Borderline Personality Disorder

Good afternoon everyone. It's Dr. Niger again with our next edition of Psychology Unplugged. Thanks again for everybody who's been reaching out. It's been really helpful. Hopefully last uh week's edition on the pandemic uh shed some light on the importance and prevalence rates of mental health during this Surreal and bizarre time. Uh, the week prior I introduced the topic of personality disorders and today we're gonna focus on

Borderline personality disorder. Uh probably one of the more frequent topics that patients have asked me to elaborate on. And a lot of you guys who've been following our program uh have asked to get a better understanding of. So From my perspective, borderline is one of the most fascinating of the personality disorders. And it falls into the there's three clusters of personalities, cluster A, cluster B, cluster C. So in the cluster B group is the borderline.

the antisocial, the narcissist, and the histrionic. And other subsequent episodes will elaborate more on those. But borderline is constantly depicted in movies. It's a term that is used many times out of context and people referring to someone as you're so borderline, which really diminishes the significance and the severity of it.

And as I talked about in the personality episode These early foundations and tenets of who an individual is start at a very young age with personality being crystallized between five and eight years of age. Which as I said before i i is is scary.

So if we take the framework of borderline pathology and how I kinda use the model of my view of myself, my view of other people. my view of the world around me and the therefore's I draw. This would kind of be an example and again, as I've said, there's 120 different combinations, so this is just the general stereotypical one. I am unstable. Other people dictate how I define myself. The world is a dangerous place.

Therefore I will do whatever However, whenever, whether it transcends my better judgment, my values, my morals, my upbringing, in order to do one thing, to stave off. The perceived fear of real or imagined abandonment. And this goes back to the work of Piaget. about object permanence and a failure to master object permanence is really the cornerstone of borderline personality pathology. So when they were doing research on this, they had kids that would Go into a room, play with toys.

And moms would leave the room and there were some kids that just kinda looked up like, Okay, whatever and went back to playing with the toys. And there were these other group of kids that once mom left the room, they just freaked out. almost out of sight, out of mind evoke this intense panic. And that is how an individual's borderline personality operates is they constantly are walking on a tightrope.

And it's really an identity diffusion. And there's a lot of a lot of overlap with bipolar disorder, but those these are two totally separate diagnostic categories. Bipolar is a clinical disorder and is neurochemical in etiology and is generally managed through medication. Borderline, there's no medication for any of the personality disorders, is typically medicated like bipolarity, but also symptoms of depression,

suicidal ideations and there's a common misconception that people with everyone with borderline personality cuts and that's not true. It's only one symptom. Psychosis or transient hallucinations uh in times of extreme duress are also another. diagnostic criteria as part of borderline personality and also like derealization and depersonalization. Those are separate disorders in of themselves, but they can manifest as a specific symptom in the manifestation of borderline pathology.

These if you think of this as uh we kinda call them the mercurial style, a dysregulated thermometer. And of all of the personality disorders, it has the highest success rate of treatment. because all of the component parts are there. And let me use the analogy of the Easter bone. Imagine pristine chocolate Godiva Easter bunnies. They're beautiful. You want to look at them. You want to take a bite of them. They're majestic. Now the narcissist

is probably the most beautiful of the group. But they are desperately afraid of you ever taking a bite into them because they're vapid and hollow inside.

Same with the historianic. Their self esteem is derived from other people. See a lot of comedians have histrionic tendencies. Antisocial and borderline personality share many common com many commonalities and there's something called diagnostic overshadowing where there's a The criminal behavior is what separates you know, is the at past age eighteen is what separates uh qual I guess meets the diagnostic criteria for antisocial personality. But from a

ideology perspective, antisocial and borderline personality are very much the same disorder with the exception of criminal behavior. But it doesn't mean somebody with borderline can't commit criminal behavior.

But borderline pathology is exhausting for an individual. They live their lives as chameleons. And you you see the manifestation of the syntaxology. in interpersonal relationships, whether they're sexual, intimate, platonic, because A borderline will I wanna pull you close to feel that sense of security and attachment. But one of two things is going to happen. Once you get so close and it feels so good, I'm going to do one of two things. I am going to push you away. And I'm gonna push you away.

