Pod Insights Speaking of Psychology Encore - What is borderline personality disorder? With Carla Sharp, PhD About this episode Borderline personality disorder (BPD) is one of the most frequently diagnosed personality disorders, and one of the most misunderstood. Carla Sharp, PhD, of the University of Houston, discusses how BPD is diagnosed, defined and treated, how family members can help children and adults with BPD, and how the disorder fits in with researchers’ evolving understanding of personality disorders in general.
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Transcript Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.
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0:15 Kim Mills? Speaking of psychology is taking a winter break, so we're rerunning some of our favorite episodes from the past. In 2022, I talked to psychologist Carla Sharp about borderline personality disorder, including how this frequently misunderstood disorder is diagnosed and treated. We hope you enjoy this episode from the archives. Speaking of psychology, we'll be back with new episodes in January. Thank you for listening. Today, we're going to talk about the most frequently diagnosed personality disorder that many of you may never have heard of. But if you have, you might not really understand what it is, because even its name is somewhat enigmatic.
0:59 Kim Mills? Borderline personality disorder is a condition marked by intense emotions that are typically hostile, angry, or depressive in nature. People with BPD may have a history of impulsive behavior and chaotic relationships. Many fear being abandoned and may tend to see the world as purely black or white. Some engage in self-harm or suicidal ideation. And what may be the most challenging about this disorder is that many people with BPD are able to project an appearance of total normalcy. So what makes borderline personality disorder its own diagnosis? How does it affect people's trajectory in life? How is it different from other personality disorders?
1:41 Kim Mills? How might you tell if someone you know has it, or if you yourself might have it? And if people with BPD are high-functioning and appear "normal," how can the disorder be diagnosed and treated? Is it really a discreet mental illness? And what makes BPD controversial among mental health researchers and practitioners? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills.
2:17 Kim Mills? My guest today is Dr. Carla Sharp, Professor and Associate Dean for Faculty and Research at the University of Houston. She is also Director of the University's Adolescent Diagnosis Assessment Prevention and Treatment Center and the Developmental Psychopathology Lab. She holds adjunct positions at the University of Texas, Baylor College of Medicine, University College London, and the University of the Free State in South Africa. Dr. Sharp has a longstanding interest in social cognition as a cause and correlate of psychiatric disorders across the lifespan with a special focus on youth. She has published over 300 peer-reviewed articles, numerous chapters, and eight books.
2:58 Kim Mills? A large proportion of her research uses borderline personality disorder and other personality pathology to study where social cognitive function goes awry. Thank you for joining me today, Dr. Sharp.
3:10 Speaker 03 Thank you so much, Kim. I'm so glad to be here with you, talking about this topic that's very close to my heart.
3:17 Kim Mills? Well, let's start by talking about personality disorders in general. How does psychology categorize and define personality and personality disorders? And how is this area of psychology evolving?
3:29 Speaker 03 Well, that is a very big question, and I'm going to try and keep it succinct. The diagnosis of personality disorder is a disorder or a diagnosis in transition. For the last 20 to 30 years, since the publication of the DSM III, we have been ascribing to a system of diagnosing personality disorder that we call the categorical system. It is based on a medical model in the sense that we see disorder as something that a person has or does not have. You can think a little bit about pregnancy as an example. You know, you can't be halfway pregnant. You're either pregnant or you're not pregnant.
4:13 Speaker 03 And in the same way, in the categorical system of diagnosis, we view someone as having a personality disorder or they don't have a personality disorder. Now, this has been the way we've diagnosed personality disorder since the DSM III. Three, which was published in the nineteen eighties. However, over the last twenty to thirty years, we have discovered that this categorical system has some limitations to fully understanding and treating personality disorder. So um one of the um important data points in this regard is that when we take all of the personality disorder symptoms. And I should just explain first that there are in the categorical system.
4:55 Speaker 03 There are ten personality disorder, ten categories of personality disorder. And one of them is, for instance, B P D that you mentioned, borderline personality disorder. Another one is narcissistic personality disorder. A third one is antisocial personality disorder. So there's ten of these personality disorders in the current system of diagnosing personality disorders. When you take all of the symptoms of those ten personality disorders and you put them together into a big factor analysis, you would expect you will get ten factors pushed out by the factor analysis. This is our factor analysis work. If we wanna understand a particular phenomenon,
5:38 Speaker 03 we put the the signs and symptoms of that phenomena into a factor analysis and we get one dimension out that explains that that that phenomenon. In the in the case of personality disorder, we wanna be able to see if they really exist in nature, like the D S M would suggest. We wanna be able to see ten personality disorders come out of the factor analysis. So we want to see the symptoms of B P D hang together to form borderline personality disorder. We wanna see the symptoms of narcissistic personality disorder to hang together to form narcissistic personality disorder. Same with antisocial, same with avoidance, same with histrionic, all of those ten personality disorders. What happens in actual fact when you put all of those symptoms into a factor analysis?
