Selects: BPD: The Worst Disorder or Not a Disorder at All?

Borderline Personality Disorder has been described as emotional “third degree burns over ninety percent of your body.” It’s as close to a curse as a personality disorder can be: deep fear of being abandoned creates behaviors that end up driving people off. Learn all about it in this classic episode. See omnystudio.com/listener https://omnystudio.com/listener for privacy information.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

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• 0:04Josh Clark?

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• 0:35Speaker 02

  With no fees or minimums on checking accounts, it's no wonder the Capital One Bank guy is so passionate about banking with Capital One. If he were here, he wouldn't just tell you about no fees or minimums. He'd also talk about how Capital One cafes are open seven days a week to assist with your banking needs. Yep, even on weekends. It's pretty much all he talks about, in a good way. What's in your wallet? Terms apply. See capitalone.com/bankguy. Capital One, N-A, Member FDIC. Hey, good morning, everyone. This is Chuck here on a Saturday with a curated selection of one of my favorite episodes. This is B P D colon, The Worst Disorder or Not a Disorder at All.

• 1:16Speaker 02

  This is all about borderline personality disorder, and it's pretty fascinating stuff, and I hope you guys enjoy it.

• 1:27Speaker 00

  Welcome to Stuff You Should Know, a production of iHeartRadio.

• 1:37Josh Clark?

  Hey, and welcome to the podcast. I'm Josh and Chuck's here, too. It's just the two of us, and that's cool, because this is Stuff You Should Know.

• 1:46Speaker 02

  Yeah, Jerry's got the week off, and she said, "Press on, dudes."

• 1:51Josh Clark?

  Yeah. Party on, dudes.

• 1:53Speaker 02

  Party on, Wayne.

• 1:56Josh Clark?

  That was also from Bill and Ted's Excellent Adventure, wasn't it? Party on.

• 2:00Speaker 02

  Oh, was it?

• 2:01Josh Clark?

  I think so. I can see George Carlin saying it.

• 2:04Speaker 02

  Yeah, I'm probably wrong.

• 2:06Josh Clark?

  I'm probably wrong. So Chuck, we're talking today about something we've kind of touched on before, but when we touched on it, we were like, well, this is something that deserves its own episode for sure.

• 2:18Speaker 03

  Yeah, we're talking, this is another in our suite on mental health conditions. And boy, we've got a lot of them, but we've still got more to go.

• 2:30Josh Clark?

  Yeah, we do.

• 2:31Speaker 03

  You know, and I think these are important shows. And every time we do these, I feel like we get good feedback on people who suffer from these conditions and say, thanks for either educating me and/or getting the word out to people who may be a little, what's the word, ignorant about some of this stuff.

• 2:50Josh Clark?

  As Michael Jackson would have said, "You're ignorant about this."

• 2:54Speaker 03

  What's that from?

• 2:55Josh Clark?

  He just used that word a lot.

• 2:57Speaker 03

  Oh, really?

• 2:58Josh Clark?

  Yeah, but regardless, that has nothing to do with anything. When you mentioned just now that people like kind of wrote in or write in when we do episodes like this, when we did our emotional pain episode and we mentioned borderline personality disorder, a lot of people wrote in, well, I don't want to say a lot, but some people wrote in and they said, you know, "Thank you for treating it compassionately," because when most people talk about it, they talk about it like they despise it, or they despise people with BPD. And the more you look into it, the more you realize like, wow, this is maybe one of the hardest mental illnesses that you can possibly have. And I think we kind of said that in the emotional pain episode, but if I didn't know it before, I definitely do now after doing this research.

• 3:43Speaker 03

  Yeah, and it's also clear that it's one that somehow seems to garner the least amount of empathy.

• 3:50Josh Clark?

  Right.

• 3:51Speaker 03

  Not only among just people who, you know, may or may not know much about it, but even clinicians and therapists, that stuff you sent me, like a lot of times try to avoid or severely limit the number of patients they have that they treat with BPD, which makes it even more sad because it is a really tough one. I guess we'll just define it kind of off the bat and, you know, a lot of this episode will kind of be defining it in different ways because it's fairly complex, but it is a, what's known as a Cluster B personality disorder, which is in the antisocial personality disorder category, along with histrionic personality disorder and narcissistic.

• 4:35Speaker 03

  Uh, personality, I'm just gonna start saying PD.

• 4:38Josh Clark?

  Yeah, PD's, it'll make it sound like you know what you're talking about even more.

• 4:42Speaker 03

  Narcissistic PD, but um, it seems like a lot of what it can be is sometimes a disorder of perception. Uh, and while there are very real things that, that do, um, that can trigger people with BPD. Um, a lot of times is the way things are perceived incorrectly, either about themselves or about others or others' actions.

• 5:05Josh Clark?

  Yeah, and I saw a, um, a lot of people confuse, um, borderline personality disorder with bipolar. Or at least think they're similar, I guess because they both start with Bs or something like that. But no, they're not similar. Bipolar has much more of a, um, a brain and central nervous system basis. Whereas while, um, borderline personality disorder has a, a component of that. The executive function of the person in their prefrontal cortex. Either didn't develop in, in a fully normal way, or it, um, it's not functioning up to snuff, I guess. More than anything, and the thing that differentiates it from bipolar is it's a, an, um, an assignment of meaning.

• 5:49Josh Clark?

  It's psychological as much if not more than it is, um, physiological.

• 5:55Speaker 03

  Yeah, and also bipolar is characterized, and we, we did a, a good episode on that quite a while ago, but. Um, it's characterized by like these highs and lows. And then in between those periods, they can be relatively stable. Uh, whereas with border, uh, borderline personality disorder, it's, it's sort of always there. Um, this one thing you sent me had a really, kind of really nailed it on the head at the end. Uh, those with bipolar may have a hair trigger kind of response during an episode. Whereas when you have, uh, borderline PD, you have a hair trigger response all of the time. And I can't imagine how tough that must be.

• 6:32Josh Clark?

  Yeah, so that, that kind of, um, calls out one of the big hallmarks of BPD, which is, um. It's emotional dysregulation.

