7 ms·

I'm a psychiatrist, and I'm heartened to see this show up in the HN top-10. Lots of people have someone in their life with Borderline PD (or at least features).

I'm a psychiatrist, and I'm heartened to see this show up in the HN top-10. Lots of people have someone in their life with Borderline PD (or at least features). It's a serious impairment that sometimes gets vilified or downplayed as "just a personality disorder." If people could "just stop doing it," they would. It can be hard to maintain steady, honest empathy for people with Borderline PD, but their suffering is very real.

cjalmeida 9y ago
A close relative suffers from a PD. Borderline with likely schizophrenic co-morbity, he's not cooperative to diagnostics. I'm not a professional, but think he's untreatable mostly due to his completely non acknowledgement of his disease. The added paranoia and delusion makes him aggressively dismiss any kind of intervention as "conspiracy" against him. It's sad too see an individual waste his life this way for something that seems treatable, from this report.
- mjburgess 9y ago
  > non acknowledgement of his disease Lack of insight is a feature of the disorder, to be able to treat BPD at all is partly to improve this. Self-insight is developed in childhood in healthy interactions with a caregiver: roughly a parent displays an appropriate emotional reaction to your behaviour which allows you to recognise your own behaviour by observing this emotional reaction. Without an ability to observe yourself emotionally through the mirror the parent provides, you fail to develop an awareness of your identity/emotions/etc. The process of developing it anew in an adult requires re-running childhood again in a particular kind of way, with a therapist, and have the therapist provide you with the healthy responses that your parent failed to provide. It is, in my opinion, an exercise in retraining the emotions -- particularly developing the reflective frontal-lobe responses and suppressing the fight+flight amygdala responses which is often way out-sized in traumatized people. Insight into oneself is a trainable faculty like many others, and its deficit is not the end of treatment but the usual starting point.
  - 0xdeadbeefbabe 9y ago
    > Insight into oneself is a trainable faculty like many others, and its deficit is not the end of treatment but the usual starting point. But he won't start treatment?! > As a result, the term “treatment resistant” can fuel views of patients as “oppositional” and recalcitrant, instead of expectably symptomatic.
  - benbreen 9y ago
    I think you seem to be confusing "lack of insight" (the clinical term, as a manifestation of a severe mental disorder) and "lacking insight" in a more general sense. The latter may well be cured by therapy or reflection on childhood problems. But as someone with a schizophrenic brother who, like the parent poster's family member, totally lacks insight into their own illness, I can say that the former really is not curable in the way you imply. It's a terrible thing to witness, and as far as I can tell, there are no simple solutions.
    - mjburgess 9y ago
      They're both connected in this instance. A person with a personality disorder is really on a continuum of insight in which schizophrenia is the most extreme example and represents a complete dissociative break with self-awareness. I'm not claiming that the kind of dissociation a person experiences when psychotic can be treated by therapy. Pharmacology is essential, and actually I do think after awhile therapy can be helpful (I have family members who have had psychotic episodes too). The lack of insight in both cases is a product of dissociation. In a personality disorder this is a "mild" chronic state (compared to psychosis) which is amenable to very long term (years+) therapy, unlike psychosis. It is why BPD people with quite severe dissociation or who have episode of severe dissociation report mildly schizoprenic-like problems with their identity (eg. thinking that they are multiple people, lost time, etc.). I was assuming his BPD friend had this background state, which would not preclude treatment. Treatment would, in part, be to deal with that.
    - dsego 9y ago
      Anosognosia.
- phren0logy 9y ago
  This is incredibly common in Schizophrenia, and hard to watch.
- xor1 9y ago
  >I'm not a professional, but think he's untreatable mostly due to his completely non acknowledgement of his disease. Yeah, this has been the entirety of my experience with people who have personality disorders.
0xdeadbeefbabe 9y ago
phrenology nice. How do you detect BPD when the subject is so uncooperative and knows how to act normal enough to trick you? I suspect someone of having BPD who doesn't want any help at all (suprise?). What will convince a psychiatrist or counselor?
- phren0logy 9y ago
  Well, if they won't come in for treatment that will be the most significant barrier, no matter who you convince.
  - brookside 9y ago
    What is treatment for BPD, if you don't mind me asking? I confess to a personal interest as I've sought at times for things like anxiety and depression, and frustratingly enough would not be able to tell you what treatment I was actually receiving under the name of therapy.
    - phren0logy 9y ago
      The gold standard is DBT for BPD, and treating other co-occuring conditions. It's hard to find somewhere that does by-the-book DBT, and other approaches can also help, but I might recommend starting with an academic center if possible.
    - DanBC 9y ago
      The document "Meeting the challenge, making a difference" lists several different therapies. People should have a choice of what works for them. http://www.crisiscareconcordat.org.uk/inspiration/meeting-the-challenge-making-a-difference/ http://www.crisiscareconcordat.org.uk/inspiration/meeting-th... That document lists: Dielectical Behavioural Therapy Mentalization Based Therapy Cognitive Analytic Therapy Transference Focussed Psychotherapy Interpersonal Group Psychotherapy Cognitive Therapy for Personality Disorders Schema Therapy and it lists intensive therapeutic programmes, therapeutic communities, and arts therapies. Of these DBT probably has best evidence, and has most people providing it.
  - 9y ago
ataturk 9y ago
Their suffering may be real, but so is the suffering of absolutely everyone who is nearby! I ended up at a job working with someone with it. Let's just say the only winning move is not to play.
