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Experts Discuss Borderline Personality Disorder

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Stephen O'Connor: Hello. Thank you for joining us today. I'm Dr. Stephen O'Connor, chief of the Suicide Prevention Research Program in the National Institute of Mental Health or NIMH's division of services and intervention research. May is borderline personality disorder awareness month or BPD for short. So our discussion during the next half hour will be on BPD. I'm glad to have, joining me today, two NIMH grantees who are both experts on BPD. We have Dr. Stephanie Stepp, who is an associate professor of psychiatry and psychology at the University of Pittsburgh. Dr. Stepp's research interests are in risk factors for the development of BPD in children and adolescents. We also have Dr. Shireen Rizvi joining who is an associate professor of clinical psychology at Rutgers University. Dr. Rizvi's expertise is on cognitive behavior therapy and dialectical behavior therapy for BPD. Thank you both for being a part of today's discussion.

Stephen O'Connor: During the next half hour, we will provide an overview of the signs and symptoms, proper diagnosis, and treatments for BPD. We'll also discuss the latest research on BPD and some of the challenges that the coronavirus or COVID-19 outbreak has presented for individuals living with BPD. If there's time at the end, we will also take some of your questions, so please ask them in the comments under this video feed on Facebook or tweet NIMH on Twitter. It's important to note that we cannot provide specific medical advice or referrals. Please consult with a qualified healthcare provider for diagnosis, treatment, and answers to your personal questions. If you need help finding a provider, please visit www.nimh.nih.gov/findhelp. If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-8255. You can also ask for help in the comment section of this feed, and someone from NIMH will assist. All of the websites and phone numbers I just mentioned will also be posted in the comment section of the feed so that you can easily access them.

Stephen O'Connor: So to start our discussion, I wanted to first describe BPD, and then we'll cover signs and symptoms. BPD is an illness marked by an ongoing pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with BPD may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days. Dr. Stepp, can you talk more about the signs and symptoms for BPD and how symptoms differ between children and adolescents and adults?

Stephanie Stepp: Yes. Thank you, Dr. O'Connor. So people with borderline personality disorder tend to view things in extremes, such as in all good or all bad. Their opinions of other people can change very quickly. An individual who might seem a friend one day may be considered an enemy or a traitor the next. And these shifting feelings can lead to intense and unstable relationships, and that's true for both children and adults. And the symptoms also are the same in children and adults that I'm about to read, just go over with you here. So efforts to avoid real or imagined abandonment, such as rapidly initiating intimate physical or emotional relationships or cutting off communication with someone in anticipation of being abandoned; a pattern of intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love to extreme dislike or anger; a distorted an unstable self-image or sense of self; impulsive and often dangerous behavior, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge-eating.

Stephanie Stepp: And the impulsive behavior typically occurs sort of regardless of outside of a manic state. So that's not what we're talking about here; that's a different kind of problem. Self-harming behavior, such as cutting; recurrent thoughts of suicidal behaviors or threats; intense and highly changeable moods, and like Dr. O'Connor mentioned, these shifts might last from a few hours to a few days; chronic feelings of emptiness, inappropriate intense anger or problems controlling anger, difficulty trusting other people and feeling sometimes dissociation or disconnected, cut off from oneself or seeing oneself from outside one's body or feeling unreal. And those kinds of symptoms happen during periods of extreme stress.

Stephanie Stepp: And I will say that if we're going to think about how this might look differently in adults and children, for adults, we would expect to see these symptoms happening for a longer period of time than in children. So for children and adolescents, we're looking for these symptoms to occur for about a year. And for adults, it's several more years than that. So otherwise, the symptoms are the same. So it is also important to remember that not everyone with BPD experiences every symptom. Some individuals experience only a few symptoms while others may have many. And symptoms are triggered usually by interpersonal events, so something happening in a close relationship, and that often triggers the symptom that you're seeing or experiencing [crosstalk].

Stephen O'Connor: Very helpful. Yeah. Thank you. BPD has historically been viewed as difficult to treat. But with newer evidence-based treatment, many people with the disorder experience fewer or less severe symptoms and an improved quality of life. It's important that people with BPD receive evidence-based specialized treatment from an appropriately trained provider. Dr. Stepp, can you talk about testing and diagnosis for BPD?