• 6:42Speaker 03

  Yeah.

• 6:42Josh Clark?

  Things that would affect other people a little bit, maybe not at all, stuff that most people let roll off of their back.

• 6:50Speaker 03

  Right.

• 6:51Josh Clark?

  Could set somebody with BPD off into a rage that could last days, potentially. They also might use self-harm, what's called non-suicidal self-injury, to kind of externalize the pain because they're, the emotional dysregulation is so profound, they don't know what they're feeling. They just know they're feeling everything all at once. And it's kind of like standing in a, in an ocean and a huge wave hits you. And you're just, you're as profoundly enveloped by emotion at that moment as you are when a, by a wave, when it just completely knocks you off your feet and sweeps you away.

• 7:33Speaker 03

  Yeah, there was another, and we'll talk about her in great detail. Her name is Marsha Linhan. Or is it Linhan?

• 7:42Josh Clark?

  I'm gonna go with Linhan.

• 7:44Speaker 03

  Yeah, she, as we'll see, is a, someone who not only suffered from BPD, but kind of pioneered the, the treatment of BPD. But she said it's like having third-degree burns on 90% of your body metaphorically. So you're lacking emotional skin and you feel agony at the slightest touch or movement.

• 8:06Speaker 03

  And since you did mention self-harm, non-suicidal self-harm, it also, people with BPD have a suicide rate of, was it like 50 times higher than average in the population? Yeah, so this is, this is no joke. This is a very hardcore disorder that bears more empathy and understanding.

• 8:29Josh Clark?

  Yeah, for sure. Let's, let's go back to the beginning, shall we? Because borderline personality disorder is one of those terms that has taken on its own meaning in the general population. But if you stop and think about it, it doesn't really reveal much about what it's describing. It's just one of those terms.

• 8:47Speaker 03

  Not at all. Frustratingly so.

• 8:50Josh Clark?

  Yeah, and that goes back to a jerk named Adolf Stern, who really jerked it up back in 1938.

• 8:56Speaker 03

  Yeah, he was a psychoanalyst and he basically, I mean, if you didn't know what it was, and I didn't even fully know what it was, I always wondered what borderline meant. And it very simply meant, it means, uh, this is Stern saying, you're, you're not quite on the psychotic level and you're not quite, uh, psychoneurotic, uh, you're basically on the border between those conditions while encompassing a bit of each, so we're just gonna call it borderline.

• 9:24Josh Clark?

  Yeah, and psychosis is what we would still consider psychosis, but under psychoanalysis, um, psychoneurosis is what we call like anxiety, depression, that, those kinds of mental illnesses. So, I guess Adolf Stern wasn't really that big of a jerk because he really kinda did combine them appropriately. It was Otto Kornberg who was the serious jerk in this, in this situation.

• 9:49Speaker 03

  Okay, so he was a psychoanalyst in the mid 1970s, so that's, well, you know, like forty something years later, and, um, he described it as an unstable personality and disorganized conception of the self. And this is just when it was sort of starting to become more and more, um, kind of talked about and officially, I think five years after that was, uh, in the DSM version three.

• 10:14Josh Clark?

  Yeah, I mean, that's pretty quick for something you just started to identify and five years later it makes it in the DSM, because they don't churn those DSMs out like, you know, every few months, it takes years to put one together. So, Kornberg seemed to have stumbled onto something that was worth, um, looking at very, very, um, very quickly.

• 10:33Speaker 03

  Yeah, and isn't there a, a sort of movement or belief now that it's, a lot of people think it's something that, it's like a diagnosis you shouldn't even give, right?

• 10:43Josh Clark?

  Yeah, there's, we'll talk about that, I think we can kind of pepper it throughout, you know?

• 10:49Speaker 03

  Okay, sure.

• 10:50Josh Clark?

  But, but, yes, there is, um, a, a school of thought that basically says, BPD is not a personality disorder, it's not even a mood disorder, although some people say it would better be characterized as a mood disorder. They say it's, it's a cluster of symptoms that overlap with a bunch of different... Actual disorders. And that the problem with that, you say, what, who cares? You're identifying people, a group of people whose rate of suicide is 50 times the general population. That alone is worth like identifying and helping those people out. But they're, what they're saying is, number one, BPD has gotten such a bad name in the general population that you are literally stigmatizing somebody when you give them that diagnosis.

• 11:35Josh Clark?

  It is an enormously heavy weight you put on somebody. You say, I'm a trained psychiatrist. I know what I'm talking about. And you have borderline personality disorder. Everybody step back, basically.

• 11:49Speaker 03

  Yeah, I mean, it's, it's almost in line with saying someone is a sociopath. It's different things, but as far as like the stigma goes.

• 11:57Josh Clark?

  Very much so. Yeah, for sure. That's a great analogy, actually. So, so some people are like, okay, it's stigmatizing. But even more than that, just the science isn't necessarily there. Like we were saying, it's, it's symptoms rather than an actual disorder. And then apparently the working group for personality disorders for the DSM five, that's the most recent one. They actually said, we're not sure that this should be a categorical disorder, which is the type that you either have it or you don't. They, they, they suggested it should be dimensional, which means that it exists on a spectrum.

• 12:33Speaker 03

  Right.

• 12:33Josh Clark?

  So you can have a little bit of BPD, a lot of BPD, or right in the middle, or whatever. And that got rejected. And now, so it's a categorical diagnosis where if you don't have BPD, you don't have BPD. If you don't fit the criteria. If you do, you got BPD.

• 12:51Speaker 03

  Right. And we'll talk about the criteria in a second. But we do want to sort of reintroduce Marcia Linehan, who, like I said, was a real pioneer for her work in the treatment and recognition of BPD. Very late in her life, revealed that she suffered from BPD after, you know, patients and friends encouraged her to come forward. And she said, basically, you know, I'm going to do it. I'm not going to die a coward, is what she said. But for the longest time, was not out with that information. Was born in Oklahoma in, I guess, the 50s. And in the 1960s in high school, was diagnosed with schizophrenia.

