Thread by @DrWinarick

1/ In honor of #bpdawarenessmonth, here is a thread that gives you a general historical overview of #BPD, current conceptualizations, diagnostic criteria, and experience-near descriptions & recommendations for the individual w/BPD & those they have close relationships with.

2/ This is a lofty goal & I don't know how far I will get in one sitting but bear with me. While the history of BPD as a diagnostic category can be traced to historical precursor syndromes as documented by many I'm sure, I think most salient as an influence on the construct is 2/

the Freudian/psychodynamic conception of mental functioning as existing on a continuum from neurotic (healthy) to borderline (as in on the border between neurosis & psychosis) to psychotic. It was viewed as severe pathology but with generally intact reality testing, 3/

less severe than psychosis but more severe than e.g., melancholia, phobias, & maybe even hysteria. So the relationship between the constructs underlying the Freudian descriptor and the DSM nomenclature is somewhat unclear. The major similarity is severity of psychopathology & 4/

in some sense, behavioral patterns such as extreme mood lability, maladaptive defense style, and manipulative recurrent interpersonal, problematic, patterns, when extreme & severe may resemble the Freudian level of mental functioning referred to by the term, "Borderline." 5/

Borderline Personality Disorder today does not refer to a general level of functioning on the continuum of psychopathology that exists at the border between neurosis and psychosis. It is viewed as a discrete personality disorder by and large, i.e., a personality type 6/

In around 1985, the DSM-III came out, fundamentally changing the paradigm for diagnosing mental disorders. BPD became operationalized in a way that is still used today: the presence of X out of Y diagnostic criteria. This is straight from the DSM: 7/

What is at the core of these diagnostic criteria? What are the underlying dimensions of behavior that theoretically give rise to this list of discrete, purportedly objective, behaviorally observable sentences known as “diagnostic criteria?” 8/

Much empirical and theoretical work exists in this domain. It’s great when they overlap. In connection to the core clinical features or underlying dimensions of BPD, areas of theoretical & empirical overlap point to the following pattern:

-Attachment insecurity

9/

-Emotion dysregulation
-excessive impulsivity/Self-destructive/high-risk/pleasure seeking patterns (eg addiction, cutting.)
-internal emptiness/lack of a sense of a grounded self/maladaptive defense style & coping skills/deficits in self-soothing

10/

People with BPD are known for moving a lot - jobs, romantic partners, physical geographic location. They are known for their emotional outbursts “emotional storms.” 11/

They are especially known for making repeated threats of abandonment in romantic relationships, threatening self harm ie suicide, and self harming behaviors ie cutting. Eating disorders & substance use disorders are frequently comorbid with BPD. 12/

People with BPD in romantic relationships often provoke jealousy & triangulate frequently in most interpersonal relationships. They tend to split people into categories of all good or all bad, treat people accordingly, & then have their expectations confirmed when ppl respond 13/

to them in a manner consistent with the “all bad” expectation placed on them (there is a clinical term for this interpersonal dynamic between people. It’s called projective identification. & it’s the hallmark of BPD imo.) 14/

Projective identification occurs when all of sudden you are treating someone like they were your annoying little sister that you had to take care of because the other person starts acting all dependent & grateful, pulling at those tendencies which resonate in your history. 15/

Happens inside and outside therapy. For ppl w/bpd, they go around protectively identifying with teachers, peers, lovers, parents, children, etc in a dysfunctional, emotionally gut wrenching manner in which all parties are playing out some scripted dynamic in which the person 16/

w/BPD is sort of an unconscious puppeteer in the puppet show of their life in which they are also a puppet in a plot characterized by constant emotional turmoil, drama, rocky relationships, & a constant need for feeling like one has a self despite lacking a core self resulting17/

in frantic efforts to avoid abandonment, disappear, or feel something, anything very strongly. In any event, as you can imagine, being a mother father daughter son sister brother lover wife husband bf gf fried bf bff w/someone w BPD is more than a little challenging. It can 18/

One minute the person loves you. The next they hate you. One minute you are planning a vacation & the next they have packed a suitcase & are threatening abandonment. “Look at what your doing to me [as person w BPD self-harms]” would be an unsurprising utterance for example. 19/