- curun1r 9y ago
  I think what you describe is the main reason for a lack of sympathy for people with BPD. For people with other mental disorders, it's much easier to see how the person is suffering or negatively impacted by their illness. But it's often too difficult to see past one's own anger, frustration and annoyance to recognize that suffering in people with BPD. I've had work experiences with BPD co-workers and ended up just needing to extricate myself from the situation for my own sanity rather than to try to help or do anything productive that could've made their situations improve. I always felt bad about it, but I just don't have the patience and fortitude to help in those situations.
  - xor1 9y ago
    >I think what you describe is the main reason for a lack of sympathy for people with BPD. For people with other mental disorders, it's much easier to see how the person is suffering or negatively impacted by their illness. But it's often too difficult to see past one's own anger, frustration and annoyance to recognize that suffering in people with BPD. It's not just this, but it's the frustration that comes from not being able to, for lack of a better term, fix BPD. You can pour your heart and soul into a relationship with someone who is borderline (as I did), and it will all be for nothing as soon as they split you. You can have a relationship spanning back years, maybe it's even someone you've known since you were a child, and suddenly a switch goes off in their brain and you may as well be someone that they just met yesterday. There is no parity between Cluster Bs and "normal" people when it comes to things like friendship, loyalty, and obligation, and that has the potential to really hurt people. Some (most?) never figure out what Cluster B personality disorders are -- to them, these people are simply evil. At best you have some success getting them to change and improve themselves, but then they just discard you and move on without so much as a second thought about you or your feelings. Unless they need you again in the future, that is.
jetti 9y ago
Just to add on, speaking from experience, many insurance companies in the US will not cover things like Borderline Personality Disorder since they see it as not curable. Most of the personality disorders are not covered.
- valuearb 9y ago
  Also, that it's not a disorder, just like Psychiatry is not a science.
  - xor1 9y ago
    What is it then?
    - owebmaster 9y ago
      A conscious/mental pattern.
39387gjk34i 9y ago
I was diagnosed in college. I went through a few relationships and got attached like crazy, early. That drove the person away and I'd get desperate/angry. Rinse, repeat. Prescribed a drug that made me much more depressed and started cutting. I stopped taking it, and later met the person who is now my spouse. Early in the relationship I got fraught that it would end, so I tried to end it preemptively. That didn't work, thankfully. It was really a relationship where I could for the first time just be myself and not "front", so it just felt right. My pysch was not convinced and warned me, rightly so. But, we moved away from that college, got married, have kids, and really haven't had any emotional rollercoasters since (over 10 years later). But occasionally I have emotional scares/thoughts but they usually subside. Also, since I'm on a throwaway, when we first had our first child I kept getting murderous thoughts about how to kill it whenever I got frustrated. These scared me, and through some introspection, my own aim seemed to be to get an emotional response from myself. Especially since these thoughts typically included how I would immediately regret harming my child and how others would react. So I feel like it's still there, but my hormones leveled out or something happened to allow me to manage it.
- kbenson 9y ago
  > Also, since I'm on a throwaway, when we first had our first child I kept getting murderous thoughts about how to kill it whenever I got frustrated. These scared me I imagine so. There are always errant thoughts of taboo things (well, I assume that's a common thing...), but to keep coming back to something like that without some obvious priming (such as media) sounds terrifying. Just experiencing those thoughts and wondering about myself would probably leave me a wreck, so good on you for recognizing them for what they were and finding a way to deal with them.
  - 39387gjk34i 9y ago
    Yeah I got pretty wrecked. Sometimes it was "what would your parents/in-laws/wife think if you did this..." Other times it was more insidious, "would your baby still be so fond of you if you slowly crushed its head". Ugh, I struggle just trying to type that last one out. They would always bring me to tears. I'm pretty good at compartmentalizing I suppose. These have disappeared now that our kids is older and our emotional input is requited. I am still contemplating whether I should mention it to my spouse. She knows about my diagnosis in college but not these intrusive thoughts.
tomcam 9y ago
I try to hear that. I succeed a little. Mostly I think about the incalculable cost to the rest of us. I have two children who are suicidal from time to because of a person close to them who is borderline. Me too.
slv77 9y ago
BPD comes in two flavors. The first, acting out, is the stereotypical BPD that is the better known variety. The second, acting in or quiet BPD, is less well known. For someone in a relationship where it seems to rhyme but not fit understanding the two flavors can be eye opening. There is also some exploration of the relationship between BPD and trauma as most people with BPD have a history of trauma. There may be some gender bias when diagnosing BPD. Men who report the same symptoms as women are more likely to be diagnosed with PTSD than BPD.
aisofteng 9y ago
Off-topic, but I'm curious how you, as a psychiatrist, came to browse HN. I don't think I know anyone that browses HN that isn't in technology.
- norlys 9y ago
  Well, there are. I'm studying philosophy, for example and while I'm interested in tech I can't say I understand much of it. I come here for the interesting mix of news and refreshingly critical points of view.
  - eigenstuff 9y ago
    Same here. I'm an artist, but my work is in math and physics visualizations so I come here for that kind of content as well.