Stephanie Stepp: Yes. Of course. So it's really important that you see someone who is accredited and licensed by their professional guild. So it's important that you see someone who has experience in treating mental disorders. And I would say it's also important to see someone who has experience in treating borderline personality disorder. And so if you think you're having a problem like that or the problems that we're discussing today, it's okay to ask your provider if they are an expert or if they have expertise in treating that condition. And we know it's really important actually that you feel like your provider understands you and is able to give you the help that you think you need. So having those conversations, even though sometimes they're with people who have a lot more degrees or maybe are supposed to know everything, it's important that you remember that you know what's best for you and that you can go to different providers and try to find the one that fits what you're looking for the best. So it's important that they would complete a thorough interview, and they would ask you to describe your symptoms. And they might also ask to talk to family members or other significant people in your life to see if those symptoms also kind of confirm or show up in ways that you might miss that they might also-- that they might notice. It's important that they might ask you to do other kinds of tests like get basic blood work done just to-- making sure that it's not due to some other underlying medical condition that you're having some of these symptoms.

Stephanie Stepp: And then also, they might ask about your family history and any history of mental illness in your family. It's also really important that your provider would be comfortable talking with family members or significant others with you and providing some psychoeducation about your disorder and about the treatment course. Borderline personality disorder often can co-occur with other illnesses. And from what we know, it's important that even if you have depression or substance use disorder or any other disorder, that actually, borderline personality disorder needs to be treated, and it needs to be treated usually as the primary diagnosis before addressing any other kind of comorbid condition.

Stephen O'Connor: Okay. Thank you. And I would point out that NIMH-funded studies do show that people with BPD who don't receive adequate treatment are more likely to develop other chronic medical or mental illnesses, less likely to make healthy lifestyle choices. And BPD is also associated with a significantly higher rate of self-harm and suicidal behavior than the general public. So psychotherapy is the first-line treatment for people with borderline personality disorder. A therapist can provide one-on-one treatment between the therapist and patient or treatment in a group setting. Therapist-led group sessions may help teach people with BPD how to skillfully interact with others and other skills for managing distress in emotional responses more effectively. Dr. Rizvi, can you talk more about the different types of psychotherapies used to treat BPD?

Shireen Rizvi: Sure. And I also want to preface this by echoing what Dr. Stepp said, which is that I believe it's incredibly important that individuals with BPD find a therapist who's competent at treating the disorder and also a therapist who has a non-stigmatizing and compassionate approach to understanding and treating BPD. So arguably, the most well-known psychotherapy for BPD is called dialectical behavior therapy or DBT, which is a form of cognitive behavioral therapy. DBT was developed specifically for individuals with BPD and has the most evidence to support it today. DBT uses concepts of mindfulness, blends acceptance strategies with change strategies, ultimately, all designed to help individuals develop a life worth living. DBT also teaches concrete skills that can help people learn to manage intense emotions, reduce self-destructive behavior, and improve relationships. Then there's other psychotherapies that have been developed and tested for BPD specifically, including therapies called transference-focused psychotherapy, mentalization-based therapy, and systems training for emotional predictability and problem-solving or STEPS for short, among others. So if you have borderline personality disorder and you seek out therapy for problems related to the disorder, I think it would be really important-- imperative, actually, to ask any potential therapist about what treatment approach they use and their justification for that approach so that you can make an informed decision.

Stephen O'Connor: So what about medications to treat borderline personality disorder?

Shireen Rizvi: Yes. So what you typically find is that individuals with borderline personality disorder are prescribed a number of psychotropic medications for their symptoms. However, it's important to know that actually, at this time, there's no specific medication designed to treat BPD in its totality. And there's actually unclear benefits about any one given medication for BPD. So they're actually not recommended as the primary treatment for the disorder. In fact, we would say that therapy is recommended as the primary treatment, especially in evidence-based treatment like ones that I mentioned. However, in many cases, a prescriber may recommend medications to treat specific symptoms or problems associated with the disorders such as mood swings or depression or other co-occurring mental disorders. Research has indicated that some medications, and specifically benzodiazepines, should be avoided by people with BPD because they tend to be habit-forming and have also been found to exacerbate impulsivity in individuals with BPD. So it would be important to talk to your doctor about what to expect from any particular medication and also the prescriber's rationale for why they're prescribing.

Stephen O'Connor: Okay. Very helpful. Thank you. We're now going to shift our discussion to the latest research of BPD. Dr. Stepp, can you tell-- or can you talk about the research that you've been working on?

[silence]

Stephen O'Connor: We can't hear you right now, Dr. Stepp. That might be on our end.

Stephanie Stepp: Okay. Let's try that again.

Stephen O'Connor: Here we go.

Stephanie Stepp: Can you hear me now?

Stephanie Stepp: [crosstalk].