For one of two reasons. Either because I don't believe that I deserve to feel this. I'm not good enough for this. Or I am going to push you away because I'll hurt you before you hurt me. Then once the anxiety gets to a level that surpasses an individual's threshold for distress tolerance, that's when the individual will engage in whatever behavior

appropriate, inappropriate, acceptable, unacceptable, adaptive, maladaptive, in order to bring the individual back into their lives to assuage the anxiety. So it's a constant roller coaster ride And there's a great book, uh, for anybody who is Wants to really know more about borderline personality and anybody who is involved with a person with borderline personality, and I've recommended this over the years. It's called Stop Walking on Egg Shells.

'Cause with the borderline it's your walking in an invisible minefield. You don't know what is gonna set the individual off because they are in a constant state of hypervigilance. constantly in guarding their fragile sense of self and and they give an inordinate an inordinate amount of control. over other people. So when I go back to this quote by Maslow that I I kinda you end every episode with of learn to become independent of the good opinions of other people.

in my professional opinion, that's the end result of treatment of borderline personality. To stop giving other people and the world so much control over how you define themselves. But people who are in these relationships They're volatile, but it's like a slot machine. You know, there's a little city in Las Vegas that is based on the whole principle of intermittent reinforcement. And we get into the reinforcement schedules. Intermittent reinforcement is the most powerful one because you know

It's gonna pay out. But you don't know when it will, but you have evidence that it will. So I put ten bucks in the slot machine, I get down to six dollars, five dollars, four dollars, three, I'm down to my last fifty cents. Ding ding ding, it pays out. So I have evidence. That it will pay out and that payout feels good.

Which makes me more inclined to want to go back and put another twenty dollars in, another fifty dollars in because I have evidence that's going to pay ba pay out again. This is what happens for individuals who are involved in relationships with people with borderline personality because they have evidence. So they will weather the storm of of it could be abuse, it could be verbal abuse, physical abuse, it could be um just complete mental breakdowns.

And you know, when somebody says, if you leave me, I'm gonna commit suicide, that's pretty tough for most people to walk away from. Is suicidality, you know, there's suicidality and there's parasitic suicidality. Uh

Both of which need to be taken incredibly s seriously. Uh I, as a professional, always are on the side of caution. Um I will assess and probe deeper and in doing diagnostics, watching people's body language. Uh a recent study that came out, I think it's the New England Journal of Medicine talked about uh detecting how people uh whether someone's lying. And they they they the conclusion was basically it comes down to pupil dilation.

So when someone is lying, they are confronted with trying to maintain two thoughts simultaneously with equal amount of cognitive energy. which the brain cannot do. it cannot it cannot give equal amounts of energy to two simultaneous thoughts. And so you go into psychological survival mode. And one of the things we talked about with the autonomics nervous system response and the fight or flight response is pupil dilation. All right. I'm not telling you look.

Everybody out there go go look at your partner and ask them a bunch of questions and then measure their pupil dilation. But it has shown to be a positive indicator, research proven that pupil dilation Is related is related to lying. So i again, borderline often presents like bipolar. Can you have both? Yes you can. That that complicates the picture even more.

But when I when I diagnose people and kind of do feedback sessions and there is a diagnosis of borderline personality Nine out of ten times there's comorbid diagnoses, meaning there's possible bipolarity. major depressive disorder, PTSD, uh anxiety, those are the things that tend to get treated and that's what a lot of therapists get focused on in using a tree as a metaphor. People come into therapy and therapists focus on the branches.

They focus on the things that our people are complaining about. The goal is to treat the root system. If you treat the root system, the branches tend to become healthier and the anxiety, the depression, the emotional dysregulation Will start to subside, hopefully. But this is a long term process, and I've said before, therapy doesn't take place in the office.

People, you know, you get forty five minutes, an hour session. Um test not gonna happen. It it's really, you know, there's there's a technique Uh I reference Adler a lot, but an Adlerian lifestyle analysis is a great way to kind of understand the trajectory of someone's development, of how their belief systems came to be. So you can easily go online and look up uh Ed Learning Lifestyle Assessment, look up the work of uh Alfred Adler and specifically uh Rudolf Dreikers.

