Daniel Knoepflmacher, MD (Host): Hello, and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry.

I'm your host, Dr. Daniel Knoepflmacher. In each episode, I'll be engaging in thought-provoking conversations with experts on mental health, neuroscience, and other important topics on the mind. On the next two episodes of the podcast, we'll be discussing borderline personality disorder or B P D. This complex condition affects up to 2% of the population.

While B P D has been discussed more openly in recent years with a few prominent public figures acknowledging their struggles with it, it remains widely misunderstood and stigmatized, and it comes with significant risk and suffering for those affected by it with up to 10% dying by suicide and even more engaging in cutting or other self injurious behaviors.

Our goal is to bring clarity to this complex condition by understanding what it is, how it's diagnosed, and what evidence-based treatments are available to help those suffering from B P D.

Despite the intense feelings of self-hatred, anger, depression, impulsivity and anxiety that are common in borderline personality disorder, meaningful recovery can be achieved with the right resources, support, and treatment, all of which will be exploring on the next two episodes of On The Mind.

We're very fortunate to have two guests with specific expertise on this topic. I'm happy to welcome Paula to Ang, the co-founder and Executive Director of Emotions Matter, a nonprofit organization dedicated to education, support and advocacy for those impacted by borderline personality disorder.

Our second guest is Dr. Frank Yeomans, who's an associate professor of psychiatry at Weill Cornell Medicine and Director of Training at the Personality Disorders Institute in New York. He's a world renowned expert in personality disorders who teaches people around the globe about transference focused psychotherapy.

One of the evidence-based treatments for B P D. I know I'm not alone in saying that I myself have learned a lot about personality disorders from his exceptional teaching over the years. In our first two episodes, we'll be focusing on describing what borderline personality disorder is and how it's diagnosed.

Paula and Frank, thank you both for joining us for what should be an interesting and helpful discussion,

I want to begin by learning more about the two of you and your connection to this topic. Paula, can you share the story of how you became involved in helping to support people struggling with BPD?

Paula Tusiani-Eng: Sure. And thank you so much for having us here today. I became involved with helping people with BPD because of my younger sister, Pamela. Pamela was diagnosed with BPD at the age of 19 in 1998. She had a breakdown in college and the symptoms that she struggled with at the time included self-harm, difficulty communicating in relationships, emotional sensitivity, fears of abandonment and rejection, and struggles with self-identity. Back then, in the late 1990s, we didn't know what BPD was and it was hard to find information or clinicians trained in BPD as treatments were emerging at the time and not available to the general population.

Nine hospitalizations and two residential stays later, my sister started to make some improvements in daily functioning, relationships, work, but she still continued to struggle with internal self-hatred and impulsivity. Sadly, about three years into her mental health journey, she was put on an MAOI inhibitor, and she had an adverse drug interaction with one of the contraindicated foods for being on an MAOI, and she died unexpectedly of a stroke. She died 24 years ago this April, in April of 2021.

Losing my sister the way we did was traumatizing for my family. Through our grief, we wanted to make sure that other people living with BPD and family members could get the help that we never had. My sister, had she gotten the better care, might be alive today. So, this caused my parents to start the Borderline Personality Disorder Resource Center at New York Presbyterian Hospital in 2004. That center will be celebrating its 20th anniversary this year, and it later caused me to co-found Emotions Matter, a nonprofit dedicated to help and support people with BPD to promote recovery. And so, I became involved in this field really because of my sister and my family experience.

Daniel Knoepflmacher, MD: Thank you for sharing that. And it was a really meaningful experience with unfortunately a tragic story. But you and your family have really made an impact as a result of that, both with the Borderline Personality Resource Center and with Emotions Matter. Frank, what about you? What was your path to becoming an expert in personality disorders?

Frank Yeomans, M.D., Ph.D: My interest started at Weill Cornell when I was a resident in psychiatry back in the early '80s. And very much in line with what Paula described, there was something very compelling about this patient population. Their suffering was enormous, their condition was complex, and it was a challenge to be met. Unfortunately, at the same time, even more unfortunately currently, there was a stigma with regard to these patients. A lot of people in the mental health system who did not understand this kind of difficulty were prejudiced against the patient's thinking, that there was something problematic about the patients in and of themselves, that the patients created difficulties, they were often considered, I hate to say this, but bad patients. And the challenge often rather than being confronted was turned away from. We still encounter some of that. But through efforts such as the BPD Resource Center and our own Personality Disorders Institute as well as the work of others, there's a lot of progress in overcoming the stigma.

But just to summarize one additional point, there's something compelling about BPD patients. Their condition is so pervasive, it's not just a symptom. Often in psychiatry, we treat a symptom, a depression or an anxiety, but the whole person is involved and I find that the most important mission a psychiatrist can undertake is to try to help the person as a whole and not just work on the alleviation of a symptom.