Stephanie Stepp: Okay. Great. Great. Great. Great. Yes. Thank you. So there is a NIH-funded paper that I'm an author on. It's coming out soon. And this is a paper where we-- it was an NIH-funded study designed to examine some of the mechanisms that might help us explain the high degree of co-occurrence between borderline personality disorder and alcohol use disorder. And so we tested two mechanistic pathways that might link BPD symptoms and alcohol-related problems, and there's an affective pathway. We hypothesized that BPD symptoms would be associated with alcohol-related problems through affective instability and drinking to cope. And in the sensation-seeking pathway, we propose that BPD symptoms will be related to alcohol-related problems through sensation seeking and drinking to enhance positive experiences. The recent study highlights coping enhancement drinking motives as possible mechanisms that explain the co-occurrence of BPD symptoms and alcohol-related problems in young women.

Stephanie Stepp: And also, another study that I'm involved with right now is regarding suicide prevention, developing a new intervention for suicide that might be useful for children and adolescents that are in primary care, that are sort of identified in primary care. And suicide is a really important area, and getting interventions that are sort of scalable to wider groups is also something that's really important to me and I think has high significance for people with borderline personality disorder. And so suicide and suicidal behavior are definitely one of the leading causes of adolescent mortality and morbidity. And the majority of suicide descendants have their last clinical contact with a primary care provider and not with a mental healthcare specialist. So there's a big gap there because we lack empirically supported treatment strategies that might be used by primary care clinicians or pediatricians when youth present with acute suicide risk.

Stephanie Stepp: And in previous work, we've developed a smartphone safety planning app called BRITE, and that was used, though, for psychiatrically hospitalized suicidal adolescents. So we found that that reduced the suicidal events post-discharge by 42%. And we've been adapting BRITE over the past several years to use in primary care by developing-- we developed an electronic-- I call it an electronic treatment guide, that allows a clinician who is not a specialist or has very little specialist training to use this electronic treatment guide to walk them step by step through onboarding. We call it onboarding a safety plan. So by the end of getting through that treatment guide, the adolescent will have a gold standard kind of safety plan developed and available to them on their app that they can use in real time. And then there are different skills that are linked to that. And so that’s the goal, and we're continuing to work on that project. But the preliminary results are promising.

Stephen O'Connor: Very interesting. And we've received a question from an attendee about how to support children that have these symptoms, diagnosis. And maybe we'll return to that topic of a safety plan to really describe that in a little bit more detail once we get to the Q&A section at the end. That's really helpful to hear. So Dr. Rizvi, can you talk more about the research that you've been focusing on related to BPD?

Shireen Rizvi: Sure. So I'm actually also working on a NIMH-funded study right now related to identifying treatment approaches for suicidal college students. Suicide is the second-leading cause of death among college students, and suicidal ideation and suicide-related behaviors are a frequent presenting problem at college counseling centers, which are heavily overburdened. So evidence-based treatment strategies are needed to address this heterogeneity in responsivity and the complexity of the population. So we're conducting a multisite study along with several colleagues to investigate these treatment sequences to address suicidal risk in treatment-seeking college students. And given the large sample that we're proposing to acquire, we'll be able to look at how individuals with BPD or BPD features respond in comparison to individuals who don't have BPD. Then also in my research and training clinic at Rutgers, we're engaging in studies that incorporate technology such as multiple assessments per day via smartphones and psychophysiological monitoring via wristwatches to see whether we can detect more granular emotion regulation changes in people while they're receiving DBT.

Stephen O'Connor: Very novel. Very interesting. So the pandemic has been really challenging for individuals with mental illness, especially those with BPD. So Dr. Stepp, can you speak on these challenges?

Stephanie Stepp: Yes. And I do think it's been challenging for all of us. And I think that for folks who have a vulnerability to emotion dysregulation, especially when relationships are strained and when we're all living together, very close-knit quarters with people that are close to us. Or if you don't have people that are close to you and you're living alone, it could highlight some interpersonal vulnerability there. So if there's high-- there might be some more conflict between these relationships. And if you are a person who has a particular vulnerability for emotion dysregulation, I think the pandemic and the length of how long this has been going on, it's just no wonder that we're all struggling. But, of course, folks who have the [inaudible] are suffering even more now.

Stephen O'Connor: So, Dr. Rizvi, what coping tips do you have for people with BPD during this pandemic?

Shireen Rizvi: So I genuinely believe that DBT skills have helped a lot of people cope more effectively during the pandemic. And surely not just individuals with BPD, I have benefited a lot from using DBT skills over the past year plus. So some skills that I think people have found especially helpful during this time has been radical acceptance skills of accepting life as it currently is, even if we don't like it, as well as distress tolerance skills for coping with immediate and seemingly constant stressors. Last summer, during the COVID pandemic, we received funding from Rutgers for a study to develop 14 animated videos teaching DBT skills, which we have since posted to YouTube so that anyone who can access YouTube can access these skills videos for free. So anyone who's interested can find them at youtube.com/dbtru.

