- Welcome to "Healthy Minds".

I'm Dr Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

(mellow music) Today, on "Healthy Minds", - Well, one of the biggest things that's happened over the last couple of decades is an increased recognition of the BPD diagnosis.

So it often goes missed in high school, college, and adult settings.

Borderline personality disorder has one of the highest comorbidity rates of all of our psychiatric diagnoses, and that's because it is such a painful and frustrating disorder to live with.

And it's becoming much more wide knowledge that this disorder exists, and it's also very treatable.

- You cited the very frightening statistic of the number of people with BPD that can die as a result of suicide.

What should families look for, and what should they do when they're concerned about this?

That's today, on "Healthy Minds".

This program is brought to you in part by The American Psychiatric Association Foundation, (mellow music continuing) and The John and Polly Sparks Foundation.

(mellow piano music continuing) Welcome to "Healthy Minds".

I'm Dr Jeff Borenstein.

Borderline personality disorder, BPD, what is it?

What are the symptoms?

What's the treatment?

Today, I speak with Dr Ed Selby, an expert in this condition.

(mellow music continuing) Ed, welcome to "Healthy Minds".

Thank you for joining us today.

- My pleasure, Jeff.

- I wanna jump right in and ask you to describe borderline personality disorder.

Tell us about the symptoms.

What occurs when somebody has this condition?

- Certainly, Jeff.

Borderline personality disorder, sometimes called BPD, is a personality disorder that can be quite serious when people are afflicted with it.

It has several symptoms that can be a little bit tricky, because they can seem a little bit variable from person to person, but generally, they include high emotions and emotional intensity, behavioral considerations, such as impulsive behavior, reckless behavior, self-injurious and suicidal behavior, and then interpersonal difficulties, where people can get very upset at the smallest problem, which has led to some to call the disorder "walking on eggshells", because people often have very many interpersonal challenges arising from the diagnosis.

- And when do these types of symptoms typically begin?

What's the age that they may appear?

- So that's something that the field is still trying to really understand, but most evidence seems to suggest that these problems start to really arise when someone's in their teenage years, especially as they get further into being a teenager.

And these problems will start to really come into fruition during high school, and then into young adulthood.

And that's often when we see more complex relationships being developed, and more challenges in terms of regulating oneself.

And that's why it becomes such a problem in the early teen years, and then lasts well into adulthood for many people.

- So if somebody begins to experience these types of symptoms as a teenager, or the family sees that it's occurring, what should you do?

- The sooner that these problems can be addressed, the better it is that someone can manage both emotions and behaviors and relationships throughout the course of their life.

Because of this, there's a number of treatments being developed that are aimed specifically at teenagers and adolescents, to try and help them learn these skills early, rather than waiting until someone's really become set in their behaviors and patterns later in life.

- So tell us about some of the treatments that we have available to help people.

- So the primary treatments for borderline personality disorder include what's called dialectical behavior therapy, DBT.

But also, other options can include traditional cognitive behavior therapy, CBT, and then transference focused psychotherapy, TFP, and what's called mentalization-based therapy.

And all of these have shown some varying degree of helpfulness for borderline disorder, with the most evidence being in favor of dialectical behavior therapy.

- So tell us.

It's a big word.

What does it mean?

What does it actually entail in the treatment?

- So dialectical behavior therapy, the dialectical actually refers to trying to find the synthesis between two extreme opposites.

So it's traditional thinking, with people with BPD, is they will flip between, "I love you" and, "I hate you."

And in reality, relationships can be kind of complex, and you can love someone while also being frustrated by them or disappointed by them.

And so it's really not a matter of one or the other, but finding a synthesis, or a dialectic, between those two extremes.

And that's the base philosophy for DBT, which is you can be upset and yet remain in control of your behavior.

You don't have to potentially have some problem behaviors because your emotions are so extreme, we can find a balance between the two.

- You've described the condition in a variety of ways.

One relates to a snowball going down a hill and gathering more snow.

I'd like you to speak a little bit about that.

- Certainly.

So in my work, we've described what we call an emotional cascade, but a snowball effect is another helpful way to think about it.

What we think is that people with BPD have underlying biological vulnerabilities that heighten their sensitivity to emotions.

And what this can result in is, when somebody with BPD feels an emotion, they have a higher tendency to ruminate or think repetitively and deeply about the problem.

But what that does is it actually makes it worse.