Okay, uh, and Harold Mozak. They've done a lot of work and the lifestyle assessment is really important. So from diagnostics, now the Rorschach and the TAT are which is the thematic apperception test are what are called projective personality assessments. So the M MPI is one that I use. It's five hundred and sixty seven questions.

And they're true-false. And there's ten clinical scales, there's restructure clinical scales, there's the Psi V scales, there's the content scales, the supplementary scales, but most importantly are the are the ten core clinical scales. So In in in doing diagnostics, the the MPI is interesting because it has built in validity scales and it could pick up on idiosyncrasies of how somebody responds.

lying, defensiveness, over endorsement of symptoms. Now when you get into the projective personality assessments and I I'll do a different episode on diagnostics'cause I th I think at some point I should talk about, you know, testing because that's what I do every day. Um When you're presented with the projective All you have in terms of responding to questions is who you are.

versus a true false. I a person can decide do I want to say yes to this? Do I want to say no to this? And there's also an adolescent version that starts at age fourteen. Um So there's some navigation and and people can be more contemplative because the question is very black and white. Do I want to admit this? Do I not want to admit this? Where do you get into the projectives?

That's where you get into information because the nobody knows what the test is looking for. And all you have when you're doing these types of tests is in the individual's personality right in front of you. And that is what is coming across in the in the answer profiles. And these tests and you know, I'm not that old but I've been doing this long enough. I tell my wife, I am Impressed and fascinated by how accurate the diagnostic picture is. So when I do like diagnostics.

And I've done this since I graduated my doctoral program. I go through the thirty six page interview. And I tell people, I said, all right, I can ask questions in a certain way. I can't explain how my mind works, but it does. But it's through asking the questions and watching how people answer the questions. I get through this and I always write in the upper left hand corner of my first page what I think the diagnoses are. Then I do the testing and I kind of see how close I am to it.

Which is a game I've done with myself. Um but when you get into the projectives, that's what breaks down the personality construct. So idiosyncratic. to an individual. And that's when I talk about those 120 different combinations, that's where you're gonna I'm able to pull apart and dissect.

how all of those things manifest specific to that person. So I could be doing therapy with somebody for two, three years. There is no way that I would ever know the information that these tests are able to yield even if again doing therapy back to the person three times a week, there's no way you can ever get to this information. So If you want clear diagnostics, get a neuropsychabile. Get a full combined neuro and psychovel. Both are separate. I do both. So

Again, back back to Borderline Personality. It's the hallmark feature again is the intense fear of real or imagined abandonment and living life on a tightrope With and people always say like borderlines are manipulative. Or I get asked questions like I got this label, am I gonna does that mean I'm manipulative? Um yes and no. Yes, in the sense of are you manipulating with the purposeful intent of benefiting?

No. Are you manipulating with the intent of maintaining psychological survival of the preservation of an already fragile self esteem. Yes, that's where the manipulation will come from, but it's based on psychological survival. I mean, again, I don't I can't think of a movie, I can't think of a song, I can't think of a book, I can't think of

Anywhere I can direct you to to d help you to really understand what borderline pathology is. But the good news is it has the high success rate of treatment. So think of a jigsaw puzzle. If you open the jigsaw puzzle for a narcissist, the box is empty. But they will do everything in their power to make sure you never, ever, ever have a chance to open the box. Same with the narcissist.

The borderline, if you open the box, all the puzzle pieces are there. They just need to be rearranged. And can you do it in ten minutes? Can you do it in an hour? Can you do it in a week? Uh It maybe. Um but this is long work. This is constant this is reconstructing the belief system about the individual in terms of their perception of their self.

reconstructing the belief system about how they view other people, reconstructing the belief system about the therefores or how they view the world and then the therefores. And the transformation is amazing. It it takes hard work. It and again it takes work in between the sessions. It takes work, you know, when you're confronted with the situations. But if you're constantly living a life

to not feel abandoned, to not feel alone, to not I mean you're going to transcend better judgment. And you know, the the tendency to go inward with self injurious behaviors

There's generally three reasons the research has shown why people engage in self-injurious behaviors. And I I I ask these and kinda give these examples when I'm doing my my structured diagnostic clinical interview, and the first question is Okay, how do you get rid of a headache? You drop a hammer on your foot. If I drop a hammer on my foot. I temporarily forget about the pain in my head and I focus on my foot. So one reason people will engage in self-injurious behaviors.

is it's a transference of emotional pain that a person perceives that they cannot control to physical pain that a person perceives that they can control. A second reason is A form of self punishment. I deserve to hurt. I deserve to be in pain. Whether that's because I do I believe that myself. Or because messages I've received from other people in my life, and again, this is an interpersonal, interactional d diagnosis. The third reason is I feel so numb that I wanna feel something.