cjalmeida 9y ago

A close relative suffers from a PD. Borderline with likely schizophrenic co-morbity, he's not cooperative to diagnostics. I'm not a professional, but think he's untreatable mostly due to his completely non acknowledgement of his disease. The added paranoia and delusion makes him aggressively dismiss any kind of intervention as "conspiracy" against him. It's sad too see an individual waste his life this way for something that seems treatable, from this report.

mjburgess 9y ago
> non acknowledgement of his disease Lack of insight is a feature of the disorder, to be able to treat BPD at all is partly to improve this. Self-insight is developed in childhood in healthy interactions with a caregiver: roughly a parent displays an appropriate emotional reaction to your behaviour which allows you to recognise your own behaviour by observing this emotional reaction. Without an ability to observe yourself emotionally through the mirror the parent provides, you fail to develop an awareness of your identity/emotions/etc. The process of developing it anew in an adult requires re-running childhood again in a particular kind of way, with a therapist, and have the therapist provide you with the healthy responses that your parent failed to provide. It is, in my opinion, an exercise in retraining the emotions -- particularly developing the reflective frontal-lobe responses and suppressing the fight+flight amygdala responses which is often way out-sized in traumatized people. Insight into oneself is a trainable faculty like many others, and its deficit is not the end of treatment but the usual starting point.
- 0xdeadbeefbabe 9y ago
  > Insight into oneself is a trainable faculty like many others, and its deficit is not the end of treatment but the usual starting point. But he won't start treatment?! > As a result, the term “treatment resistant” can fuel views of patients as “oppositional” and recalcitrant, instead of expectably symptomatic.
- benbreen 9y ago
  I think you seem to be confusing "lack of insight" (the clinical term, as a manifestation of a severe mental disorder) and "lacking insight" in a more general sense. The latter may well be cured by therapy or reflection on childhood problems. But as someone with a schizophrenic brother who, like the parent poster's family member, totally lacks insight into their own illness, I can say that the former really is not curable in the way you imply. It's a terrible thing to witness, and as far as I can tell, there are no simple solutions.
  - mjburgess 9y ago
    They're both connected in this instance. A person with a personality disorder is really on a continuum of insight in which schizophrenia is the most extreme example and represents a complete dissociative break with self-awareness. I'm not claiming that the kind of dissociation a person experiences when psychotic can be treated by therapy. Pharmacology is essential, and actually I do think after awhile therapy can be helpful (I have family members who have had psychotic episodes too). The lack of insight in both cases is a product of dissociation. In a personality disorder this is a "mild" chronic state (compared to psychosis) which is amenable to very long term (years+) therapy, unlike psychosis. It is why BPD people with quite severe dissociation or who have episode of severe dissociation report mildly schizoprenic-like problems with their identity (eg. thinking that they are multiple people, lost time, etc.). I was assuming his BPD friend had this background state, which would not preclude treatment. Treatment would, in part, be to deal with that.
  - dsego 9y ago
    Anosognosia.
phren0logy 9y ago
This is incredibly common in Schizophrenia, and hard to watch.
xor1 9y ago
>I'm not a professional, but think he's untreatable mostly due to his completely non acknowledgement of his disease. Yeah, this has been the entirety of my experience with people who have personality disorders.

0xdeadbeefbabe 9y ago