• 13:33Speaker 03

  Uh, drugged up, um, given electroshock, hospitalized, uh, was in, was, was practicing self-harm uh, of all kinds and then had, it sounds like a, not a moment of clarity, but a pretty profound uh, religious experience.

• 13:50Josh Clark?

  Yeah, the only thing missing was a visit from Saint Michael.

• 13:53Speaker 03

  Pretty much. I mean, she's Catholic and, uh, after this religious experience, she was able to, uh, which, you know, had a lot to do with self-love, but after this, she was able to still have these emotions that she had before, but managed it, uh, to the point where she wasn't practicing self-harm. And did she come up with the term radical acceptance, or did she just buy into that?

• 14:18Josh Clark?

  I don't know if that was a descriptor of hers or not.

• 14:21Speaker 03

  Okay, I don't think she came up with that, but basically is, you know, radical acceptance is like, hey, listen, this is how things are with me, this is how things are with the world. Uh, I accept this and I'm not gonna compare this, uh, to what I think the reality should be, or what other people think it should be.

• 14:42Josh Clark?

  There's a huge but that follows that, though.

• 14:45Speaker 03

  But?

• 14:46Josh Clark?

  But, but, um, I am going to do what I can to change those things about myself.

• 14:53Speaker 03

  Right.

• 14:54Josh Clark?

  So that is the basis of, um, a type of cognitive behavioral therapy that she came up with called dialectical behavioral therapy. And it is, it's based in radical acceptance and the desire to examine and change how you interact with the world externally. And it's basically the gold standard for treating, um, a borderline personality disorder right now.

• 15:18Speaker 03

  Yeah, and it seems like it really works. I saw that it was, um, kind of the only proven treatment to reduce, um, suicidal behavior, which is, you know, the, at the, the tail end of, um, what a lot of people experience with BPD. And the good news, and we'll, we'll talk about treatment later, but the good news is if, if you have BPD or know someone that does, you can get better. And they have, they have proven and shown time and time again now that through the treatments that we'll discuss later, it is, it is absolutely something that someone can get a hold of in most cases.

• 15:53Josh Clark?

  Right.

• 15:54Speaker 03

  Which is great.

• 15:55Josh Clark?

  It is great. I mean, like, as bad of a stigma as BPD has, the idea that it has a very high success rate of treatment is pretty encouraging.

• 16:04Speaker 03

  Yeah.

• 16:05Josh Clark?

  So, Lenihan's basis of, or her understanding or her definition of borderline personality disorder is that it's biosocial, that people who have BPD are either genetically or biologically predisposed to having BPD, but not everybody who has that predisposition is going to be triggered into developing BPD. It takes basically a biological substrate for BPD. Usually, your prefrontal cortex hasn't developed in a certain way, and so your executive function isn't functioning like an executive should.

• 16:43Josh Clark?

  That gets joined together with a trigger, usually mistreatment, whether it's abuse, neglect, invalidation by your parents as a kid, and you put those things together, and very often it results in what you'd be diagnosed with later as BPD.

• 17:03Speaker 03

  Yeah, and man, one thing I really took away from this, and this is something that, you know, Emily and I, and most parents that I know are way into, is, oh, you gotta validate your kids.

• 17:13Josh Clark?

  Yeah, that's new, which is crazy, but it's...

• 17:16Speaker 03

  Yeah, you gotta validate their emotions and validate their experiences and their feelings, even if it's something that you don't think is, like, has the most relevance or whatever, or even if, like, the kid is wrong about something, or, like, emotionally wrong, like, you still have to validate that and then talk them through it. What you can't do is just discount a kid's feelings, because that's, like, telling them that their truth isn't real, and that's damaging.

• 17:46Josh Clark?

  I know, and doing parenting right sounds like a waking nightmare to me.

• 17:50Speaker 03

  Doing what? Parenting?

• 17:51Josh Clark?

  Parenting correctly, yeah.

• 17:53Speaker 03

  Nah, nah.

• 17:54Josh Clark?

  I can't imagine the exhaustion along combined with the fear of just misstepping once or twice and then, there you go, you screwed your kid up for life.

• 18:03Speaker 03

  Yeah, what you gotta do is, in my experience, is like, you can't beat yourself up too much because parenting fails, you can really go down a rabbit hole of your own

• 18:14Josh Clark?

  I'll bet.

• 18:15Speaker 03

  depression if you, if you screw up. Uh, and you can't do that because kids are resilient and you just gotta like, you gotta prove to them that you can like, pick yourself up and move on and do better, you know?

• 18:26Josh Clark?

  Yeah, and I, I, I don't think Lenihan's idea is that it, it just takes one or two missteps. It takes like a parent who is a genuinely bad parent, very frequently, they have BPD themselves.

• 18:39Speaker 03

  Yeah.

• 18:40Josh Clark?

  And, um, that is a real challenge to parenting well in and of itself. But you don't have to have had a, a parent with BPD to develop BPD. But typically, it's a, a parent that is not at all meeting your needs.

• 18:53Speaker 03

  Right.

• 18:53Josh Clark?

  Especially emotionally. And, um, I say we take a break and we'll come back and talk about how you would be diagnosed with BPD. What do you think?

• 19:01Speaker 03

  Let's do it.

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• 20:39Josh Clark?

  Okay, Chuck. So we said that BPD is in the DSM V. It's a personality disorder. And just to differentiate real quick, a mood disorder describes patterns in feelings. Like you have mood swings in that highs and lows. And it's pretty reliable that you're going to have it one way or another. Personality disorder focuses more on how you relate to others. And that definitely makes sense to me that you would consider a BPD a personality disorder, then.

• 21:09Speaker 03

  Yeah, that seems to be a really key thing is that it really disturbs your relationships.

• 21:19Speaker 03

  So to be diagnosed, you fit at least five out of the following nine that we're going to read for you. Chronic feelings of emptiness.

• 21:28Josh Clark?

  And that's emptiness feeling like isolated or lonely or hopeless.

• 21:32Speaker 03

  Sure. Emotional instability and reaction to day to day events. That's the thing we were talking about earlier, like saying mountains out of molehills seems slightly reductive, but that's kind of a basic way to say it.

