everything you've been taught about borderline personality disorder is wrong for decades students have been taught that borderline personality disorder is unchangeable and that working with these patients is not only frustrating but futile as well we've been taught that you should never diagnose patients with bpd and if you do then you should certainly never tell them of their diagnosis we've been taught that there are no treatments for bpd or that if treatments exist then they can only be provided by highly specialized doctors or clinicians with extensive training none of these things are true as we'll find out in this video nevertheless these myths continue to pervade our understanding of bpd which not only deprives clinicians of the satisfaction of being able to actually help these patients but also prevents patients themselves from achieving a brighter future so pay close attention because we're going to spend this video learning the truth about bpd and hopefully dismantling a few myths along the way the starting place for understanding bpd is to learn the core patterns associated with it the dsm boils these down into nine key criteria let's use the mnemonic to remember these the phrase i despair not only evokes the feeling that many patients with bpd have but is also a handy acronym for these signs and symptoms we'll go over each of these one by one first the i is for identity people with bpd often have an unstable identity that manifests as an inconsistent sense of self and purpose whereas most people have a clear sense of who they are what they believe what they stand for and how they behave in different situations patients with bpd have a sense of identity that may change from moment to moment depending on who they're around such as having certain values beliefs preferences and hobbies and with a group of friends but then showing no interest in those same things on their own this lack of a stable identity leads to a sense of purposelessness or drifting over time that can make many patients feel like they're lost in their own lives for many patients it actually hurts not to have this clear sense of identity a phenomenon known as painful incoherence some patients try to make up for this by putting all of their identity into a single trait or interest like defining themselves entirely in terms of a political cause that they support or a tv show that they're into rather than these interests being just a single part of a complex and multifaceted identity like they are for most people next the d is for dysphoria you might not know the word dysphoria but you're likely familiar with the word euphoria so let's start there if euphoria is a deep sense of pleasure happiness and well-being then dysphoria is a profound feeling of sadness dissatisfaction and discontent the dsm lists dysphoria as a chronic feeling of emptiness and when you ask patients with the disorder about this many of them will strongly identify with those exact words dysphoria can often be mistaken for depression although it differs from depression both in terms of how it feels to the patient as well as how it responds to treatment the best way to describe the difference between depression and dysphoria is that depression is what it feels like during bereavement when someone you love dies while dysphoria is what it feels like during a breakup when someone you love rejects you while on the surface these may seem like similar feelings when you examine them closely there are actually a lot of differences when someone dies it feels like a constant heaviness or a dark cloud that doesn't lift whereas after a breakup there is a much greater sense of self-doubt and questioning your self-worth along with a greater range of emotions including not just sadness but irritation anger and jealousy as well take a moment to internalize this bereavement versus breakup distinction then do your best to remember that this is how people with bpd feel most of the time which hopefully will give you some empathy for these patients next the e is for emotional instability people with bpd tend to feel emotions very strongly and have been said to experience grief instead of sadness humiliation instead of embarrassment rage instead of annoyance in panic instead of nervousness their emotions are not just strong they can change quickly as well with patients experiencing drastic swings between extremes of emotions a phenomenon known as effective ability people with bpd can seem to fly off the handle and quickly go from laughing at a funny video they found online to crying about a perceived slight to raging about another person's mistake all within a matter of minutes these swings and emotions are often precipitated by interpersonal events with rejection and abandonment being particular triggers these emotional responses can often come across as wildly out of proportion to the events that prompted them which can make living with effective mobility disorienting not only for the patient but also for those around them to assist in distinguishing bpd for mood disorders look for the rapid speed of emotional instability to differentiate it from the mood changes in depression or bipolar disorder which instead occur over weeks or months next the s is for self-harm and suicide people with bpd often engage in self-harm with non-suicidal self-injury like cutting being common in fact cutting is a highly specific sign of bpd and is rarely found in other disorders which can be diagnostically helpful when learning about bpd many people wonder why people with bpd hurt themselves after all why would anybody intentionally inflict pain upon themselves while it seems paradoxical people with bpd often self-inflict physical pain as a way of reducing their emotional pain as cutting and other forms of self-harm seem to help dissociate them from their current mental state which as we learned just now is often defined by feelings of dysphoria and emptiness in addition to non-suicidal self-injury people with bpd also show a pattern of frequent suicidal