6:22 Speaker 03 It's a big mishmash of dimensions and none of these categories come out very clearly. And so this has been one of the first and most important signs that these categories don't exist in nature as we have always. Always thought they did. In fact, when you do meet criteria for something like BPD, you probably also meet criteria for two or three other personality disorders. When you do meet criteria for BPD, you probably also meet criteria, this makes the picture even more complex, for depression and anxiety and substance use disorder. We are now at a point in our history, in the field, where we have decided to move away from this categorical system of personality disorder diagnosis
7:08 Speaker 03 to what we call a more dimensional system. And so when you open the Diagnostic and Statistical Manual for Mental Disorders, the DSM, the fifth edition was published in two thousand and thirteen, when you open the DSM, you will actually find two parallel systems for diagnosing personality disorder. In section two of the DSM, you will find the old ten categories. BPD will be there, narcissism will be there, antisocial and so forth, they will all be there. But when you page forward, you will find in section three, the alternative model for personality disorder. And this is the dimensional model for personality disorder. And that is where we are moving towards um in the in the future.
7:51 Speaker 03 And I could tell you a little bit more um about what that means and why that is important, that we are moving towards this dimension. But I'll I'll stop there for now and see if you have any follow up questions about just the categories to start with.
8:04 Kim Mills? Well, it's very complex and um it's got to be a challenge then for clinicians who are trying to come up with a diagnosis. I mean, how could you actually say somebody has BPD if it overlaps with so many other things? Or there's a certain number of traits, a kind of formula that says this person has BPD or has a different disorder?
8:24 Speaker 03 Well, at the moment, at present, when we use section two of the DSM, which is what most clinicians still use, clinicians find it relatively straightforward to diagnose someone with BPD in the sense that there are nine criteria. So, you know, those criteria are affective instability, so mood instability, anger, suicidality, emptiness, identity disturbance, abandonment fears, relationship problems, and impulsivity.
8:57 Speaker 03 And so when a clinician meets someone and the person tells them that, you know, they don't know what's going on with them. They have a lot of relationship difficulties. Um, they've been on an NS, uh, you know, uh, SSRI for a long time, doesn't seem to be helping. They've tried all kinds of therapy, doesn't seem to be helping. They still have lots of relationship difficulties. They self harm, they're suicidal. The clinician will start thinking this may be personality disorder because the person is not responding to traditional treatment approaches for depression, anxiety, substance abuse. Usually that tells us that there's something extra going on in the personality functioning domain.
9:40 Speaker 03 And so the clinician can then go through those nine criteria. And if the person meets five or more of those nine borderline criteria, then the person is deemed to be meeting criteria clinical threshold for borderline personality disorder. And that's all fine. Um, and the clinician will then simply do what they do currently, which is diagnose BPD, diagnose depression, anxiety, substance use disorder, which usually hang together. If they explore a different personality disorder, a person may then meet criteria for another personality disorder as well. And all of that information goes into the person's chart. And the clinician has the job to treat all of this co-occurring disorders at the same time.
10:26 Speaker 03 And I think that is okay. That's how we've been functioning for the last thirty years. And we have moderate success with that. Once a person's been diagnosed with BPD, they usually get one of the frontline treatments for BPD, which is either dialectical behaviour therapy, which is most common in the US, or they would get mentalisation based therapy, which is more common in the, in Europe. Um, there are some other treatment approaches too that are evidence based, like transference focused uh, therapy, schema focused therapy. And actually, there's good evidence showing that good old CBT can actually be helpful for people with BPD as well. So there are ways in which we. That's right, cognitive behavioral therapy.
11:12 Speaker 03 So there are ways that we, that this system has worked well enough, but we think we can do better. We think with a new system of diagnosis, we can actually be more precise in diagnosing people with personality disorder more generally. But we can also just make it a little less complex than having this co-occurring mismatch of disorders that each require their own manualized treatment. And so the field has been looking for common factors, common dimensions that is shared by all of the personality pathology so that we can simplify this very complex process that I've so far outlined.
11:56 Kim Mills? So how debilitating is BPD among the constellation of personality disorders?