Daniel Knoepflmacher, MD: So, really treating the whole person was a compelling part of what made you interested in this and seeing how the needs of this population weren't really met with what you were experiencing as a resident.

Frank Yeomans, M.D.,Ph.D: Yes. And in addition, seeing that with treatments that have been developed for these patients, they can make very significant progress. And I don't think there are too many things in the field of psychiatry as gratifying as seeing someone who's afflicted with this condition get better and begin to get some satisfaction out of a life that up until then had been mainly suffering.

The field of psychiatry and the related field of psychology are always refining their diagnosis, their definition of particular conditions. These are complex conditions that it's hard to describe succinctly, and the official diagnostic manual has a rather complex system of defining it.

When I talk to people in general, including to my patients, I describe it in the following way, which I think is more user-friendly, that BPD is a condition that consists of difficulties in four areas. First, there's the area of the emotions. Emotions in someone with BPD are experienced with a great intensity, and they shift rapidly from sometimes great moments of exhilaration to terrible, horrible feelings of desperation, depression and self-hatred. So, life is like an emotional rollercoaster, highs, lows, very little in between. And it's exhausting for the person and sometimes for those in the person's life.

So, the secondary of difficulty after the emotional dysregulation is the area of interpersonal relationships, which tend to be conflicted and chaotic. There's very little peace and harmony over time in the relationships. Relationships start, they might be idealized at the beginning, and then they fall into a devaluing state. And then, there's all kinds of shifts between positive and negative emotions. And the person either has a series of relationships that start and stop or continues in relationships that go on with a lot of conflict characterizing them.

The third area of difficulty is that of behaviors, and this is the area for which the condition is best known. BPD I think for worse-- I was going to say for better or for worse-- but I think for worse is best known for what are called acting out behaviors. Now, acting out behaviors doesn't mean misbehaving. It means putting into an action an emotion that is difficult to tolerate. And sometimes people act out their intense emotions through self-harm or through substance abuse or through chaotic sexual activity or through eating disorder. So, these behaviors get the most attention and they do need to be dealt with.

But I think the fourth and most important area of difficulty is the sense of self. People with BPD do not have a solid, coherent and satisfactory sense of who they are in the world. Their mind is characterized by a condition we call splitting, where they are either feeling an emotion, very strong positive emotion, or perhaps an extremely strong negative emotion with no mixture, with no integrating of emotions into a more complex state, which would help the person deal with the complexity of the world around them.

So if your emotions are always shifting rapidly, it's hard for you to develop a core sense of self, a sense of your direction in life. What do you want to do with your life? Where do you want to go with your life? And it's very hard for you to invest a pathway in terms of relationship or work or career that has continuity to it.

So, to put it in one sentence, most of my patients say the worst aspect of the condition is when they're not involved in some kind of emotional chaos or acting out, they're left with a horrible sense of internal emptiness that plagues them.

Daniel Knoepflmacher, MD: Thank you, Frank. So, you specifically brought up the sense of self being diffuse. And I noticed, Paula, when you described Pamela, you had mentioned that about her. And as you listened to Frank describe these characteristics, can you share how you experienced some of these on the outside with your sister?

Paula Tusiani-Eng: I love the way Frank defines these four areas because it captures BPD so well. And very often, these things are overlapping, they're interacting at the same time. As family members, you know, we didn't have the language at the time to identify these as they were happening. Now, looking back, I could understand when impulsive behaviors were happening, it was because of what was going on internally, you know, and that affected relationships and it was like a cascading effect.

I think, with BPD, it's understanding that what you see on the outside is connected to what's going on inside. And that's often what people miss. People often make assumptions because it's what they see on the outside, and that's usually just people who are doing their best to get their needs met. People with BPD themselves, when they say, you know, "Could you describe what BPD feels like to you?" And my sister would've said this, "It feels like my brain's on fire," "It feels like I'm driving a car that's accelerating and I can't hit the brakes," or "I'm riding a roller coaster with emotional ups and downs all day long," or "I feel constant shame and worthlessness and self-loathing," "I feel like a burn victim. Every time someone touches my skin, it's like I'm on fire because..." So, we live with emotions every day in the world and I always think with such compassion how hard it must have been for my sister to live with that and feeling like you're on fire all day long because any kind of interaction that you have with the environment, with people can trigger such emotional responses on the inside, it's a really difficult challenging way to live. And I think when we look at outward behaviors, but we understand the internal experience that helps us to have so much more compassion because nobody wants to live with BPD, nobody wants to live with that kind of emotional intensity.

Daniel Knoepflmacher, MD: It's some of the tragic elements of the condition that the external experience of others can sometimes make the person suffering in the way that you're both describing become even more disconnected from others because relationships blow up, things become unstable in their interactions with the rest of the world. These are really helpful descriptions of both the internal and the external elements of BPD. Can you help us understand, Frank, how to accurately diagnose BPD? Because as you pointed out, there are people in medicine, perhaps even in mental healthcare, that sometimes say, "Oh, this is just a bad patient," or "This is not something that gets fully understood.