phrenology nice. How do you detect BPD when the subject is so uncooperative and knows how to act normal enough to trick you? I suspect someone of having BPD who doesn't want any help at all (suprise?). What will convince a psychiatrist or counselor?

phren0logy 9y ago
Well, if they won't come in for treatment that will be the most significant barrier, no matter who you convince.
- brookside 9y ago
  What is treatment for BPD, if you don't mind me asking? I confess to a personal interest as I've sought at times for things like anxiety and depression, and frustratingly enough would not be able to tell you what treatment I was actually receiving under the name of therapy.
  - phren0logy 9y ago
    The gold standard is DBT for BPD, and treating other co-occuring conditions. It's hard to find somewhere that does by-the-book DBT, and other approaches can also help, but I might recommend starting with an academic center if possible.
  - DanBC 9y ago
    The document "Meeting the challenge, making a difference" lists several different therapies. People should have a choice of what works for them. http://www.crisiscareconcordat.org.uk/inspiration/meeting-the-challenge-making-a-difference/ http://www.crisiscareconcordat.org.uk/inspiration/meeting-th... That document lists: Dielectical Behavioural Therapy Mentalization Based Therapy Cognitive Analytic Therapy Transference Focussed Psychotherapy Interpersonal Group Psychotherapy Cognitive Therapy for Personality Disorders Schema Therapy and it lists intensive therapeutic programmes, therapeutic communities, and arts therapies. Of these DBT probably has best evidence, and has most people providing it.
- 9y ago

ataturk 9y ago

Their suffering may be real, but so is the suffering of absolutely everyone who is nearby! I ended up at a job working with someone with it. Let's just say the only winning move is not to play.

curun1r 9y ago
I think what you describe is the main reason for a lack of sympathy for people with BPD. For people with other mental disorders, it's much easier to see how the person is suffering or negatively impacted by their illness. But it's often too difficult to see past one's own anger, frustration and annoyance to recognize that suffering in people with BPD. I've had work experiences with BPD co-workers and ended up just needing to extricate myself from the situation for my own sanity rather than to try to help or do anything productive that could've made their situations improve. I always felt bad about it, but I just don't have the patience and fortitude to help in those situations.
- xor1 9y ago
  >I think what you describe is the main reason for a lack of sympathy for people with BPD. For people with other mental disorders, it's much easier to see how the person is suffering or negatively impacted by their illness. But it's often too difficult to see past one's own anger, frustration and annoyance to recognize that suffering in people with BPD. It's not just this, but it's the frustration that comes from not being able to, for lack of a better term, fix BPD. You can pour your heart and soul into a relationship with someone who is borderline (as I did), and it will all be for nothing as soon as they split you. You can have a relationship spanning back years, maybe it's even someone you've known since you were a child, and suddenly a switch goes off in their brain and you may as well be someone that they just met yesterday. There is no parity between Cluster Bs and "normal" people when it comes to things like friendship, loyalty, and obligation, and that has the potential to really hurt people. Some (most?) never figure out what Cluster B personality disorders are -- to them, these people are simply evil. At best you have some success getting them to change and improve themselves, but then they just discard you and move on without so much as a second thought about you or your feelings. Unless they need you again in the future, that is.