12:03 Speaker 03 I think it is the most diagnosed personality disorder and that is partly due to the fact that BPD appears to capture something that is common among all of the personality disorders. And I, I do want to talk a little bit about this dimension that I've been mentioning that is shared by all of the personality disorders. So what is this dimensional approach that the field is moving towards that helps us better define personality disorder? So if you, I'm going to go back to factor analysis, which I introduced a little bit earlier as a way of legitimizing disorders, right?
12:45 Speaker 03 And if you actually do factor analyze all of the symptoms of, of personality disorder, what you do get out of that factor analysis in more recent studies is what we call a general factor, a general factor of personality functioning. Now, if your listeners have been hearing about how IQ works in the past, they will know that when we think about IQ, we think about a person with an IQ of a hundred as having average IQ. And we think about a person as having an IQ of a hundred and twenty as above average. And a person with a hundred and forty as superior, right? And we would also think about someone at seventy as someone who is is lower in IQ.
13:29 Speaker 03 So there's a common dimension, a a general factor of intelligence. Now, within that general factor of intelligence, we can think about people that are very good at math but not so good at language. Or people that are very fast at processing speed, but they're not so good at math. So we can think about um specific ways in which people differ on specific aspects of intelligence, even though their average, their general IQ can be at a certain level. The field of personality has moved in that same direction, where we, rather than thinking about the ten categories, we are now thinking about a general personality functioning, a sort of personality quotient, if you will,
14:14 Speaker 03 rather than an intelligence quotient. Rather than IQ, we can think about personality quotient. And what we wanna talk about when we think about your personality functioning is how good are you at managing yourself in the context of interpersonal interactions? How good are you at reading other people's interactions, reading their minds and managing yourself when you are busy interacting with other people? So uh the shorthand version of this is adaptive or maladaptive self and interpersonal functioning. And that appears to be the general factor of personality functioning. How good are we at managing the self in the context of our attachment relationships?
14:59 Speaker 03 How good are we at managing the self in in the context of interpersonal relationships? If you're good at that, then you have a high personality quotient. You're doing pretty good on your personality functioning. If you're poor at that and you get dysregulated really easily, you get defensive really easily. You start compensating in the interpersonal interactions. You get confused about what's in your mind and what's in the mind of other people. You start projecting what's in your mind onto other people. You start blaming people and not owning what's going on for you. Um, rather than taking responsibility for for your contribution to the breakdown in a relationship.
15:40 Speaker 03 When we are in that domain, we are saying you've got low personality quotient. You're not doing so well in the personality functioning domain. And it seems that all that this dimension is the common factor for all personality disorder. Whether you've got B P D or narcissistic personality or antisocial. All people who have problems in personality functioning struggle to manage thems- themselves. To regulate theirself in the context of interpersonal interactions. So to get back to your question, you know, how debilitating is B P D? B P D is debilitating, but I would, I think we we're at a time where we wanna move away from the concept of B P D per se.
16:20 Speaker 03 And just think about the general factor of personality functioning as maladaptive self and interpersonal functioning. And that we all lie on a continuum there. You know, I have good personality days where I'm well regulated and I have bad personality days where I'm not so well regulated. We all can uh identify with that. The question is, do I get over, you know, average on most days? In terms of my ability to regulate myself in the context of interpersonal interactions? And if I do, then I need to seek help because then I probably have problems in the relational domain. That needs a specific kind of treatment um uh in order for it to to get better.
17:02 Kim Mills? Right, right. So if it's interfering with your everyday life, then you should seek some treatment.
17:07 Speaker 03 Yeah, I was gonna just say, if you're struggling at work to get on with people. And if you're struggling in your personal life to get on with people, then you know you're probably someone that struggles with personality functioning and you need to seek help that that from an expert or people that understand personality.
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18:06 Kim Mills? So I wanted to ask a really basic question, which is, what is the meaning of the term borderline in the context of BPD? What's the border between?
18:16 Speaker 03 That's a really good question, and it is a very interesting question as well, because originally when the term was coined by Spitzer, he actually tried to articulate the border between psychosis and neurosis. And this was, you know, 60 years ago, more than 60 years ago. And at that time, we thought about mental illness either as psychotic or neurotic. The neurotic disorders are, you know, the depression, anxiety disorders where there's not a real break with reality occurring. The psychotic disorders are the ones where there is a break with reality occurring, like in schizophrenia.
