Brief BPD background

When you read a diagnosis of Borderline Personality Disorder, how most people respond, there may be eye-rolling, groaning, and any number of jokes told by residents, attendings, and med students all for the purpose of coping with the challenges of managing patients with BPD. BUT, it doesn't have to be this way. Yes, patients with a BPD diagnosis are challenging, but despite what others may say they can be treated and can have improvement in sx and their overall condition. Next time you interview a BPD patient consider the following.

1. Their problems are real- Evidence suggests(both statistical and anecdotal for all Psychiatrists) that nearly all BPD patients have a significant h/o trauma and neglect, often early in childhood. We easily validate PTSD patients for their trauma, and should remember to do the same for BPD patients.

2. Remember Ericksonian Stages of Development when approaching these patients- Many of us know BPD patients can be "child-like" with the classic "teddy bear sign" and affective instability that may remind you more of a child than an adult counterpart. If you've ever wondered why we learn stages of development, BPD patients illustrate the need for this part of our education. In reviewing Ericksonian stages, you can see many potential pitfalls for BPD patients depending on when in life their trauma occurred, and the idea that they may be "stuck" in a previous stage helps explain some of their personality structure(ex. neglect in early childhood may lead to trust issues, or lack of self-esteem, feelings of guilt, etc).

3. Remember coping mechanisms when approaching BPD patients- The need for learning coping mechanisms is also illustrated in BPD patients. We always say "staff splitting" is a sx of BPD, but really "Idealization and De-valuation" is a more accurate coping style to outline. In truth, "staff splitting" is more of a result of this coping mechanism rather than the coping mechanism itself. Essentially, BPD patients believe people are all good or all bad, the reason for this belief is outlined below.

4. Think about object constancy- Most of us understand other people have both good and bad qualities and recognize believing others are "all good or all bad" is a limited view of the reality of complexities of human life. This idea is given a term in Psychology termed "Object Constancy," which is essentially the idea that people can have a mix of both good and bad qualities but still be themselves. BPD patients live in a world(metaphorically speaking) that is more like a cartoon or comic book with clearly defined "good guys and bad guys"(hence black and white thinking), and this is rooted in a lack of object constancy; again, this is part of having a more child-like personality structure. The point of all this is...

5. BPD patients are not all that different from other patients- While we know these patients can be challenging, remember they have lives outside the hospital(or clinic), they have been making and breaking relationships throughout their lives, they have capacity and desire for loving relationships, and they are capable of building an alliance with providers and medical staff, and that can be used to your advantage(and, dare I say, is NECESSARY for their improvement).

Interviewing the Borderline Patient

So, highlighting point number 5 above, in seeing BPD patients both in an inpatient or outpatient environment, forming an ALLIANCE with the patient is of paramount importance. In approaching interviews with these patients, one should consider the following.

1. Alliance is your first goal- In building an alliance, a warm and inquisitive approach should be considered with a mix of open and closed-ended questions, focusing on validating feelings(no matter how childhish you feel they may be) and identifying goals, so that you can align your goals with theirs(ex. "I can hear your depression has been having a profound effect on your life; let's work together to help you feel less depressed and find some treatment that can help you moving forward).

2. Understand they are emotionally immature- This is meant as a point of understanding rather than a judgment on these patients. When you approach them, you should understand they are like teenagers or, in some severe cases, like children emotionally speaking. Therefore, you should not be offended or upset if you are ever mistreated by them, just as you would not be personally offended by a child's tantrum or a teenagers acting out. Remember to remain calm and steadfast in your support. If they are not able to tolerate an interview, don't force things or angrily hold boundaries, you can maintain boundaries without being harsh, just as you would with a child.

3. Use Psycho-education and salesmanship to your advantage- Following the teenager analogy mentioned above, it's worth remembering that BPD patients feel very misunderstood by others and even struggle to understand themselves. Explaining their diagnosis to them(without necessarily using the name, until the end of the explanation) can be incredibly helpful in validating their feelings as it makes them feel understood, which usually furthers your alliance with them as it makes them feel genuinely cared for and fosters a greater sense of trust(both in you as a person and in you as a provider, as they are often impressed if/when you can demonstrate an understanding of them).

Consider the following example interview below as a potential guide of how such an interview could go:

Provider: Hello Ms. Smith, I'm Dr. Jay, I have heard you had a suicide attempt last evening and have been depressed. It sounds like this has been related to several stressors in your life, can you tell me more about what went on before coming to the hospital?

Ms Smith(rolls eyes): I tried to kill myself Dr. I've been through this all before! I told those guys in the ER everything. Why don't you just talk to them?

Dr. Jay: I can tell you ma'am that I read some documentation from the ER, but if you could give me some more information that would be very helpful. I'd like to know how best to help you. We don't necessarily need to go through your entire history again, but if I am able to get to know you some more it will help us work together to help your depression improve. I know being in the hospital can be difficult.

Ms Smith interjects loudly: Do you know Doctor? Do you really? I think you just want to give me drugs like everyone else. No one understands what I go through and no one ever will!

Dr. Jay: What is it that you go through? What do you mean when you say that?

Ms Smith: You wouldn't understand....(trails off into silence).

Dr. Jay: Well, are you having more thoughts about hurting yourself?

Ms Smith(now becoming tearful): I have them all the time.

Dr. Jay: How long have you felt that way?

Ms Smith: All my life.

Dr. Jay: I can see that this has been really challenging for you. It looks like your depression is having a really profound impact on your life.

Ms Smith(continuing to cry): Dr. I've cut myself since I was 14 years old(rolls up sleeve and dramatically shows forearm with several scars).