• 21:45Josh Clark?

  Okay.

• 21:47Speaker 03

  Frantic efforts to avoid abandonment, whether or not they're real or imagined.

• 21:51Josh Clark?

  That's a huge one.

• 21:53Speaker 03

  Yeah, as we'll see abandonment issues and this very, very much includes emotional abandonment is a really big precursor.

• 22:02Josh Clark?

  Yeah.

• 22:03Speaker 03

  Unstable self-image or sense of self. Uh, what else?

• 22:07Josh Clark?

  Um, impulsive behavior is usually a big one and you have to have impulsive behavior in at least two areas that are harming your day-to-day life. Like an eating disorder and gambling addiction or something like that.

• 22:21Speaker 03

  Right.

• 22:22Josh Clark?

  Um, another one is, this is based on, and so this is where some psychiatrists would be like, see, this is not, this is, this is a symptom that we're talking about here. But it's unstable and intense interpersonal relationships. Meaning like you're really, really close to somebody for, you know, a couple of days and then they do something you don't like and they're the worst person in the world. And it can happen very, very quickly with people with BPD. Um, and if you stick around and stay in that person's life, you can find yourself walking on eggshells very quickly because you don't want them to turn on you all of a sudden.

• 22:57Speaker 03

  Right.

• 22:57Josh Clark?

  Um, so that's a huge one. If you have a lot of unstable, intense relationships with people, that's just kind of MO, that is usually a big giveaway with BPD.

• 23:09Speaker 03

  Yeah. Um, the last three, recurrent suicidal or self-harming behaviors, we've talked about that a little bit. Um, stress-related paranoia or dissociative symptoms like feeling like the self or the world isn't real.

• 23:23Josh Clark?

  Yeah.

• 23:23Speaker 03

  Uh, that's, uh, it feels like that's probably at the far end of the spectrum or the most severe end. Uh, and then one we, uh, missed earlier was, uh, inappropriate and intense anger or difficulty controlling anger.

• 23:36Josh Clark?

  I didn't miss it. That was purposeful.

• 23:38Speaker 03

  Oh.

• 23:39Josh Clark?

  Wanted to end with that big one.

• 23:41Speaker 03

  Okay, all right. Speak to it.

• 23:43Josh Clark?

  Well, there's a lot of, um, I can't, I always hate saying those qualifiers. It's just so easy to say, but I think it perks people's ears up like, oh, this person doesn't know what they're talking about. So let me rephrase that. I have seen that there are schools of thought regarding borderline personality disorder, that it is a rage.

• 24:03Josh Clark?

  Response to trauma.

• 24:05Speaker 03

  Hmm, okay.

• 24:06Josh Clark?

  That that is your response to unresolved trauma. That's how you learn to deal with those feelings and those emotions is to rage at people. Because rage is as much a hallmark of BPD as fear of abandonment is.

• 24:18Speaker 03

  Right.

• 24:19Josh Clark?

  And that's why some people are critical of including it as a categorical diagnosis in the DSM five. They're saying you're pathologizing rage. No, you just need to teach people how to identify their emotions and how to express them in a more appropriate, less hostile manner. And then that's how you would treat somebody with BPD or not even with BPD, somebody with a rage disorder. But some people think that that is what what people are mistaking for BPD.

• 24:45Speaker 03

  Oh, I got you. Okay, interesting. Uh, you're gonna to be diagnosed, like I said, five of those nine. Um, it'll probably be, you know, like you'll be talking to a psychologist or or someone in an interview. You might fill out a questionnaire or something.

• 25:00Josh Clark?

  They're gonna go, hmm, interesting.

• 25:01Speaker 03

  You're right. Click, click, click, click. Uh, or they may speak to your family or something like that. Uh, it can be difficult to diagnose. Um, and there, like you said, there's, there's a lot of overlap between, you know, things like anxiety and depression and things like PTSD and eating disorders, a lot of comorbidities. So I get why people can have issues with like this diagnosis rather than it's like a cluster of symptoms of other things. But I don't know, if you group that all together, then it and call it its own thing, then I don't know. I'm not sure I see the harm in that.

• 25:39Josh Clark?

  Uh, again, I think it's the stigma and then also it might be distracting from treating the other underlying stuff.

• 25:47Speaker 03

  Maybe, because they there also isn't, and we'll talk about pharmaceuticals, but there isn't a specific pharmaceutical for BPD.

• 25:55Josh Clark?

  That's another clue that some people point to that it's not, it's, it's, it's, we're mistaking it somehow. And I don't want to like overstate the, um, that school of thought. It is widely considered like a, an accepted, um, diagnosis.

• 26:12Speaker 03

  Right.

• 26:12Josh Clark?

  Borderline personality disorder is. So I don't want to make it seem like other, the cracks are in the facade. It's about to crumble any day now. My point is. People make some pretty good points about how well we understand it, or how well we're defining it, and we're possibly missing some component of it.

• 26:31Speaker 03

  Yeah, and isn't that stuff debate usually, or I guess it should be, and I hope it's couched in how to best treat people and help people, right?

• 26:40Josh Clark?

  Yes.

• 26:41Speaker 03

  Rather than just like poo-pooing ideas?

• 26:44Josh Clark?

  Yeah, no, I think that's exactly right. But I mean, again, if we come to this place where even if, if a BPD is the center of a giant Venn diagram of a bunch of different disorders,

• 26:57Speaker 03

  Yeah, yeah.

• 26:57Josh Clark?

  and we're mistaking that center overlap of all of them as its own thing, if you, if you zero in on that group and they have a 50, 50 times higher rate of suicide than the general population, again,

• 27:09Speaker 03

  Yeah.

• 27:10Josh Clark?

  that is worth zeroing in on, you know, as its own thing. And like you said, dialectical behavior therapy is focused initially on individual sessions that are, that are, that are aimed to control that, that behavior suicidality.