Frank Yeomans, M.D.,Ph.D: I'd be happy to do that. But first, I want to just build on what Paula said because I think implicit in what Paula said is a very important message both for people in the health professions and for families and friends of people with BPD. However difficult your experience might be with the person, keep in mind that their experience is more painful. And having that empathy can help us hang in there and continue in an effort to be there for the person.

With regard to diagnosing it, it's extremely important to go beyond superficial symptoms. I think in the mental health field these days, we're too preoccupied with what's there on the surface. BPD patients are very often misdiagnosed as having a major depressive episode. Now, they do have depression, but it's not as simple as the kind of depression that responds to medication. People of BPD have anxiety. They're often misdiagnosed as simply having an anxiety disorder. And most particularly, because of the rapidly shifting emotional states, they're very commonly misdiagnosed as bipolar disorder.

So, what the clinician has to do when you have somebody who looks depressed or anxious or having rapidly shifting emotions is spend enough time evaluating the person to get a sense of their inner subjective experience. We do what we call a structural diagnosis. We try to look at the internal structure of the person. By that I mean in simple language, do they have a coherent sense of self? Do they have a continuity in their experience of others? If it's discontinuous, if it's very fragmented, then you're probably dealing with somebody who has BPD and not one of the other more symptom-based conditions.

Daniel Knoepflmacher, MD: I want to focus on that idea of self because I think it's a complex concept and you say that a skilled clinician should be evaluating whether that person has a good sense of self or whether there's diffusion there. How do you do that? How do you define self? And how do you use a structured interview to determine whether someone may not have that coherent sense of self?

Frank Yeomans, M.D.,Ph.D: Well, I'm smiling because even though it sounds simple, a very basic question in this interview is to say to the person, "Can you please describe yourself to me as fully as possible?" Then after that, we say, "Can you please describe an important person in your life as fully as possible?" And these are challenging questions. I would say any listener should think about it. How does one define one's self? Is there complexity? Is their richness? Is there breath in the definition or is it kind of superficial without any complexity to it? Or even more so, does it contain contradictions? If you just leave the person an open field to elaborate their response, you can get amazing contradictions. A person can say, you know, "I'm basically a loving person. Later on, a few minutes later, I might say, 'When somebody crosses me, they better watch out. They're going to be in big trouble.'" Now, I mean, you might say that that's not so unreasonable. But they often say this without any awareness that the two things seem a little contradictory. Then, you would ask them how they put that together.

The interesting thing about continuity and sense of self is that it goes hand in hand with continuity in the experience of others. So when you ask to describe another person in their life, sometimes you get very contradictory responses. Like one patient said, "You know, my father is a horrible person. He was very abusive when we were growing up." And then later on, as she was talking, she said, "You know, my father's really my best friend." And you sort of are sitting there saying, how can we put this together?" And of course, that's an intervention with the patient, which might get them to begin to reflect on their internal contradictions. But without the encouragement in a very interesting way, the person lives with internal contradictions without being aware of them and without reflecting upon them.

Daniel Knoepflmacher, MD: So, a really thorough psychological evaluation using this structured interview that can help solidify a diagnosis of borderline personality disorder, help you distinguish from a more symptoms-based evaluation, looking at symptoms of anxiety, of depression, maybe changes in mood that might be mistaken for bipolar disorder. You give the diagnosis to the person. I imagine for a lot of people that getting that diagnosis is complex. I could see how given all the stigmatizing that it might be a hard thing to hear, but I also could imagine how there might be relief. Can you comment on that?

Frank Yeomans, M.D., Ph.D: You're absolutely right. Most usually, there's relief. The person feels, "Finally, somebody understands me." In the old days and still in some professional's practice, the custom is not to describe or even mention the diagnosis of BPD to a patient. It's considered a bad word. Research and clinical experience both show that it's beneficial to say, "I'd like to give you my diagnostic impression, my clinical impression," and the patient usually says yes. "My impression is that you have this thing we call BPD." And then in a very non-judgmental, user-friendly way, you go into something like what I described earlier in this broadcast, the four areas of difficulty. And much more often than not, the patient says, That really fits. I'm glad somebody knows about this. I'm glad somebody can understand this. I'm glad somebody can put this together."

Daniel Knoepflmacher, MD (Host): that brings us to the end of the first episode of our two-part series on borderline Personality disorder. Be sure to tune into part two where we'll discuss the various treatments for B P D and highlight resources available to help those struggling with this condition.

Thank you for listening to this episode of On the Mind, the official podcast of the Weil Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, apple Podcasts, and iHeartRadio. If you like what you heard today, please give us a rating and subscribe so you can stay up to date with all of our latest episodes.

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