Stephen O'Connor: Thank you for sharing that. They're very engaging and great teaching tools. So I want to make sure that we have enough time for some questions from the audience, so I'll stop here. Let's take a look at some of the questions that have come in. Maybe I'll start, Dr. Stepp, by posing this question around, how do you support a child that has symptoms? And can BPD be diagnosed in childhood?

Stephanie Stepp: Yes. I mean, BPD can be diagnosed in childhood, although I would say that really, you don't see a diagnosis of a personality disorder prior to puberty because of some other maturational changes that are happening. So we would expect this disorder-- and what we know from studies is that really, the onset occurs in adolescence, early to mid-adolescence. And so the best way to support a child who you think may have this disorder is getting them evaluated and treated by an expert as quickly as possible because the sooner you do that, the better the prognosis. So getting someone treated and getting treatment early is really helpful. And so I would say the most important thing you can do is keep taking them to their appointments or help them to keep logging on to their appointments and support them in the work that they do. And it's also important that you as a parent are involved. I think it's actually critical. And so working with a provider that works with families and is comfortable working with families and would give you access-- would develop a safety plan in some way and would help you know how to use that safety plan with your child to be the most effective, those things are key.

Stephen O'Connor: Could you just briefly describe in a little bit more detail a safety plan, how that works, and what the purpose of it is?

Stephanie Stepp: So a safety plan is when we would come up with what are-- we would try to help the young person identify what are some triggers or what are some environmental stimuli that might elicit a strong emotional response that has been difficult for the child to manage effectively without engaging in suicidal or self-injurious behavior in the past. So we would try to identify some of those factors. And sometimes it's conflict around homework or conflict around friends that they're hanging out with, those kinds of areas that might be particularly difficult for the child to manage or that has typically resulted in a high emotionally distressed state. And then we would try to identify those factors and then either talk about ways that we can either avoid those stressors altogether, in the beginning, at least, or talk about ways that we can more effectively manage those so that they don't maybe get quite as intense. And then we would identify, then, things that the youth could do, either alone or in support with a parent or their therapist, maybe some skills that they can utilize in the moment when their distress was very high so that they could engage in some distress tolerance skills, [inaudible], and doing pace breathing. Those are the two go-to's that I [inaudible]. That's how to do those two things, right from the beginning.

Stephanie Stepp: And then the other things that are important about the safety plan is that if there are any lethal means available, if there are guns in the home that are not secured or if there are pills that are-- yeah, or alcohol, things that a child could injure themselves with or kill themselves with, that the means are restricted, and those are moved and not available at all to the child. And then the other thing to do is to identify people that the youth can call when they need support. So we would list individuals that they might call or reach out to. And in dialectical behavior therapy, the kind of treatment that I do, that person is me. So I'm on call 24/7 to my patients to do coaching calls in those moments and families [inaudible] parents [inaudible]. [laughter]

Stephen O'Connor: Yeah. Very helpful. And you're really emphasizing the point of making the home safe. I'm glad that that’s a key part of safety planning. Dr. Rizvi, sometimes individuals with BPD give the impression of being difficult to manage. How do we help them understand what's happening?

Shireen Rizvi: So I'm not sure, based on the question, if we're talking about helping individuals with BPD understand what's happening, but that's the way I understand that question. So how do we help individuals with the disorder understand the way in which their behavior or transactions with others affects others people's perceptions of them? I think it's also very consistent with approaches in dialectical behavior therapy. And specifically, we talk about can we emphasize teaching interpersonal skills in terms of learning how to be more effective in our interactions with other people with some idea that if we're more effective with other people, that will lead to a reduction in other people thinking that we're being difficult, right, or that we are difficult. And I think there's also a large focus in DBT on teaching individuals, again, with a compassionate and nonjudgmental approach to understand how the problems that they're experiencing may have developed over time. And so in DBT, we use something called the biosocial model to describe how borderline personality disorder develops, which is often perceived by individuals with BPD as being highly validating, as understanding that these problems didn't just come out of nowhere, and these problems are occurring because the person wants to be perceived as difficult or wants to be unskillful, but that there's reasons for it. And what's really nice about the treatment approach is that we can address those reasons and causes and make really significant changes.

Stephen O'Connor: Thank you both. We've reached the end of our discussion today on borderline personality disorder. Dr. Stepp, Dr. Rizvi, thank you for sharing your expertise, and thank you for all your questions and for joining us today. To learn more about BPD, please visit www.nimh.nih.gov/bpd. Thank you, and stay well.

Shireen Rizvi: Thank you.

Stephanie Stepp: Thank you.

[silence]