• 27:26Speaker 03

  Yeah, yeah, for sure. You did mention earlier, as far as causes go, that sometimes there is a genetic link, but it seems that it's not really the disorder that is like maybe passed from parent to child, but some of those traits, and maybe that's because it is sort of a cluster. Sometimes you can't, you know, you can have BPD and come from like a pretty good, you know, stable upbringing, but that seems to be the outlier. And it seems to be that like most people that end up suffering from this had a pretty lousy childhood.

• 28:04Josh Clark?

  Yeah, so they were either neglected or just kind of saddled with emotionally unavailable parents who just weren't really there for them, didn't go to their dance recital kind of thing. Never went to a single one. Excessive control, it sounds very Freudian, but I saw one classic example is an absent father and a domineering mother. And it's like, how many times have you guys trotted that one out? But apparently it really does have a screwy effect on people as a kid. And then also if your parents or parent had a mood disorder themselves or misused substances, that would probably have affected their parenting as well.

• 28:50Speaker 03

  Yeah, this also made me think about like parenting of old versus parenting now and parents can, there are still, of course, a huge range of bad parents these days. I'm not saying that everyone's doing it right now, but it definitely seems like things turn to corner and parents are trying a lot harder these days and like sort of the old days of like, oh, you know, kids raise themselves and you can ignore them and blah, blah, blah. And like, I'm sure that, I mean, I know that still happens, but it just seems like that happened a lot more back in the day and maybe in the future, things like this will be less and less.

• 29:29Josh Clark?

  Yeah, that's the hope for sure.

• 29:31Speaker 03

  I know that's sort of a basic, sort of an elementary way of looking at it, but I just feel like parents are more aware of stuff these days and like, you know, people of our generation and certainly the generations before that, it was even worse as far as parental involvement and parents who either one or the other, you know, fathers a lot of times, you know, historically are the ones that were like, no, we're not going to parent because we're doing the work and we're going to bring home the paycheck. And so, like I had, I've talked about it before, I had a dad that wasn't very involved, but it wasn't like the kind of thing where he, I ended up with BPD because of it, you know?

• 30:07Josh Clark?

  Yeah, for sure.

• 30:09Speaker 03

  If that makes sense.

• 30:09Josh Clark?

  You raise a question, though, in my mind. I wonder what percentage of boomer grandparents aren't allowed to see their grandchildren? I'll bet it's higher than you'd think.

• 30:22Speaker 03

  Are allowed to or not allowed to?

• 30:23Josh Clark?

  Not allowed to, like just don't have contact with their grandkids.

• 30:27Speaker 03

  Yeah, or it's very limited and supervised and sort of, actually, though, a lot of those grandparents all of a sudden are the most doting. And it's kind of like, I know some parents are like, oh, okay, well, this is great. Where was that when I was a kid?

• 30:40Josh Clark?

  Right, yeah, for sure. But also, I think in some of the cases, the more they don't, they're actually also undermining the parenting of their kids.

• 30:49Speaker 03

  Yeah.

• 30:49Josh Clark?

  Under their grandkids.

• 30:50Speaker 03

  Yes, and imagine it can be very painful for a parent who had an unattentive parent to now have that parent be a very attentive grandparent.

• 31:00Josh Clark?

  If you have BPD, I would guess that would be a rage inducing trigger.

• 31:03Speaker 03

  I imagine it would be.

• 31:06Josh Clark?

  There are plenty of other ways that you could probably develop BPD. Another very classic one is any kind of abuse, emotional, sexual, physical abuse at the hands of your parent or a caregiver. And they say that about 80% of people with BPD experience some level of childhood trauma, whether it was emotional neglect or some sort of abuse. It is a, it's a huge factor, a huge risk factor in developing BPD for sure.

• 31:35Speaker 03

  Yeah, absolutely. And it seems to be exacerbated if you're a kid who is, maybe you're just innately a little more unsure of yourself or a little more vulnerable as a person. And then that is reinforced with a parent who is not validating your experience and your emotion as a kid. So you're, you're already starting back sort of behind the eight ball and then your parents are making it worse. And so that can definitely, you know, ease you toward that condition.

• 32:05Josh Clark?

  Well, it's like, that's a chicken or the egg question, though. Like, were you like that, you know, already and your parents is reinforcing it? Or did you get that kind of, did you learn to do that because of your parents' behavior? It's like a, not chicken or the egg, but parent or the disorder.

• 32:20Speaker 03

  Right.

• 32:20Josh Clark?

  You know? But we said earlier that there's also believed to be a biological component to it, too, that it's not all psychological. And it does seem to have something to do with executive function in the brain. One of the big things that executive functioning does is it helps you control your emotions, not just in accepting things and dealing with them and moving on, but also your outward display of emotions. If you don't have executive function, your emotional dysregulation is more likely to include explosions of anger, uncontrollable anger. And then one of the things, it's not just BPD that has that. There's plenty of other disorders that have it.

• 33:06Josh Clark?

  But one of the, one of the key traits of BPD is it can last a really long time, too.

• 33:12Speaker 03

  Can we make a T-shirt that has a chicken? That says parent across the chicken's chest. And then next to an egg that says mental disorder.

• 33:22Josh Clark?

  Love it.

• 33:24Speaker 03

  And just, that's the shirt. No explanation. Figure it out or don't.

• 33:27Josh Clark?

  How about this, though? On the back of the shirt, mork is coming out of the egg. All right, to really confuse people.

• 33:37Speaker 03

  Oh, wow. That just really changed things. I like it.

• 33:39Josh Clark?

  Okay.

• 33:40Speaker 03

  So as far as the number of people who experience BPD, it's kind of a wide range, like all this stuff, because it's one of those disorders that is, a lot of people don't admit it or seek treatment, so it's really hard to nail it down. But Livia helped us out with this one, and she said 0.5% to 6%, and they find it about four times more in women. But they've also found other studies are like, no, it's the women who are brave enough to come forward and seek treatment, and it happens just as much in men.

• 34:11Josh Clark?

  I also saw that it's a, that's an indictment of clinicians who basically have to figure out for themselves whether the person has BPD, and that they're more likely to assign it to a woman than a man, a male patient.

• 34:24Speaker 03

  Oh, interesting.

• 34:26Josh Clark?

