ADVICE ON MENTAL HEALTH: Understanding Borderline Personality Disorder

ADVICE ON MENTAL HEALTH - from Brain & Behavior Magazine, May 2022 issue

Q&A with Anthony C. Ruocco, Ph.D., C. Psych.

University of Toronto Professor,

Interim Graduate Chair and Director of Clinical Training,

Department of Psychological Clinical Science

2014 BBRF Young Investigator

Families for Borderline Personality Disorder Research Investigator

Dr. Ruocco conducts research at the intersection of clinical psychology, neuropsychology, and cognitive-affective neuroscience. His focus is on externalizing psychopathology (disinhibited behaviors, personality disorder diagnoses and traits, substance use disorders), suicidal thinking and behaviors, and depression, with particular emphasis on executive functions, especially cognitive control.

Dr. Ruocco, personality disorders (PDs) are remarkably common in the population, perhaps affecting as many as 9% of adults, according to the National Institute of Mental Health. About 1.4% of U.S. adults (over 3 million) experience Borderline Personality Disorder in a typical year, the NIMH says, making it the most common PD. But you don’t hear very much about BPD or other PDs. Is this due to stigma?

In the current DSM classification system, there are 10 distinct personality disorders. I study borderline personality disorder, in particular. Regarding BPD, I would say, yes, there is a stigma, but I would say we’re starting to see change. We’re starting to see more people talking about it. Although not as much, perhaps, as bipolar disorder, or autism, or depression, or schizophrenia.

One problem associated with the diagnosis is that many medical professionals don’t know enough about personality disorders or how to treat them. You hear the story of the parent who goes to a local clinic and tells the doctor, “I think my child has borderline personality disorder.” And the doctor replies, “Well, we don’t actually treat people with that diagnosis at this clinic.”

Not because they don’t want to, I assume, but because they don’t know how?

Yes. The honest answer in such a case might be: “We don’t have the expertise.” Generally speaking, treatment for BPD does need to be specialized to be effective. Because of this issue, many parents are being turned away and their children—often in their late teens and early 20s—are are not receiving the care they need. This can have real life and death consequences.

Let’s start with some basics. What does it mean, exactly, to say someone has a personality disorder? It somehow sounds fundamentally different from saying a person has depression or schizophrenia.

In the way they have traditionally been defined, personality disorders can involve disturbances in up to four areas. One area is identity: how you perceive yourself, and yourself in relation to other people. A second area is disruption in interpersonal functioning—how you relate to other people. Those two areas are tightly related. A third area of potential disruption in the classical definition of PDs is in the area of impulse control. Finally, one can see disruptions in the regulation of emotions, or what we sometimes call affective stability.

There have been proposals in recent years to revise the way we clinically define PDs. The latest research suggests that while problems with impulse control and emotion regulation can be part of the clinical picture, it’s likely that disturbances in one’s identity and how one relates to others that forms the core of a personality disorder.

In this discussion, you and I will focus on one of the PDs, borderline personality disorder. I have to ask about the term “borderline.” What does it mean?

Some people ask me, “Does it mean I’m at the borderline of having a personality disorder? Or does it mean something else?” In fact, when you are diagnosed with BPD it does mean you have a personality disorder. But the term “borderline” is a legacy of the original notion of the illness, from decades ago, when clinicians were unclear as to whether someone had psychosis, or whether they had some form of what was then called neurosis.

“Borderline” came into the picture because some people with BPD can appear “psychotic-like,” and at the same time, have a severely unstable mood. When they’re experiencing high levels of stress, they can experience difficulties with testing “reality.” They might feel strongly that someone is out to get them, or they may have dissociative experiences in which they may feel they’re floating above their body—or, that the world has slowed down; or, they have disruptions in their memory and time lapses they can’t account for. At the same time, patients with BPD were described as having a very unstable mood, which could exacerbate their psychotic-like experiences. These are some of the reasons why the terms “borderline” was originally used and it has remained part of the terminology.

But to be clear: today, BPD is more strongly associated with the emotional components of the original conceptualization— it’s largely thought of as a disorder centering on emotional dysregulation, and to some extent, impulsive behaviors.

On the other hand, that is not all that is involved, right?

Exactly. There are other types of symptoms. But the way many major theorists think about it these days is that emotion dysregulation might actually be the reason that people with BPD, for example, have problems having a stable sense of identity— because their emotions are so up and down, it’s hard to have a sense of who you are. We also think they have difficulties with controlling their impulses because their emotions might be so intense that they do things that are out of character for them.