They sort of delve into their emotions too much, and that makes the emotions more intense, and a vicious cycle.

The more they focus on their emotions, the more intense those emotions feel, in a way that, kinda like a snowball rolling down a hill, builds up to a really intense and very painful emotional state.

- So part of the treatment is for people to realize that that snowball is building up, and try to block it before it gets too big, before it gets halfway down the hill.

- Yeah, exactly.

What we think is happening in borderline personality disorder is people will be experiencing these cascades, or these snowballs, and they essentially wait until they get out of control, and then that's when they engage in some of these behaviors that we talk about, substance use, self-injury or cutting.

Binge-eating is another common symptom.

The reason we think that they engage in these behaviors is that they help kinda stop the snowball effect to their very intense and very powerful behaviors that essentially distract someone from their own upsetting emotions.

And they're effective, in terms of getting that emotional snowball to stop and getting the pain to stop, but they're not effective in terms of living a high quality life.

So what we wanna do is help people learn skills and behaviors, that they can stop that snowball effect earlier on, to recognize that emotions are getting out of control, use healthy behaviors to get those emotions to calm down, and avoid the snowball or cascade effect altogether.

- You spoke about walking on eggshells.

And I'd like you to speak a little bit about therapy for family members, loved ones, of people with borderline personality disorder.

What could be done to help them with their loved one?

- That's a big challenge of borderline personality disorder, because a lot of people with the diagnosis will often feel like their families are not supportive, or, potentially, mean.

And yet when I meet these families, I'll see families that are very dedicated to their loved one and trying to do everything that they can to help them.

And this really comes back to the extremes in borderline personality disorder, of where they might focus on negatives, potentially, while ignoring positives.

So what that means is that involving family in the treatment process can be really helpful, on several levels, one of which is helping both the patient as well as the family communicate in a way that's a little bit more open, a little bit more what we call validating, where the family member learns to acknowledge the emotional experience that the patient is having, while also potentially finding ways to improve the situation or communicate in a more effective way, that reduces these back-and-forths that can really build up and cause major problems.

- So when you say validating, it really is saying to the person, whether they fully understand or agree with the emotion that they're expressing, to at least be able to respond to that emotion with some level of sympathy, again, to hopefully slow down that snowball effect, that emotional cascade.

- Yeah, exactly.

And what can happen in this disorder, because there's so much emotionality to it, is sometimes people can get frustrated with the patient and say, "Why do you always have to act like this?"

Or, "Why do you have to be so crazy," is something that might be said.

And that can just make things worse, because it's what we call invalidating, it's just adding more emotional fuel to the fire that's going on, or throwing more snow into that snowball.

And we wanna try and stop those cycles and help someone learn that if they just approach a situation in the right way, they can help calm it down, and also express being upset or disappointed, without having to become a huge problem.

- One of the challenges with BPD is the occurrence of co-occurring conditions, such as depression, anxiety, chemical dependency.

Could you speak a little bit about that, please?

- Absolutely.

Borderline personality disorder has one of the highest comorbidity rates of all of our psychiatric diagnoses, and that's because it is such a painful and frustrating disorder to live with.

And because of the routine problems that happen throughout the disorder, people are very commonly gonna end up with comorbid depression, where they're feeling very despondent about their situation in life, and that actually also leads to increased suicidal behavior.

And this is a disorder where about 10% of people with the diagnosis end up dying by suicide.

So it's a very serious problem.

In addition to that, people also experience other disorders, often as a result of trying to cope with having borderline personality disorder.

Substance abuse is one of the most common that we see.

A really problematic but effective way of regulating emotions is to use drugs, because drugs make you feel good.

However, they do so in a very bad way.

And if a patient wants to go from feeling bad to feeling good, drugs are one of the fastest ways to do that.

That's what results in the substance abuse behavior and diagnoses in the disorder.

And that's why we have to try and, again, help people learn effective coping earlier on so they're not prone to these substance use behaviors, and then that's something that can be avoided in the future.

- I wanna pick up on the important issue of suicide prevention.

And you cited the very frightening statistic of the number of people with BPD that can die as a result of suicide.

What should families look for, and what should they do when they're concerned about this?

- Suicide is a major problem, both for the the country, but also very specifically for the diagnosis of borderline personality disorder.

And one of the best things that families can do to try and prevent suicidal behavior is not to be afraid to ask about it.