thoughts intentions and even attempts in contrast to the episodic suicidality seen in mood disorders most people with bpd are chronically suicidal this makes the decision to hospitalize someone trickier than with depression or bipolar disorder as suicidality and bpd tends to be more of a constant rather than something that can be changed during a brief hospitalization next the p is for psychotic and dissociative symptoms up to half of all people with bpd will report symptoms that sound psychotic in nature including auditory hallucinations paranoia and delusions however while these symptoms superficially resemble those seen in schizophrenia they don't ultimately fit the same pattern psychosis-like symptoms in bpd are often transient and tend to occur in times of severe interpersonal stress and when the stress decreases the symptoms will as well paranoid thoughts do not typically involve complex delusional belief systems like in schizophrenia but rather are related to interpersonal sensitivity such as someone thinking that their classmates are spying on them just to laugh at them behind their back in addition to these psychotic sounding symptoms patients with bpd often report dissociative experiences as well including derealization or feeling that their experience is not real as well as depersonalization or feeling that they're somehow detached from their mind or body next the a is for anger anger antagonism and disappointment with others are frequent emotions for patients with bpd with many patients experiencing anger and irritability on a daily basis while some people with a condition frequently yell or engage in aggressive or even violent behavior not all people with bpd will show these outward expressions of anger so-called quiet borderlines instead hold these emotions inside though they will still report having them when asked next the eye is for impulsivity people with bpd have a tendency to act quickly without considering the consequences of their actions including substance abuse unsafe sex reckless driving violent acts and self-harm these impulsive acts are often motivated less by the pursuit of pleasure than they are by the desire to escape from negative emotions for example while it's common for people without bpd to seek sex for pleasure someone with bpd may hook up with multiple partners within a few days more to escape from feelings of being unloved or unwanted than for any physical sensation finally the r is for relationships relationships are often difficult for people with bpd they tend to show a pattern of short-lived and unstable relationships with people in their lives including not only romantic partners but also family friends and co-workers this pattern is often related to these patients tendency to see the world in extreme or black and white terms a phenomenon known as splitting when interacting with the patient with bpd people often find themselves on one side or the other of a split they're either the best person ever or the cruelest person ever to walk the face of the earth much of this stems from the fact that people with bpd are extraordinarily sensitive to interpersonal rejection while being rejected dumped or abandoned doesn't feel good for anyone people with bpd often react to these circumstances in an extreme way or will engage in frantic efforts to avoid abandonment such as threatening to kill themselves if their partner leaves them when learning about these signs and symptoms you'll notice that they're all related to each other for example someone with bpd may fear abandonment because being alone makes them have to confront their chronic feelings of emptiness and the painful sensation of lacking a sense of identity the desire to avoid this feeling can lead to impulsive actions like self-harm as a way of dissociating from the rapidly shifting emotions in this way you can see that these signs and symptoms form a complex web that can easily trap patients in maladaptive patterns when diagnosing bpd in clinical settings you can use the i despair mnemonic to remember the nine core signs and symptoms of this condition at least five of these nine criteria must be met for a diagnosis but wait you might say why are there only eight letters in i despair but nine symptoms in the dsm the reason why is that the dsm splits relationships into two domains unstable relationships and sensitivity to abandonment which is why there are only eight letters in the mnemonic but nine criteria in the dsm more than most disorders a diagnosis of the bpd should not be based on a snapshot view of the patient's presentation at a particular moment in time but rather on a consistent pattern across the life span so with that in mind let's dive into the life course of bpd including who gets it what happens once they get it and what forms of treatment are helpful bpd is common with around five to ten percent of the population showing signs and symptoms of the disorder that is severe enough to cause dysfunction in clinical settings bpd is significantly more common and may account for up to one-third of all patients in any given psychiatry clinic this prevalence gives it a high base rate and makes it liable to being under diagnosed many patients show at least some symptoms of the disorder such as emotional instability or trouble with impulse control from a very young age even as early as the first few years of life however these symptoms often do not fully bloom into a full-blown disorder until the teenage years with most patients first meeting criteria for the disorder during adolescence or young adulthood this brings up an important point while it's commonly believed that you can't diagnose bpd in patients under the age of 18 this is not true at all and the dsm does allow for the disorder to be diagnosed earlier than that however because of what we know about the changeability of personality during development you must be certain that the pattern has been present for at least one year and is not just the normal swings of emotion and identity that can occur