Why not, then, call it “impulse control disorder”? Perhaps that would carry less of a stigma?

You are not the first person to suggest something like this. Dr. Marsha Linehan, who is one of the main figures in the field of borderline personality disorder and developed dialectical behavior therapy (DBT) to treat it, proposed the term “emotion regulation disorder.” That being said, BPD can be expressed in a range of additional ways. It’s important to try to capture those, too.

If I hear you right, the aspect of the disorder that has to do with uncertainty about one’s identity and/or a shifting perception of the self and one’s relation to others, may be but isn’t necessarily related to “emotion dysregulation”—and these other common aspects of BPD are important to keep in focus?

Yes. Another thing is that the disorder really differs from one person to another. One can be highly emotionally dysregulated and highly impulsive, but that doesn’t necessarily capture whether the person has more of an identity or interpersonal problem. Often people with BPD have a really unstable sense of who they are. They’re very fearful of people abandoning them. They have really chaotic interpersonal relationships. They may have anger difficulties. These are all aspects that can also be part of the picture.

Let us now turn to BPD as it is defined in the current 5th edition of the DSM. What kinds of traits are mentioned in DSM-5 and how many of them do you need to receive a diagnosis?

Anybody who’s going to receive a diagnosis needs to meet what we call the general diagnostic criteria for a personality disorder. That’s in the DSM, and it includes having a disturbance in at least two of four domains, as I mentioned earlier: identity, interpersonal functioning, impulse control and emotion regulation. That’s the starting point. For BPD specifically, you need to meet any combination of five of nine potential symptoms. Impulse control symptoms involve things like substance abuse, binge eating, reckless driving, etc. These in turn often go hand in hand with suicidal behavior. The latter can include self-harm without the intent to die and self- harm with the intent to die, which are often related to people’s emotion regulation abilities and impulse control. People with BPD can be set off easily in terms of their emotions and have a difficult time getting back to their baseline emotion, because they tend to be so highly reactive. They find it difficult to control their emotions. Acute episodes like this can last several hours. Often what people talk about as being one of the most impairing aspects of BPD is feeling out of control of one’s emotions and feeling like they’re experiencing their emotions very intensely. In addition to this, patients sometimes express fears of abandonment. This is one of the other interpersonally relevant symptoms. Another symptom that’s relevant to interpersonal functioning, as I said earlier, is chaotic, turbulent, up-anddown relationships, where people with BPD will view others in an “all or nothing” way.

This is splitting between “all good” and “all bad,” and it can shift— the view of a person can go from positive, maybe unrealistically so, to unrealistically negative, and rather rapidly, right?

Exactly. It can be a really rapid shift, and we think this can contribute to chaotic relationships and having a really hard time maintaining relationships. This often comes out in a familial context as well. So many of the people that we’ve studied aren’t in contact with family members because of this history of chaotic relationships.

Another trait often seen in BPD is outward displays of anger, where people are breaking things, or constantly experiencing feelings of anger, and really having a hard time regulating it and having that anger subside.

In contrast with the symptoms I’ve so far mentioned are two contrasting traits of the nine mentioned in the DSM. The first is a pervasive sense of emptiness. And, as I mentioned earlier, people with BPD may also have stress related to dissociative experiences, i.e., disturbances in one’s sense of reality that occur under stress. Also, people with BPD could, when they’re under stress, experience suspiciousness and paranoia around people they normally trust. So you can see it’s a bit of a mixed bag, but at least five of these symptoms in combination is what leads to a BPD diagnosis.

And BPD is often comorbid or co-occurs with a number of other psychiatric diagnoses?

Yes, BPD is comorbid with a wide range of diagnoses. Most commonly, these include depression, especially chronic, long-standing depression. It can also be co-diagnosed with post-traumatic stress disorder (some have proposed that BPD might be a form of complex PTSD). BPD is also comorbid with substance-use disorders, whether it’s alcohol or other substances. Occasionally BPD overlaps with bipolar disorder, but I think of this mainly in the area of mood instability. The two can sometimes be confused and it’s important for patients to work with a psychologist or psychiatrist with expertise in BPD to understand whether one or both of these disorders might be diagnosed for a given person.

And what about ADHD?