jetti 9y ago

Just to add on, speaking from experience, many insurance companies in the US will not cover things like Borderline Personality Disorder since they see it as not curable. Most of the personality disorders are not covered.

valuearb 9y ago
Also, that it's not a disorder, just like Psychiatry is not a science.
- xor1 9y ago
  What is it then?
  - owebmaster 9y ago
    A conscious/mental pattern.

39387gjk34i 9y ago

I was diagnosed in college. I went through a few relationships and got attached like crazy, early. That drove the person away and I'd get desperate/angry. Rinse, repeat. Prescribed a drug that made me much more depressed and started cutting. I stopped taking it, and later met the person who is now my spouse. Early in the relationship I got fraught that it would end, so I tried to end it preemptively. That didn't work, thankfully. It was really a relationship where I could for the first time just be myself and not "front", so it just felt right. My pysch was not convinced and warned me, rightly so. But, we moved away from that college, got married, have kids, and really haven't had any emotional rollercoasters since (over 10 years later). But occasionally I have emotional scares/thoughts but they usually subside. Also, since I'm on a throwaway, when we first had our first child I kept getting murderous thoughts about how to kill it whenever I got frustrated. These scared me, and through some introspection, my own aim seemed to be to get an emotional response from myself. Especially since these thoughts typically included how I would immediately regret harming my child and how others would react. So I feel like it's still there, but my hormones leveled out or something happened to allow me to manage it.

kbenson 9y ago
> Also, since I'm on a throwaway, when we first had our first child I kept getting murderous thoughts about how to kill it whenever I got frustrated. These scared me I imagine so. There are always errant thoughts of taboo things (well, I assume that's a common thing...), but to keep coming back to something like that without some obvious priming (such as media) sounds terrifying. Just experiencing those thoughts and wondering about myself would probably leave me a wreck, so good on you for recognizing them for what they were and finding a way to deal with them.
- 39387gjk34i 9y ago
  Yeah I got pretty wrecked. Sometimes it was "what would your parents/in-laws/wife think if you did this..." Other times it was more insidious, "would your baby still be so fond of you if you slowly crushed its head". Ugh, I struggle just trying to type that last one out. They would always bring me to tears. I'm pretty good at compartmentalizing I suppose. These have disappeared now that our kids is older and our emotional input is requited. I am still contemplating whether I should mention it to my spouse. She knows about my diagnosis in college but not these intrusive thoughts.

tomcam 9y ago

I try to hear that. I succeed a little. Mostly I think about the incalculable cost to the rest of us. I have two children who are suicidal from time to because of a person close to them who is borderline. Me too.

slv77 9y ago

BPD comes in two flavors. The first, acting out, is the stereotypical BPD that is the better known variety. The second, acting in or quiet BPD, is less well known. For someone in a relationship where it seems to rhyme but not fit understanding the two flavors can be eye opening. There is also some exploration of the relationship between BPD and trauma as most people with BPD have a history of trauma. There may be some gender bias when diagnosing BPD. Men who report the same symptoms as women are more likely to be diagnosed with PTSD than BPD.

aisofteng 9y ago

Off-topic, but I'm curious how you, as a psychiatrist, came to browse HN. I don't think I know anyone that browses HN that isn't in technology.

norlys 9y ago
Well, there are. I'm studying philosophy, for example and while I'm interested in tech I can't say I understand much of it. I come here for the interesting mix of news and refreshingly critical points of view.
- eigenstuff 9y ago
  Same here. I'm an artist, but my work is in math and physics visualizations so I come here for that kind of content as well.