  So regardless, it is very frequently diagnosed, more than you would think. It's one of the more common, serious mental illnesses. Apparently, people receiving inpatient mental health treatment, one in five of those people are diagnosed with BPD. So it is very prevalent, at least in, inside the, the, the clink.

• 34:48Speaker 03

  Yeah.

• 34:49Josh Clark?

  The mental clink.

• 34:50Speaker 03

  Yeah, the mental clink. One other aspect is a very black and white thinking. You kind of talked before about splitting, which is, you know, really revering and idolizing somebody, and then very quickly despising them. And this can happen very, very frequently, and like several times throughout a day even. Or it can be like just a switch that is permanent. Like someone you used to really like and idolize, all of a sudden, it, just no more. You despise them and they're, they're on the, the bad person list forever.

• 35:24Josh Clark?

  Yeah, and that's, that falls under the larger category of black and white thinking. It's not just applied to people, it's

• 35:30Speaker 03

  Right.

• 35:31Josh Clark?

  Events, things, anything. A dandelion can be entirely evil or the, the, fully good. And because you see things and people and events as entirely one way or the other. You set people up for unrealistic expectations. If you're like, you're 100% pure and kind person and I love you. That person is inevitably going to let you down in some way, shape or form.

• 35:56Speaker 03

  Sure.

• 35:56Josh Clark?

  Because no one's 100% pure and kind. Similarly, no one's 100% evil. And most people that you would label evil as if you have BPD probably aren't evil at all. They just did something you really didn't like. But now to you, that person is evil. Not to be trusted, not, you know, they did something wrong. At their core, they're evil. And that's another huge hallmark of BPD as well.

• 36:24Speaker 03

  Yeah, I mean, even Darth Vader was was once a young boy.

• 36:27Josh Clark?

  Yeah.

• 36:27Speaker 03

  Just trying to learn the ways of the force.

• 36:30Josh Clark?

  But boy, did he get pale as he aged.

• 36:34Speaker 03

  He sure did. This can also, this splitting can happen with yourself. You may vacillate wildly from feeling like you're okay and that you feel good about yourself and you have a little bit of self-confidence to really loathing yourself. And that's when like things like, you know, self-harm can come into play. Your sense of your own personality can really change. You're, you know, you could very much switch, like kind of do these wild switches between your goals in life or how you want to present yourself to the world or like your values and ethics and things like that. And this, I'm not really sure, but it kind of seems like almost like a sort of auditioning

• 37:19Speaker 03

  yourself kind of over and over sometimes. Like, let me, let me try this new me or whatever, or auditioning or trying out a new thing that you think might help. Does that make sense?

• 37:31Josh Clark?

  Yeah, no, totally. It's also circumstantial too. They might act different ways to different people depending on what they think those people want from them. Or yes, to impress like a friend or a new person or something like that. They might adopt that person's like hobbies and interests. But I saw it explained as the people who have BPD and do that, that they don't understand where they end or the other person begins because they have no idea what they believe in. They just don't know. So they're kind of open for suggestions, basically.

• 38:04Speaker 03

  Interesting.

• 38:05Josh Clark?

  Yeah.

• 38:07Speaker 03

  Should we take a break?

• 38:09Josh Clark?

  Oh geez, that came out of left field.

• 38:11Speaker 03

  Sorry.

• 38:11Josh Clark?

  Sure.

• 38:13Speaker 03

  All right, I think it's a good time to take a break. And then we're going to come back and talk more about personal relationships.

• 38:26Speaker 07

  This live check-in is brought to you by State Farm. Porque el bienestar de tu familia también merece protección. Okay, real talk. I'm about to become a dad again. And wow, it hits different the second time. Hi, I'm Wilmer Valderrama and I've done, you know, I've done the red carpets, the long days on set and all that. But nothing prepares you for that moment when you're building a crib and you realize you're building a future. Familia is everything to me. The laughs, the chaos, the unconditional love, but also the pressure, la responsabilidad. If you're stepping into something big right now, starting a family, getting engaged, moving cities, you're not alone. Take one step at a time. Why breathe?

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• 40:04Speaker 05

  Learn more about how Cleveland Clinic and IBM are using AI and quantum computing to revolutionize biomedical research at ibm.com/smarttalks.

• 40:28Speaker 03

  All right, we're back and talking about borderline personality disorder. And one kind of hallmark with someone with BPD is what's called like a favorite person, or just a person in their life that they have not necessarily even chosen, who they've hooked up with. It could be a spouse, it could be a partner, it could be a friend, or coworker, anyone that you really have latched on to as someone, maybe the only person that you really, really trust with yourself.

• 41:04Josh Clark?

  Yeah, and I don't think you even trust that person. You just, that's the person you've come to find you can lean on the most, I think.

• 41:11Speaker 03

  Okay.

• 41:11Josh Clark?

  But yeah, the FP, for those in the know, the favorite person, is very frequently somebody who is willing to kind of go along with this, at least for a while. There's a ton of flattery and admiration and praise, and all of your greatest points are pointed out all the time. But you're also in real danger of letting that person down and facing that wrath of rage or anger or hostility. And if you come back for more, you're going to find that you, as the favorite person, might start altering your behavior to fit the person with BPD's behavior. So you might start considering them when you're making plans,

• 41:56Josh Clark?

  like, oh, we can't go out of town this weekend because this, our friend with BPD was going to, you know, wanted us to come out for their Sunday picnic, or something like that, right? Like, you would be afraid to not go to their picnic. And you generally end up feeling like you're walking on eggshells. And it's a codependent relationship that evolves. The favorite person seems to be the person who's willing to take it the longest or the most, and that it's not a permanent... Thing typically, people get burned out on it and eventually abandon the person with BPD, which is again at the root of what they're fearful of. They're fearful of rejection or abandonment.

• 42:36Speaker 03

  Mm hmm.

• 42:37Josh Clark?

  The tragedy of the whole thing is that their behavior almost inevitably guarantees that they will be rejected or abandoned by the people around them.

• 42:46Speaker 03

  Yeah, that sort of self fulfilling feedback loop.

• 42:49Josh Clark?

  Right.