Dr. Jay: You must have been very depressed when cutting in the past. When you do this, what are you hoping to accomplish when you cut yourself?

Ms. Smith: I do it for relief. Sometimes I just need to feel something.

Dr. Jay: You know Ms. Smith, when I have had other patients with a similar story to yours, they have told me that they feel "empty." Do you ever feel that way.

Ms. Smith(quietly): All the time Dr.

Dr. Jay: Those same type of patients also often say to me that they feel "all of their emotions or none of their emotions." Does that describe you?

Ms. Smith: Definitely.

Dr. Jay: Did anything happen in your life before you started cutting yourself.

Ms. Smith: Well...my father touched me inappropriately when I was in grade school.

Dr. Jay: I'm so sorry to hear that. When things like that happen it can be very difficult to trust others. We all have a feeling or belief that we should be able to trust our parents. It can be very difficult when that trust is broken.

Ms Smith: Exactly. I've been hurt by so many people in my life. It has happened over and over.

Dr. Jay: I am sure that has played a big role in your depression.

Ms Smith: Definitely.

Dr. Jay: You know Ms. Smith, many of my patients with h/o trauma like yourself tell me they worry about being left or abandoned by others. Does that describe you?

Ms Smith: I'm always worried about that! Like, the reason I wanted to die was my boyfriend was talking to this other girl, and I just know he's cheating with her! I couldn't stand the thought of it. I've had other men cheat on me, and I just knew he was going to do it.

Dr. Jay: So did you have a fight with your boyfriend?

Ms. Smith: Yes! He told me they were just friends, but I don't believe him! It always happens like this. They all say one thing, but in the end they're just going to leave me, and I know my depression will worsen. I wanted him to say he loved me during the fight and that everything would be okay. He has been noticing me less and less, I know he's pulling away. Now that I hurt myself I hope he noticed.

Dr. Jay: So I hear you're worried he will leave, and you have had other people leave in the past. Have you had a hard time in relationships because of people leaving? Like, do you tend to act a certain way to try to keep them from leaving?

Ms. Smith(now very tearful): Yes, I'd do anything to make him stay! I love him! I just wish he would love me back.

Dr. Jay: Do you feel like you're a person worthy of others' love?

Ms. Smith(quiet and contemplative):....Usually not.

Dr. Jay: Ms. Smith, have you ever heard of the diagnosis Borderline Personality Disorder?

Ms Smith: No, I've heard of Bipolar, Schizophrenia, Anxiety, and Depression. I know I've been given those diagnoses before.

Dr. Jay: I certainly feel strongly that you have clinical depression, but I also feel that a diagnosis of Borderline Personality Disorder may better explain all that you go through on a regular basis and why it has been hard for you to feel well despite lots of treatment. Do you mind if I tell you more about it?

Ms. Smith: Sure, I guess that's fine.

Dr. Jay: Patients with a Borderline Personality structure usually have a h/o trauma or abuse, and it usually happens when you are young and attempting to navigate life. You are attempting to learn if you can trust others, and if you are accepted and loved for who you are. In many people, being traumatized at that stage in life causes them to doubt their worth and feel like other people are going to leave them. Due to this fear, they constantly try to prevent people from leaving and often have dramatic relationships because of this. This makes it really hard to have long-lasting loving relationships and friendships, which can also worsen your depression. On top of all that, these types of patients also often feel they are unsure of who they really are deep down inside. Because of all this, medication can be helpful for treating the mood issues associated with this diagnosis, but you ultimately need therapy to help you navigate the really difficult things you've been through in the past and learn how to better be able to cope in the present. I want you to know I am committed to helping you feel better and would like to offer some medication that may help your mood improve while we also work on getting you a therapy referral so that you can learn more about this condition when you eventually discharge. Does that sound reasonable to you?

Ms Smith(now very tearful): This sounds just like me Dr. What are my chances of getting better? I don't want all the pills! And I've had therapy for my depression before. How will this be any different?

Dr. Jay: I can tell you there is not one medication with strong evidence to suggest improvement, but we have a plethora of medications that can be helpful in stabilizing mood in patients with this condition, and I have seen several help my patients with this condition before.

Ms. Smith: Okay Dr, I'm okay with trying medication, but I'm not ready to talk about it right now. Can you just look at my chart to see what I've been on in the past?

Dr. Jay: I will certainly do that ma'am, and I'll try to circle back for clarification if there's anything I can't see on your chart. I'll let you know at that time what medication I'm thinking of, just to make sure we can be on the same page about it.

Ms. Smith: Okay.

Dr. Jay: How do you feel about the therapy aspect of treatment?

Ms. Smith: Would therapy be like what we're doing right now?

Dr. Jay: A little bit. Your therapist would work with you to try to help you, but there is also a specific type of therapy that is helpful for patients with Borderline Personality Disorder called DBT. If you'd like, I can see if one of our staff members can bring you some more information about it? Would that be okay?

Ms Smith(appearing somewhat ambivalent): I think that'd be fine Dr.

Dr. Jay: Okay ma'am. I'll circle back around to you later like I said, but thank you for your time this morning. I know we went through a lot together, and I'm sure it was very challenging, but I am optimistic that we can get you to a place where you're feeling better.

Ms Smith: I feel a little better too. Thank you Dr. (Interview ends)

Conclusion: While the previous sequence of events in this interview may seem unrealistic, I can personally say I have had many interviews just like this one. Treating patients with BPD can be daunting, but we do not have to dread it or view the patients as adversaries. While these patients can be difficult, their improvement can be some of the most rewarding and truly satisfying to obtain. Consider bearing these principles in mind as you move forward, and know that you, wherever you are at in your training have the potential to create lasting impact in the lives of patients with BPD.