A lot of times families are afraid that this will make things worse, or that it'll make someone actually become suicidal if they're not.

And all the research suggests that, most of the time, if someone's feeling suicidal and you ask them about their experience of suicidal thoughts, they might feel relieved, because they can finally let it out to someone that they're having these thoughts and these problems.

One of the worst things that you can do is ignore it, or hide, or pretend that it's not a problem, because then someone can build up over time, and either attempt suicide, or sometimes many people die on their very first suicide attempt.

So that's why, for families, you wanna pay attention to the reality that this can happen.

And also, be sure to ask if you think someone is in that risky kind of mind.

- Very important point, 'cause there's a common misperception that if you ask about it, maybe it puts the idea in somebody's mind, which we know, through clinical experience, through research, is not true, that, actually, asking about it could help save a life.

So, very important point that you're making.

You've treated many people with BPD, and I'd like you to share with us how people progress, how people get better.

What's it like for therapy for people as they see improvement in their condition?

- So with borderline personality disorder, it's both rewarding and challenging to treat, because it can be a bit slow at times, in terms of making progress.

As I mentioned before, these emotional experiences can be quite intense, and it can be easy to use problem behaviors instead of healthy behaviors, because they're fast and potentially very strong in terms of down-regulating those emotions.

On the other hand, learning healthy skills can take time and take practice, and sometimes that's hard for people when they're upset right now.

But as you progress, you can cover a variety of things, like basic emotional coping skills, and then you can delve out into more complex issues, including how to work one-on-one with other people, especially in interpersonally difficult situations, and also address more complex underlying issues.

One thing I didn't mention earlier is the number of people with BPD have trauma experiences and what's called post-traumatic stress disorder, and these often make the emotional experiences so much worse.

But as you progress through therapy and get a basic safety plan and more coping skills in place, you can start to address those more difficult problematic experiences that some people might have.

- You brought up the issue of trauma that some people who have BPD have a history of trauma.

I'd like you to speak a little bit more about other potential risk factors for developing the condition.

- Well, right now, the risk factors are quite variable, and there's no one single risk factor for this diagnosis.

To date, we haven't identified a single gene or a single neurotransmitter that's causing all these problems.

But what we do know is that there is a bit of heritability with it.

If you have parents with a higher level of emotionality, that increases your risk for developing borderline personality disorder.

And there is this underlying biological component to it, where we see higher physiological reactions in emotionally challenging situations.

In addition to that, there are a number of what we call developmental factors that go into the diagnosis, including early developmental experiences, how well you're getting along with your parents and your family, and at school.

And if someone is experiencing problems in any of those areas, for example, bullying at school, or potential challenges at home, that can potentially contribute into the development of the disorder, likely building on preexisting biological risk factors.

- So, just as is the case with other conditions, psychiatric and medical, there may be an interplay between some inherent aspect of the person, and then environmental factors that may end up triggering or increasing the risk of those inherent factors, resulting in the condition.

- Definitely.

And one of the things that we've looked at in my lab is the interplay between environment and risk factors, and that if someone gets into a really challenging environment, perhaps they're in a really bad high school setting, or they're having trouble at college, that can really interplay with those pre-existing underlying factors to aggravate symptoms and make them worse.

And again, one of these feedback cycles, where having borderline personality disorder ends up making it itself worse, because it creates additional interpersonal problems, additional things to be upset about.

And if someone doesn't potentially address those, it can potentially get very out of control.

- So all the more reason to take action when these kind of external things occur, whether or not there's a risk factor for BPD.

But if you know that your child is experiencing bullying, to get help for the child.

If your child is having some other stressor, help them through it, again, as a way to reduce the traumatic effects on that individual.

- Absolutely.

One of the best things parents can do with children, and then as they become teenagers and young adults, is to help them learn these emotion regulation skills early on.

It's not something that you have to wait to see a therapist for.

There are numerous books and training materials out there that can help a parent teach a child, "When you feel this way, how do you act and how do you think, and what are some things that you can do to help manage those situations in a way that will be healthy and make you feel better in the long term?"

And so that's why the best thing we can do to try and reduce borderline personality disorder is get that kind of education out to people earlier, rather than waiting until they develop problems and then trying to teach it.

- Early intervention is always the best as a method of prevention, or minimizing the severity of the condition.

- Definitely.

- Often, it's hard to get somebody to accept treatment, for a number of conditions, including borderline personality disorder.