18:57 Speaker 03 What makes personality pathology so interesting is that it really is neither, it's a little bit more than neuroticism, but a little bit less than psychoticism. So people with BPD or personality pathology, they don't experience a true break with reality. But sometimes they appear a bit psychotic because they seem so fixed and rigid in their view on what's going on. They could almost come across as being a bit delusional in what they think someone else is thinking about them in the absence of any good evidence. And so that has made people... Think this looks like psychosis, but it isn't really psychosis.
19:39 Speaker 03 And it certainly doesn't respond to antipsychotics like schizophrenia. But it's not as mild as neurosis, where there is a good sort of reality testing. Um, and the person can be easily, you know, reasoned with. It's very difficult sometimes with a person, um, with B P D or personality disorder. To reason with them because they get very, very fixed in their view of of reality. And we we call that. In mentalization based therapy, we call that psychic equivalence. What is in my mind is true. And to help them move away from this very fixed idea that the that what's actually in your mind is a representation of reality.
20:22 Speaker 03 It doesn't necessarily map onto reality perfectly. It's a representation of reality. That we can test and explore and uh put to the test to see how true it actually is. So that was what Border originally meant.
20:38 Kim Mills? So one of the areas where you have done some groundbreaking work is around diagnosing B P D. In younger people and adolescents. Can you talk about that? I mean adolescence is a time of stormy emotions, moodiness, confusion. And how could you diagnose a kid as having B P D when, you know, he or she is still going through all of this developmental turmoil?
21:01 Speaker 03 Oh, absolutely. So you you're right. We, up until about ten fifteen years ago. Um, even though it was allowed in the D S M to diagnose B P D in a young person in a person below eighteen years of age. Um, we we rarely did it because there were these myths about personality. And personality functioning in young people. One of the things that we thought was that personality wasn't stable. Until people reached the age of eighteen and you know, when you wake up with your nineteenth uh nineteenth year after your eighteenth birthday. People thought, you know, suddenly you had a stable personality and yesterday you didn't. Of course, that's not true. We we we now know from temperamental research in children.
21:46 Speaker 03 That um actually little babies come into the world with very um. Quite stable patterns of approach and avoidance behaviours. Some babies are smiley, open babies and they like new experiences. And some babies are avoidance babies and they just, you know, need a little bit more from the environment to help them feel calm. And so those are temperamental traits that become personality traits as they begin to interact with the environment. And so these stability coefficients turn out to be as stable in children, adolescents, as they are in adults.
22:22 Speaker 03 So the idea that personality isn't stable in adolescence was pretty much debunked a few years ago already. The other idea that people had was that, you know, there is this normative increase in personality flavoured disorder, you know. All adolescents, like you said, are a bit more emotional, they do get more impulsive, they are a little bit more self-centred, all of them. And that is normative. So how do we know whether a fifteen year old who is impulsive and emotional and egocentric have narcissistic personality disorder or whether they have BPD?
23:05 Speaker 03 And so that was the other, one of the other myths that people had and made them reluctant to diagnose BPD in young people. They thought, well, they'll grow out of it. Turns out that a good proportion of young people who show that normative increase in borderline traits during adolescence do not grow out of it. And so it's still is an important clinical decision to make whether this young person, are they on a trajectory to stay high in terms of borderline traits through adolescence and never really go down again like their peers?
23:44 Speaker 03 Because what the normative increase eventually shows a normative decrease again in borderline traits by about twenty five years of age. Most young people normalise and they don't show this sort of upheaval in terms of emotion dysregulation that they showed when they were fifteen and sixteen. But a proportion of young people get stuck. And so the clinician's job becomes to be able to predict who's going to be stuck and who's not going to be stuck. When I see young people in our clinic. Um. Who's fifteen, who meet criteria for BPD. I usually look at some of the protective factors in order to decide, is this a young person who's going to be stuck? Or is this the young person who is going to show the normative decrease?
24:27 Speaker 03 And so I would say to a parent, you know, your child meets five criteria for BPD right now. But I don't think it's going to stay. Um. Because I can see that the child is getting a lot of scaffolding at home. You're slowing down a lot around emotional content. You're patient with her, you stay with her, you validate her emotions. She's, you're here seeking help from us. That's a good sign. Um. We need to make sure that she has a life, that she continues to do sports and cultural activities so that she continues to feel engaged. Here are all the things that we can do to scaffold the personality consolidation.
25:07 Speaker 03 But sometimes I see a young person that, who doesn't have that um protective factors. And then I would tell the parent, you know, I do think there's some risk here. That she can get stuck and that she can't, she won't sort of get, get um relief from these symptoms as she age out of adolescence. But here's what I think we need to do in order to make sure that she shows the normative decrease that her peers would. So I think that becomes the clinician's decision point, you know, is what other protective factors are in the environment to to help a young person um follow her peers down the normative trend.
