in a highly controlled environment and are thought to be changing the functioning of the frontal region where they are targeted. this research is done in collaboration with physicians who are experts in brain stimulation.

wha’ are the impacts on symptoms?

generally, studies using mst show improvements in depression and perhaps in suicidal ideation swell. n'our research, it’s bein’ applied in a way similar to that in depression, but in pplz with bpd we’re also interested in whether it can potentially be used to reduce suicidal thinking, which ‘d ultimately reduce acute suicide risk.

we ‘ve read that bpd maybe caused by “a collision offa'pers’s genes and temperament with suboptimal or hostile environmental experience.” ‘d you comment on that hypothesis?

i don’t think bpd is necessarily all that ≠ in this context from bipolar disorder or schizophrenia, to cite just two exs. tis likely that major ψ-chiatric disorders s'as these are influenced by both genetic and environmental factors. for bpd, there’s a genetic component, a genetic predisposition. thris also an environmental component. some pplz with bpd experience wha’ is sometimes called an invalidating environment. you can also say, a sufferationful environment. a sufferationful, traumatic childhood, for instance. in many cases it ‘d well be these things in combination, not necessarily in isolation.

atta same time, some pplz with bpd who i ‘ve talked to will say, “i didn’t ‘ve a traumatic childhood, i didn’t ‘ve an invalidating environment. but i still ‘ve bpd.” so there are primordial differences, and not everybody looks the same. it’s primordial to ack that some pplz mite ‘ve + offa genetic component nother pplz gr8r environmental sufferationes. it’s plausible that those who ‘ve both are goin to be atta gr8est risk.

wha’ tis typical long-term trajectory of bpd?

generally, there tend to be ups and downs over time. but i think where the hope comes in s'dat when pplz enter treatment, within a few mnths, espeshly whn'we’re talking bout dialectical behavior therapy, the + severely dysregul8d behaviors, espeshly those tha're + life-threatening, tend to come under control.

and then over time, you see an improvement in symptoms, n'when they’ve been folloed up, many-pay shunt's experience wha’ is called remission, or periods when they no longer ‘ve the full symptoms. “recovery” is a ≠ ?, however. tis patient actually engaging with pplz meaningfully again? are they employed? do they ‘ve meaningful social interactions? this is where my research is goin. wha’ are somd' reasons pplz may not achieve recovery? mite there be cogg reasons? are there other reasons?

finally, if any of our readers wanna know + bout bpd, or are worried bout the mental health offa ♥d one or dear friend, wha’ ‘d you advise?

i always recommend starting w'da national education alliance for borderline personality disorder (nea-bpd). tis an excellent place to connect pplz with bpd and families with helpful resrcs. the specifics bout how to find help can vary dep'on yr geographical zone and access to mental health srvcs and speshists who treat pplz with bpd. the nea-bpd website has some very useful ?s for pplz to ponder as they think through where to find treatment and wha’ type and intensity of treatment mite be needed dep'na''pers’s specific situation. they also provide links to websites that cannelp you to narrow down yr search.

written by peter tarr, ph.d.

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