What types of steps can a family take to encourage their loved one to receive help?

- Another great question.

And it is common for people with this diagnosis to have an outside oriented viewpoint of, "Everyone's against me," or, "These are all problems that are coming from other people, and I'm not the problem."

So it can be a little bit difficult to help someone see that they might have some things that they need to work on themselves.

And as a family member, what I would do is to try to treat it in a very gentle manner, of trying to say, "You're having these problems, and I think that you might need to get some help."

And you can often help bring up symptoms.

"You get upset very easily," or, "You're having these relationship problems that I see."

And that's something that a therapist can help you address in a more healthy and productive way, rather than continuing to struggle and cause yourself potentially additional pain.

- So, in some ways, focus on a symptom or two that the person themselves would highlight as being troublesome to them, and say, "Therapy may help you with those particular symptoms."

- Yeah, I think so.

Helping them really identify something that they agree is a problem is a good place to start.

And not getting hung up on the things that, especially as a family member, you might be frustrated with the BPD family member at times, and rather than focusing on your own hurts or your own particular frustrations, you should look and see what the person that you're trying to help is struggling with most, and try to come at it from their perspective instead.

- As a researcher, in addition to a clinician, where do you see the field going, in terms of offering more and better help to people with BPD?

- Well, one of the biggest things that's happened over the last couple of decades is an increased recognition of the BPD diagnosis.

Unfortunately, this is still one that's under-recognized in society, and so it often goes missed in high school, college, and adult settings.

And it's, in my experience, it was very common for people with this disorder to come in and be diagnosed by a previous clinician with something very different.

And I would always be frustrated, that there's this lack of knowledge in the community.

Fortunately, this seems to be improving in recent years, and it's becoming much more wide-knowledge that this disorder exists and it's also very treatable.

People respond to treatments for BPD usually very well.

And in terms of the future directions, one thing that I see making big progress is getting treatments out to people in their daily lives.

Some of the treatments I described previously work really well, but sometimes they're very specialized, and it's hard for people to get access to them.

And it also requires a commitment of coming into the treatment center multiple times per week.

Newer interventions are actually trying to take the treatment out to the patient, either through smartphone technology, online video courses and other options, and ideally get out and get in the patient's living room, so to speak, and help them learn these skills from home, without these other barriers getting in the way.

- So using modern technology to reach more people and reach them where they live in a way that is even more helpful for them.

- Absolutely.

And in fact, I think it goes beyond that.

Borderline personality disorder is a daily experience, it's not a once a week when you see your therapist experience.

And so when you meet with a patient, it can be hard for them to cover all the different scenarios and problems that they're facing on a weekly basis.

So if we can actually get treatment effects out to them every day, then that has a lot higher potential to help them recognize problem patterns and make changes in their life in a much more integrated way than if we wait and see them once per week.

- As we finish up, I'd like you to, if there's somebody out there watching right now, and they think they may be experiencing some of the symptoms you described, what do you say to them?

- I think it's very helpful to know the name of the problems that you're facing, and that's why I want people to better understand borderline personality disorder, BPD.

And if you understand what the disorder is, what it looks like, and then you start to understand how it functions, in terms of the factors I've described today, with the cascading and snowballing effect, and how that's connected to problematic behaviors and interpersonal relationships, when someone knows that, that's a powerful tool to help change it, because instead of being this mysterious tormentor, so to speak, you understand the problems and how they work.

And that's the number one key to then making those changes that can help cause the borderline personality disorder to go away.

And it does go away.

With treatment, it can go away a lot faster.

- Ed, I wanna thank you for joining us today, for the research that you've done, the clinical care that you've done, and also getting the word out to people about BPD and what could be done to help them.

Thank you so much.

- My pleasure, Jeff.

(mellow music) - If you or a loved one have borderline personality disorder, don't suffer in silence.

Seek help, seek treatment.

And if you're unsure about your diagnosis, but are experiencing some of the difficulties that we described today, again, seek help.

Get a diagnosis.

Get treatment.

With help, there is hope.

(mellow music continuing) (mellow music continuing) Do not suffer in silence.

With help, there is hope.

(mellow music continuing) This program is brought to you in part by The American Psychiatric Association Foundation, and the John and Polly Sparks Foundation.

(mellow music continuing) (mellow music continuing) (mellow music continuing) (mellow music continuing) (mellow music continuing) (mellow music continuing)