My favorite book titles on this topic are pop psych self-helpey bc they have touch on experience-near BPD phenomena (at least as far as their titles. I can’t speak to what’s inside the front & back covers of the books). Such titles include “I hate you, don’t leave me.” 20/

And my personal favorite, “Sometimes, I act crazy.” These titles speak to the core experiences of people w BPD: sometimes they act cray & they often have intense feeling of love & hate towards love objects without the ability to integrate those feelings into a complex whole. 21/

So what are the risks of having BPD? For parents, spouses, partners, kids, friends, & the person w/BPD themself? When is treatment needed? What are the treatment options? What does one do if they suspect a dx or suspect they got a false dx of BPD? These questions must be 22/

addressed & will be answered in the relevant tweets below. BPD is a very serious mental disorder. It’s a personality disorder, putatively lifelong. Hard to change but possible w good therapy, meds, supports (to be defined later). BPD can be devastating. Society best recognize.23/

People with BPD might leak a government document if in a position of power if emotionally dysregulated w/or w/out intoxication. Someone might choose a policy marked by antagonism in an emotional storm that backfires. Someone may be unable to work all of a sudden bc some bs. 24/

Family members and partners are in a daily struggle for the preservation of their boundaries which are constantly under intense assault by the individual with BPD who may sniff out what boundary you have difficulties with & go charging full speed towards it. Relationships 25/

w/people w bpd can be traumatic, life destroying, or and/or a learning experience. Any trustworthy shrink would advise you to avoid getting into a love relationship w/someone w BPD if you can spot it, &I can’t echo this point enough despite its putative political incorrectness26/

27/ People with BPD get treatment either bc their parents make them, their spouse or friends or family makes them, or it’s clear to them that after failed relationship and job # 15, that there might be an issue. Sometimes they get treatment bc of comorbid conditions. What is 27/

the treatment? It’s got to be comprehensive & it’s got to involve the people the person with BPD interacts with regularly (like family or friends) bc it is such a disorder of interpersonal relating. It is impossible to treat effectively without making sure ppl in the patients 28/

life are on the same page & to avoid splitting, triangulating, & other interpersonally manipulative behaviors that the person w BPD tends to engage which negatively impact their functioning. So, depending on severity…the treatment options are as follows 29/

least severe ie no cutting, self harm, substance abuse, risky sexual behaviors, no mania just interpersonal pathology, self regulation deficits —> individual psychotherapy with licensed professional (Psychodynamic, cbt, DBT, integrative, etc.) w/ med consult w MD in office30/

Somewhat severe - higher risk in all those areas, more acting out, more negative life consequences from BPD symptoms —> still outpatient/office but either bonafide DBT or TFP (transference focused therapy) should be used. The DBT should also involve a skills group & the TFP 31/

should involve a “360” ie interviews w friends and parents.
Severe BPD - high risk, suicidal, drug abuse, risky sexual behaviors, severe outbursts, impulsivity, especially dangerous when comorbid w bipolar disorder - hospitalization (inpatient sometimes needed) or a 32/

structured hospital based day program that has groups and individual therapy and MD medication consults.

33/ Done.

*Some tips for people with BPD feeling like shit & looking for some relief:
1. Hold ice cube
2. dunk head in cold water
3. Mindful meditation from a .edu source.
4. Get in bed under cover in fetal position & watch Larry Sanders show from start to finish.
5. Take a hot bath
Etc

Tips for ppl entangled with someone with BPD.
1. Don’t take attacks/criticism personally
2. Wait until person is calm or out of the emotion storm before communicating anything of importance. Storms end.
3. Get out.

4. Buy Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder amazon.com/dp/1572246901/…

Sorry that’s all I got.

cc @MelissaJPeltier @page88 @AllenFrancesMD @ZevShalev @paulsummergrad @SameiHuda @awaisaftab @DrAaronB @Ilozue716 @DrCraigMalkin @DevinCow @Foreman1David @GoldfriedMarvin @dawso007 @DrGaryNGoodman @ProfRobHoward @docivanhoe @jonathanstea @psychunseen @myocdcare

cc @GoldfriedMarvin @tylerblack32 @amybarnhorst @awaisaftab @SameiHuda @AllenFrancesMD @ethicalpsycholo feedback from colleagues welcome.