during most people's adolescence bpd is historically associated with women and in clinical settings it is diagnosed in women's three times as often as men however research shows that when structured evaluations are used bpd is equally common in men and women there are a few reasons why bpd tends to be over diagnosed in women first while men and women share the same core patterns of the disorder like anger and impulsivity women with bpd are more likely to express these in ways that lead them into medical settings while men with bpd are more likely to engage in violent behavior or substance abuse that will instead land them in legal settings like jails or prisons that are less likely to care about psychiatric diagnosis second the diagnostic criteria for bpd themselves may be biased towards a greater rate of diagnosis in women with nearly all the symptoms of the disorder being seen as more common in women than men finally while the core patterns of bpd are found at the same rate in men and women women are more likely to have experienced things like sexual and physical abuse that can cause the pattern to reach a level of dysfunction where it gets diagnosed overall these data should make you cautious not only about over diagnosing bpd in women but also about under diagnosing it in men finally you should note that despite conceptions of bpd as an exclusively social or psychological disorder there is a large biological component as well in fact studies estimate that the heritability bpd is about 50 which is higher than many other disorders that we see in psychiatry including things like depression so what happens once the patient has bpd while conventional wisdom has long held that bpd is a chronic and unchanging disorder studies that have followed people with bpd over decades have revealed that this is simply not true in fact fifty percent of people who initially meet criteria for the diagnosis no longer have it two years later and eighty-five percent are in remission ten years later even without treatment if the vast majority of people recover from the disorder then there is seemingly no basis to label it as an unchangeable condition however the truth is more nuanced than that when looking at the data it appears that complete remission from symptoms is actually quite rare while the more intense and dramatic symptoms like impulsivity self-harm and hostility tend to decrease others such as chronic dysphoria difficulty in relationships and issues with identity tend to remain so even if most patients no longer technically meet the dsm's five out of nine criteria threshold this does not mean that they're completely free from the disorder and many patients have lower than average rates of employment and life satisfaction the take-home message here is that while the prognosis for bpd is not as bad as it was once thought to be it's still not as good as we might hope so with that in mind let's talk about treatment our understanding of bpd treatment has changed dramatically over the years while it was long taught that bpd is an untreatable condition in the late 1980s and early 1990s a specific form of therapy known as dialectical behavior therapy or dbt was developed dbt was a complete paradigm shift in that for the first time a form of treatment could clearly and directly improve patient outcomes including decreased rates of self-harm suicide attempts and hospitalizations dbt works by teaching specific skills like mindfulness distress tolerance emotion regulation and interpersonal effectiveness that are all targeted towards the core patterns of the disorder you can remember the indication for dbt by thinking of it as the d borderline therapy while dbt is incredibly helpful the downside is that it can be costly and time consuming often requiring the patient to be in treatment for at least one or two years before meaningful improvements are seen in addition dbt requires clinicians to undergo additional training before they can offer it which makes for a small pool of available providers this combined with a frequent lack of insurance coverage and long waiting lists makes it so that many if not most patients with bpd are unable to access it so while dbt is a great treatment if most patients cannot actually get into treatment then it's clear that another approach is needed for the rest of this video we're going to focus on some treatment strategies that any clinician can deliver in any setting without the need for extensive training like with dbt these strategies are based on a newer model of treatment known as good psychiatric management or gpm gpm has been found to be just as effective as dbt so it's not like you're shortchanging patients by doing this instead of dbt while each form of treatment has its own unique role the fact that gpm can be practiced by any provider in any setting makes it a great first line option for patients and one that any provider who works with bpd should be familiar with the core treatment strategies of gpm can be summed up in the mnemonic d-lapse think of a d-lapse as being the opposite of a relapse instead of allowing a patient to relapse into a bad place by following these principles you're helping them to delapse into a better pattern first the d is for diagnose while historically clinicians were encouraged to avoid telling their patients about a diagnosis of bpd this is actually the wrong approach the fact of the matter is that telling your patient about the diagnosis is one of the most helpful things you could do as it provides a unifying framework for the many concerns that your patient may have it also helps both you and the patient to avoid spending years trying treatments like medications that work for other diagnoses like depression or bipolar disorder but are completely ineffective for people with bpd however it's important that you not only give the patient a diagnosis but also educate about it as well taking the time to teach a patient about bpd the core patterns associated with it and the relationship of these symptoms to extreme