So it's important to kinda delineate and w just from my own personal professional experience, when I've explained these different reasons And I can see a person kind of vacillating between which one they espouse to. It It's really an interesting transformation that they kind of connect, like, okay, now it makes sense why I do this. Isn't it easy behavior to extinguish? Absolutely not. Because b because if you I'm just gonna generalize and take cutting. That is immediate.

That is absolutely in the moment I can do this right now, boom. Um, as opposed to like, you know, like Julie gave like great examples about the orange and about, you know, the the cold towels and the grapes. If I'm sitting up in my bedroom And I got my razor blade next to me, I'd have to disengage from the thought, walk downstairs, go into the refrigerator, and the reality is people are gonna do that.

They're not unless you put a you know get a college refrigerator or door and put it in your room. But these are not easy behaviors to eradicate because they're so immediate. Now some people who are older adults they they find might more adaptive ways like getting tattoos. That's a healthier way. So there's something that we call harm reduction. Um Using clean objects, having hydrogen peroxide, having band-aids and medical equipment necessary.

Because again, it's such an immediate gratification and an immediate sense of relief. And that in in all three of those reasons, whether it's a transference of emotional pain to physical pain, whether it is a form of self-punishment, whether it's feeling none, th this type of behavior is immediate. And it's also incredibly important when you ask where does the person cut? So do you cut on your arms? And if you do, how do you dress?

Do you dress in clothing that makes it so that people can see it? And if so, you want to ask the person, why do you want people to see it? Is it you want uh a an accolade for having this type of pathology, or is it a cry for help? Or is the show, this is how severe I am? Or is it is it a slap in the face to the world around you, your family, your social network that look how much you've done to me, look how damaged I am, this is your fault.

Another reason is, you know, somebody says I like cut on my thighs. Or I cut I cut on my hip. Okay, why would you do that? Because you don't want anybody to find out. So

This is a very complicated topic. It's it's a fascinating disorder, and I didn't want to get too much in into into bipolarity. Because there is so much symptom overlap and again like I said before, borderline is simply medicated like bipolarity, but it is a complex disorder. But As with any of the personality disorders, as I said before, we haven't evolved to call them styles. This is something, if you have it, this is something that you have. This is something that you

This is not something that you are. It is treatable. It takes work, whether it's medication whether that's therapy and you need to be with somebody who knows how to treat this disorder. This is not I read a book on it, I took a class on it, I went to a weekend seminar on it. You need to know the intricacies and the ins and outs of borderline personality.

And I I come from perspective of cognitive behavioral therapy. I am not I don't espouse dialectical behavioral therapy. That is not a modality I agree with. It's done on the inpatient unit. That's great. People are gonna disagree with me and this is where I said it's gonna be controversial, but I can tell you from efficacy from the work that I've done, my colleagues have done, this is the modality that works. So

Hopefully it kind of shed some light on this. I I do believe this is a topic that we're gonna revisit as we've been very fortunate for the grace of God to be fully vaccinated as m most of my colleagues are have been or just on the on on the precipice of being fully vaccinated to be able to bring people in who specialize in different aspects of treating

d this disorder but other aspects of the disorder. So I'm just sharing my my professional training, my professional experience, my personal opinion on this. Um

I appreciate all the feedback. I I hope you guys are getting a lot out of this that would just give you as much education. And I hope at the end of every one of these sessions I I really hope you have more questions than you have answers.'Cause that's that's what's gonna you know, like I always say blind faith in anything and just googling and going online is o you know, is gonna get you

maybe some close approximation. Until next week, um, take care of yourselves, take care of each other, and as, you know As I said before. Learn to become independent of the good opinions of other people. Be well, everybody. Spring is around the corner. Um, get vaccinated if you can. Take care of yourselves, take care of each other, and we'll be in touch. Talk to you next week. Take care.