Yes, we see high levels of comorbidity with ADHD, which is interesting to me because I study cognition, and a lot of people with BPD report difficulties with attention and memory. Interestingly, ADHD is also associated with impulsivity. So there’s a lot of overlap in the symptoms of these disorders. The other piece that I think is really important to note is BPD’s co-occurrence with social anxiety disorder. Social anxiety is often one of the more impairing aspects of BPD.

Is there a common element of social avoidance in the two?

There can be. In BPD, as we’ve discussed there can be a fear of rejection. Because of interpersonal problems, and how easily a person with BPD can be emotionally triggered, some people tend to avoid social contacts and they can become isolated. Fear of rejection is such a painful experience, and avoidance may be an adaptive thing to do in the shortrun. But this has consequences over the longer term for feeling connected to other people, feeling that you have a social support network, being able to rely on other people for support.

Is it true that more females than males have BPD? Or is that more of a myth than reality?

What I think can be a bit deceiving is that when you read research on BPD, often the people who are studied are women. I think the reason is that women tend to be more likely to seek treatment. And often, when people are doing research, they’re recruiting from a clinic. And so we see treatment-seeking samples often being highly skewed toward women. However, if you study people at a population level, you start to see a greater balance in how many people of each gender are affected.

Dr. Ruocco, your field is clinical neuropsychology. Please explain the relation of your experience with patients with your work in research to discover what may be driving the symptoms of BPD.

My training was at the intersection of psychology, psychiatry, and to an extent neurology. Integrating them has been one theme of my career. As a clinician, I’ve seen a lot of people with personality disorders, and have been involved, I would think, in diagnosing hundreds of them. What I love about what I do is trying to apply what we are learning about the biology of the brain to a disorder like BPD.

In the titles of a number of your papers on BPD there are references to the frontal and limbic regions of the brain. Tell us about the significance of those regions.

We often refer to regions deep within the brain, such as the amygdala—one of the brain areas central in processing fear and emotion—as parts of the limbic system. We tend to think about the limbic region as a somewhat more primitive part of the brain that is reacting to some type of an event—it is engaged in our response to stimuli.

In contrast, we have “higher,” regulatory regions of the brain that come online, as the name implies, to regulate the emotion centers. The regulatory regions can be called frontal regulatory regions. The frontal, functionally more advanced regions of the brain evolved to presumably impose control over those more primitive systems.

In people with BPD, my research and the research of others has found greater activation [than typical] in the limbic regions, especially the amygdala. My research has also highlighted heightened activation in the insula—a brain structure that appears to be involved in how intensely somebody experiences emotion. These two limbic-related regions tend to be overactive in people with BPD.

The frontal regions of the brain that we believe are involved in regulating the limbic regions tend to be underactive in people with BPD. And so you start to see, perhaps, one component of the biological basis for BPD, an imbalance between the emotion-generating centers and an inadequacy of the controlrelated regions. This could help explain why we see emotion dysregulation in people with BPD.

The findings you sketch out in broad terms are based on imaging that your team has performed while people with BPD have performed tasks, right?

Probably the most common way that we study emotion in people with BPD is by presenting “emotional faces” to them— pictures of people—while imaging the brain in real time. Another method is to have people with BPD generate written scripts—to literally write down an account of a time when they were abandoned by somebody. They write that down, we have them read it, and record it, then play the tape to them when they’re in the MRI scanner. We hope in this way to invoke responses that are specific to that person’s history.

Then, in terms of better understanding of impulse control, one thing we do is present people with a very simple task, like pressing a button every time they see a letter of the alphabet that comes up on a computer screen, except for, let’s say, an “S.” That means if an S comes up on the screen, they must withhold their response. If we have somebody do that for, say, 15 minutes, we’re building up their response tendency. When we infrequently present the S, they need to control that. We study brain activation that occurs during those infrequent “Stop, don’t press the button” moments.

And what have you discovered by doing this?

What we found in our recent family study of those with first-degree relatives with BPD was that people with BPD show less activation in the frontal regions of the brain that we think are important for bringing this inhibition to the fore. Interestingly, we expected that family members would show a similar type of a pattern. But instead we saw an overactivation in the frontal lobes of relatives. It was unexpected; the effect was quite robust. We think this may indicate that the close relatives of people with BPD might be compensating for a trait they share with their relatives with BPD. The difference being that they have a more capable regulatory system, so they can actually switch it on and maybe turn up the regulation, and it works for them.