• 42:50Speaker 03

  Yeah, I mean, it's a big burden for an FP. And if you are a spouse or partner of someone and you are the FP, like, that's a lot to manage. And so a lot of empathy goes out to those people as well. When you're altering your own behaviors, like literally things like, I saw people are like, you know, I had to, I've had to step out of like really important meetings just to answer a text within 10 minutes because I knew that that would set them off. And just little things like that can really add up to someone's burden.

• 43:26Josh Clark?

  One of the other things that is difficult to deal with when you're an FP is that person wants you all to themselves. They're threatened very much by other people. So they will try to isolate you from your other friends and your family so that they have you all to themselves. Not just for time, I'm sure time is a big part of it, but also to cut down on any, I guess rational explanation or rational points from those other people, like, what are you doing? Why are you putting up with this? Isolating them would help cut down on that, too.

• 43:57Speaker 03

  Yeah. And, you know, if you're an FP, there's always the sort of sad and scary possibility that there could be a split incident that all of a sudden you go from being the FP to being the most despised person. I would imagine that's something that has, probably comes over time and is not like a quick thing.

• 44:19Josh Clark?

  It can be.

• 44:20Speaker 03

  But it can be? All right.

• 44:22Josh Clark?

  For sure. It can happen. It can turn on a dime.

• 44:26Speaker 03

  Wow.

• 44:26Josh Clark?

  And the other, the other problem with it as well Chuck is that um the person with BPD almost invariably immediately regrets doing that.

• 44:36Speaker 03

  Right.

• 44:37Josh Clark?

  And so they'll make every effort to try to win the person back, which probably feels pretty gross for the FP.

• 44:44Speaker 03

  Right.

• 44:44Josh Clark?

  And they'll say things like, I'll never do that again. Like, they know what they've just done is worth regretting, is worth feeling horrible about, because they've just been abandoned or rejected. They just did it to themselves. So now they're trying to fix it or mend it. But it's all just kind of built on, you know, shaky ground, because it's, it's gonna happen again, because it's impossible for that person not to let the person with BPD down again.

• 45:08Speaker 03

  Yeah, I mean, I get the impression that people with BPD generally don't have any illusions about themselves, because it is such a struggle.

• 45:16Josh Clark?

  Well, that is a big problem with not only getting treatment, but seeking treatment. Because when your brain is structured in a certain way, and ever since you were a little kid, you've just responded a certain way to things, even if people around you are telling you that is messed up, or that you're being hostile or whatever, to you, that's normal. That's natural. So it's really, really hard to interrogate your own behavior, let alone change it, because it seems normal and natural to you. It's not that you need to change your behavior because you chase somebody away, it's that that person left you and now you need to go get them back.

• 45:54Speaker 03

  Right.

• 45:55Josh Clark?

  So even if you have people around you telling you, it's going to take a lot of emphasis, repeated, constant emphasis that what you're doing right now is abnormal and harmful, and you need to go get help for this.

• 46:09Speaker 03

  Yeah.

• 46:10Josh Clark?

  Yeah, that's one of the curses of it. They can't see it. They, at least if they can see it, most of the time they can't.

• 46:17Speaker 03

  Well, and this is, I mean, all the mental health disorders require a support system, but this one really seems to, to sort of be at the top of the list of needing a really solid, vast support system.

• 46:30Speaker 03

  For treatment, like we said, the good news is, is that treatment works. They used to think that personality disorders were untreatable and that you were just kind of stuck with it. They have found that about half the people who are treated, who seek treatment and are treated, no longer meet the criteria after five to 10 years.

• 46:53Josh Clark?

  That's amazing.

• 46:54Speaker 03

  It doesn't mean that they're, you know, they're perfect and awesome and fixed. It means they can still have some symptoms, but they have it under control enough to where they don't meet that five out of nine criteria. And that's what it's really sort of about, I think, is managing something that, like you said, that you might have had since you were like a baby, to live a productive, you know, healthy life.

• 47:18Josh Clark?

  Yeah, and that's kind of what you're gonna learn in DBT, which again is the gold standard for treating BPD, is that you're going to be taught these skills, how to deal with disappointment, with being let down, with somebody not responding to your texts. You're going to learn a different set of skills on how to deal with that, both internally and externally. And one of the things that, that kind of differentiates DBT from other kinds of behavioral therapy is that there's group sessions, but it's not a group session that, you know, you've seen in a movie. Like, my niece Mila was in a movie called No Exit, and that featured a couple of group sessions. I think you can still see that on Netflix.

• 47:59Speaker 03

  I think so.

• 48:00Josh Clark?

  But it's not like that. It's more, almost like a classroom instead, and then people get up and practice these skills in front of others and with others, but it's not like a group therapy session in the traditional sense. But that's a huge component of it, is group work.

• 48:16Speaker 03

  Yeah, and it's, you know, if it sounds a little bit like cognitive behavioral therapy, it is sort of based on that in part because it's a real, and I get how it works, it seems like a real sort of rubber meets the road, practical ways of learning new behaviors rather than, and therapy is a huge part of it, but it's not just, let's therapy and talk about your past until you're blue in the face. It's like, alright, we know what's going on and we think we know where it came from generally, now let's really talk about... Putting this into daily practice, like literally doing things and having a checklist

• 48:56Speaker 03

  and and putting stuff into practice, which I think is just, I mean, not only for DBT, but stuff like that is so, it so speaks to me as a good way forward when you have any kinds of problems, because it's it's just a practical thing. It's learning new behaviors.

• 49:15Josh Clark?

  That's another criticism of of BPD as its own disorder, that DBT can be used to treat all sorts of different symptoms of all sorts of different disorders. It just makes sense like that.

• 49:29Speaker 03

  Great.

• 49:29Josh Clark?

  Yeah, for sure. But there's also another type of therapy that supposedly works really well for DBT called psychodynamic therapy. And it is talking about what you went through as a child till you're blue in the face. But it's more about relating to relating that to how you deal with people in your current life, people in situations. It's relating it back to it so that it's not just one big confusing blob. You understand your own behavior better as a result of interrogating what you went through as a kid. And I guess it smells a lot like it believes borderline is a like a response to trauma, using anger rather than anything else.