interpersonal sensitivity provides a helpful explanatory model that allows them to understand their symptoms when they experience them in addition patients should be informed about the underlying causes of bpd including its high heritability as well as the overall good prognosis for the disorder this last part is key if this step is done correctly most patients will report feeling more hopeful about their condition often for the first time in their lives next the l is for life outside of treatment because the effects of bpd can extend into every area of someone's life you can and should provide guidance on things besides just therapy and medications inquire about the patient's life outside of treatment and try to enhance social functioning by encouraging the patient to work or volunteer in activities that they find meaningful as well as to develop healthy interpersonal relationships the phrase work before love is a helpful guiding principle as employment or school tends to provide a more consistent and stabilizing structure to a patient's life than romantic relationships next the a is for avoid medications medications should generally be avoided for patients the bpd in fact some studies have shown that the more medications a patient is taking the lower chance they have of actually getting better while this is not necessarily causative it at least suggests that medications are not the answer here nevertheless many patients with bpd end up on huge numbers of medications none of which seem to make much of a difference when working with patients you should not only try to avoid starting new medications but also actively try to get rid of any existing medications that aren't actually helping if medications are to be used they should only be for symptomatic treatment of specific symptoms rather than being seen as something that will fundamentally change the severity of the disorder anti-convulsants and antipsychotics are the most frequently used medications in bpd with anti-convulsants helping to reduce anger and impulsivity in antipsychotics helping to alleviate paranoid or dissociative symptoms next the p is for prioritize most people with bpd meet criteria for many other disorders as well including depression anxiety ptsd ocd eating disorders and more because of this it's essential to list out all of their conditions and triage which ones should be the initial focus of treatment as a general rule treatment of bpd should come first before all other disorders this is because attempting to treat other disorders without addressing bpd is often futile in contrast if you treat bpd first you'll find that not only are the patients bpd symptoms better but their other diagnoses have often gone away as well the only exceptions to this rule are any conditions that can physically harm the patient or would prevent them from engaging in treatment like if a patient with a comorbid addiction is showing up to appointments intoxicated or is so disorganized for mania or psychosis that they cannot engage or are so malnourished from an eating disorder that they end up in the hospital with these few exceptions however treatment of bpd should come first next the s is for safety plan given the high rates of suicidality self-harm and reckless behavior seen in bpd coming up with a good safety plan is essential take the time to make a plan for what the patient should do if they develop a crisis including actions they can take to calm down a list of supportive friends and family that they can contact and when it is or is not appropriate to call 911 or go to the hospital because it's so easy to get overwhelmed in these situations i will often have patients fill out a card with their safety plan on it that they can carry with them at all times to help remind them what they should do even when they're in the midst of a crisis finally the e is for expect change bpd requires a fundamentally different approach compared to other disorders that we treat while many clinicians like to think of themselves as being the one to come in and fix everything for the patient this simply doesn't work for patients with bpd as it risks encouraging the patient to split you into either the perfect savior or the incompetent idiot depending on how well things are going instead you must make it clear to the patient that while you're committed to helping them change whatever they're most concerned about ultimately your goal is to provide guidance about the disorder and treatment options in exchange you will expect the change to come from them including a commitment to bringing their best effort to treatment by doing this you avoid placing the patient in a passive role where they can reject all your attempts to help and are instead partnering with you to work effectively as a team so that's gpm in a nutshell if you're doing all seven of these things then you can rest assured that you are providing the standard of care for your patients with bpd to wrap up let's summarize what we've learned in this video bpd is often misunderstood and under-diagnosed as clinicians are reluctant to talk about it and patients often don't want to hear about it however ignoring bpd does a disservice to our patients by dooming them to a vicious cycle of failed treatments and unmet expectations instead we must do our best to understand these patients and give them the best quality of care if you have a good grasp on both the i despair and delapse demonics then you're already ahead of the curve when it comes to diagnosing and treating bpd and you're in a great position to help break patients out of the cycle that they're caught in and help them to live the lives that they want thanks for taking the time to watch this video if you enjoyed it consider subscribing to my channel for more videos like it i also encourage you to check out my book memorable psychiatry on amazon which talks more about the differential diagnosis of bpd there are also lots of practice questions to test your knowledge until next time thanks for watching and happy studying