But we went on to discover, also unexpectedly, that even if you compared relatives of people with BPD to controls who don’t have a family history of mental illness or a relative with BPD...the relatives of people with BPD still showed even more activation of control regions than the average person. We don’t really know what this means, but it could mean the relatives have some unique functioning within their brains that comes online when they need to control their behavior.

But regarding the BPD patients themselves. How do your discoveries so far about limbic and frontal regions inform the way we approach treatment?

I think there are two potential treatment implications. If these indeed are the regions that are activating differently in BPD, maybe intervening at the level of the brain will be therapeutic and help to control or reduce symptoms. There is emerging research to suggest that using a wide range of non-invasive brain stimulation techniques could potentially help, including Transcranial Magnetic Stimulation (TMS) and what I’m studying with help from my BBRF grant, Magnetic Seizure Therapy (MST), which is a newer form of brain stimulation treatment that’s related to ECT. These types of treatments seem to be not only improving symptoms in some people with BPD but they might also be having an effect on the brain. At this point, it’s too early to say precisely what effect. But there is some indication that the brain is changing, and that symptoms are changing. We need to know more.

MST is non-invasive, but does involve inducing a therapeutic seizure?

The patient is under general anesthesia, but MST is non-invasive in the sense that nothing is surgically implanted in the brain. In MST, magnetic field pulses are directed into the brain through a magnetic coil and produce a seizure. MST is applied in a more targeted way compared with ECT. One of the benefits of being more focal is that you see fewer side effects than with ECT, including cognitive side effects such as memory loss. The seizures are generated, of course, in a highly controlled environment and are thought to be changing the functioning of the frontal region where they are targeted. This research is done in collaboration with physicians who are experts in brain stimulation.

What are the impacts on symptoms?

Generally, studies using MST show improvements in depression and perhaps in suicidal ideation as well. In our research, it’s being applied in a way similar to that in depression, but in people with BPD we’re also interested in whether it can potentially be used to reduce suicidal thinking, which could ultimately reduce acute suicide risk.

We have read that BPD may be caused by “a collision of a person’s genes and temperament with suboptimal or hostile environmental experience.” Could you comment on that hypothesis?

I don’t think BPD is necessarily all that different in this context from bipolar disorder or schizophrenia, to cite just two examples. It is likely that major psychiatric disorders such as these are influenced by both genetic and environmental factors. For BPD, there’s a genetic component, a genetic predisposition. There is also an environmental component. Some people with BPD experience what is sometimes called an invalidating environment. You can also say, a stressful environment. A stressful, traumatic childhood, for instance. In many cases it could well be these things in combination, not necessarily in isolation.

At the same time, some people with BPD who I have talked to will say, “I didn’t have a traumatic childhood, I didn’t have an invalidating environment. But I still have BPD.” So there are important differences, and not everybody looks the same. It’s important to acknowledge that some people might have more of a genetic component and other people greater environmental stresses. It’s plausible that those who have both are going to be at the greatest risk.

What is the typical long-term trajectory of BPD?

Generally, there tend to be ups and downs over time. But I think where the hope comes in is that when people enter treatment, within a few months, especially when we’re talking about Dialectical Behavior Therapy, the more severely dysregulated behaviors, especially those that are more life-threatening, tend to come under control.

And then over time, you see an improvement in symptoms, and when they’ve been followed up, many patients experience what is called remission, or periods when they no longer have the full symptoms. “Recovery” is a different question, however. Is the patient actually engaging with people meaningfully again? Are they employed? Do they have meaningful social interactions? This is where my research is going. What are some of the reasons people may not achieve recovery? Might there be cognitive reasons? Are there other reasons?

Finally, if any of our readers want to know more about BPD, or are worried about the mental health of a loved one or dear friend, what would you advise?

I always recommend starting with the National Education Alliance for Borderline Personality Disorder (NEA-BPD). It is an excellent place to connect people with BPD and families with helpful resources. The specifics about how to find help can vary depending on your geographical location and access to mental health services and specialists who treat people with BPD. The NEA-BPD website has some very useful questions for people to consider as they think through where to find treatment and what type and intensity of treatment might be needed depending on a person’s specific situation. They also provide links to websites that can help you to narrow down your search.

Written By Peter Tarr, Ph.D.

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