• 50:13Speaker 03

  Yeah, I mean, if you can sort of build out your emotional life map, I imagine that's a very helpful thing to do, you know?

• 50:21Josh Clark?

  Yeah. And then one other thing that really kind of underscores how difficult dealing with people with borderline personality disorder can be. One of the main components of dialectical behavioral therapy is what's called a therapist consultation team, which is basically a group of therapists working with patients with BPD.

• 50:43Josh Clark?

  Having like a, like a blow off steam session about them.

• 50:48Speaker 03

  Right.

• 50:48Josh Clark?

  And reminding one another, like, these are people suffering and we need to have empathy for them. That's how hard it can be to treat people with BPD.

• 50:56Speaker 03

  Yeah, and like I said at the beginning, there are therapists that will refuse treatment because all the reasons that we talked about, they say that National Alliance on Mental Health basically says if you have BPD and you recognize that and you want to seek treatment, whether it's, you know, DBT or any other kind, you, well, first of all, seek out someone that specializes in DBT. But if there's no one in your area that does that, then like you, you have a right, and this, this goes with any sort of emotional or mental problems that anyone has. They're working for you, so you have the right to advocate for yourself and to find

• 51:34Speaker 03

  somebody who works for you and who, who will not stigmatize you and like really, like, it's okay to question them and make sure it's a good fit for you.

• 51:46Josh Clark?

  Yeah, for sure.

• 51:49Speaker 03

  I think people just, I don't know, it's, I think part of the problems with a lot of these disorders is people can't be advocates for themselves and then that might be part of their problem, so they're not going to advocate for themselves when receiving treatment and they'll just take whatever they can get and it's, not all therapies are created equal and therapists are created.

• 52:06Josh Clark?

  Definitely not. I think one of the problems with BPD is that they might over advocate for themselves.

• 52:12Speaker 03

  Oh.

• 52:13Josh Clark?

  And like chase a therapist off, basically.

• 52:15Speaker 03

  Right.

• 52:16Josh Clark?

  But the, the thing is Chuck, is like you said, people take what they can get in part because there's a huge shortage of psychiatrists in particular in the United States. And people will just take whoever can get them in within a year or less. The waiting lists are crazy.

• 52:32Speaker 03

  It is crazy.

• 52:33Josh Clark?

  Well, if you want to know more about BPD, there are a lot of articles and resources all over the internet to help you. And since I said that, it's time for listener mail.

• 52:47Speaker 03

  I'm gonna call this, uh, well, let's just call it listener mail. Hey, guys, one day I will write the email that I've been formulating in my mind for years, trying to put into words what the show has meant to me. I'm tearing up just writing that sentence, which provides you with a hint of why that email hasn't been written yet. Wink, wink. In the meantime, I want to let you know that both of your names are listed on my big thanks to portion of my bachelor thesis.

• 53:13Josh Clark?

  Nice.

• 53:14Speaker 03

  It's customary in my country to thank your college coach for their support during your graduation year and your thesis forward. I have felt it was only right to also thank the other people who have supported me to the same extent as my coach, and this includes you guys. I don't feel the least bit dramatic when I say my thesis would not have been written if it wasn't for you guys keeping me sane. It's what you've done for me over the years, but this year I really needed it more than ever. So, thank you, all caps, double exclamations. I've added a picture of my forward where your names are mentioned, and since I'm Dutch, I'm afraid it won't make much sense to you, but I figured it might bring you some joy to see the proof.

• 53:51Josh Clark?

  There are some rando Js scattered throughout those words.

• 53:54Speaker 03

  Yeah, totally. And Chuck has a little null sign through it. That's weird. I'm not sure what that means.

• 54:00Josh Clark?

  It means watch your back.

• 54:01Speaker 03

  It means I don't count. And that is with much love and immense gratitude from Suzanne. Oh, I'm gonna do my best here, Suzanne. Kruiswijk.

• 54:11Josh Clark?

  Let's hear it again.

• 54:13Speaker 03

  Kruiswijk. Kruiswijk.

• 54:15Josh Clark?

  I like the second one.

• 54:16Speaker 03

  K R U S W I J K. You like the second one?

• 54:18Josh Clark?

  Yeah. Thank you, Suzanne. I'm gonna call her Suzanne. Thank you very much, Suzanne. That was very kind of you. Thank you for tearing up. I think you did just write that email, if you ask me, don't you, Chuck?

• 54:25Speaker 03

  I'm tearing up.

• 54:26Josh Clark?

  If you want to be like Suzanne and let us know what we meant to you, we always love hearing that kind of thing. Or you can just write in and say anything you want. We're at [email protected]. Stuff You Should Know is a production of iHeartRadio. For more podcasts, iHeartRadio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.

• 55:04Josh Clark?

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• 55:36Speaker 09

  She's been thinking about this sleepover all week, but I think about her food allergies all the time. Fortunately, her doctor prescribed Zolair, omalizumab. It's proven to significantly reduce allergic reactions if a food allergy accident happens.

• 55:49Speaker 10

  Zolair 150mg is a prescription medication used to treat food allergy in people one year of age and older to reduce allergic reactions due to accidental exposure to one or more foods. While taking Zolair, you should continue to avoid all foods to which you are allergic. Don't use if you are allergic to Zolair. Zolair may cause a severe, life-threatening allergic reaction called anaphylaxis. Tell your doctor if you ever had anaphylaxis. Get help right away if you have trouble breathing or if you have swelling of your throat or tongue. Zolair should not be used for the emergency treatment of allergic reactions, including anaphylaxis. Zolair is for maintenance use to reduce allergic reactions, including anaphylaxis, while avoiding food allergens. Serious side effects such as cancer, fever, muscle aches and rash, parasitic infection, or heart and circulation problems have been reported. Please see zolair.com for full prescribing information. Ask an allergist about Zolair. This is an advertisement for Zolair,

• 56:33Speaker 10

  paid for by Genentech and Novartis.

• 56:35Speaker 00

  This is an iHeart Podcast. Guaranteed Human.