25:46 Speaker 03 Um. Versus get stuck um and continue to have this elevation of of borderline traits through through adolescence and young adulthood.
25:54 Kim Mills? So I want to talk a little bit more about parental involvement here. And I'm wondering about the theories around the causes of BPD. So is it, if you happen to be the child of, say, a parent who is borderline? Might you learn those behaviours and begin to exhibit them yourself as a young person, or is it the result of trauma, or do we not even know?
26:19 Speaker 03 You know, I think there is relatively good evidence to suggest a fifty-five percent heritability for BPD and for personality disorder in general. So these traits of impulsivity, of emotion dysregulation, you know, I, most young people who, and people with BPD are described as people who have a sensitive temperament. From the time they were young, they evidenced what we always refer to as thin skin, you know, their feelings are hurt easily, and they feel slighted easily by others. And so I do think there is a temperamental biological component.
27:02 Speaker 03 Marcia Linehan's theory, Marcia Linehan developed dialectical behaviour therapy, which is one of the main therapy approaches for BPD. And Marcia Linehan's theory is called a bio-psychosocial theory for BPD. And she acknowledged that there's a strong biological component to BPD, which I think the data has borne out. But there are plenty of people who come into the world with a sensitive temperament who don't turn out to have BPD. And those are usually folks who have had a caregiving environment where the parents somehow found the patience and the reserve to meet that temperament halfway.
27:46 Speaker 03 You know, there used to be a time when parents were blamed for personality disorder, and I'm so glad we passed that. I still see that sometimes among clinicians, and wherever I go, I try to promote the idea that parents are not to blame for the development of personality disorder, because it's very difficult to parent a child with a highly sensitive temperament. They do ask more of a parent. And, you know, I remember so clearly, one mother once told me. Um, uh, she had a, a young person with B P D and she said, you know, when I asked her to put her shoes away, she would find that invalidating.
28:27 Speaker 03 And so a parent has to work so much harder when they have a child with very, very thin skin, with very, very sensitive temperament, to really slow down. And that's if, if your audience can take away any nugget of truth that I've learned over the years, it's slowing down. So how do you ask a child with a sensitive temperament to put their shoes away? Most parents, including me, will just say, put your shoes away. But if you're aware that you have a child with sensitive temperament, then you are going to have to say, you know, I can see that you're busy with your iPad right now. We're gonna have guests coming over in a few moments. Can I ask you that you put your shoes away?
29:09 Speaker 03 So you can see that took longer, hundred percent longer than can you please put your shoes away? But when you're dealing with a child with a sensitive temperament, you're gonna have to slow down and you're gonna have to build into your schedule, time to create an environment that doesn't feel invalidating to the young person. Uh, of course, with the necessary balance as well. You can't, uh, have a laissez faire environment either where anything goes. Uh, you'll have to just work really hard as a parent to get the balance right between, I'm validating where you might be coming from, but I also have needs as a parent and our environment has needs and rules that need to be followed.
29:53 Speaker 03 But slowing down is the main, um, advice that I have for parents with children with sensitive temperament. The time that you take to slow down in the moment today, you're gonna save hundredfold over, um, in years to come, when you're avoiding, um, inpatient treatment and all the kind of crises that go with a, a, a young person with B P D.
30:16 Kim Mills? Does that same approach work with an adult who has BPD? I mean, let's say you're in a relationship with somebody who has a lot of these characteristics. Do you have to behave in that way in order to accommodate the way that they react?
30:30 Speaker 03 Absolutely, absolutely. So in the therapy approach that I use most often is called mentalization-based therapy. And this slowing down is really what we call the mentalizing stance. And the mentalizing stance is the stance that we take in order to help another person feel understood or validated. If you use DBT language, you would say you make another person feel validated. In MBT language, mentalization-based therapy language, we say we make a person feel understood. And people with BPD have almost an existential feeling of being misunderstood.
31:11 Speaker 03 They feel very alienated, not only from society, from their family members, but also from themselves. They don't feel homey in their own bodies. They don't feel comfortable in their own bodies, and it's a very, very lonely existence. And so what family members can do and therapists for people with BPD is to help them feel understood. And we only help people feel understood when we slow down. And when we put our mind on the table and say, you know, this is a dilemma for me. On the one hand, I feel I want to help you with this. On the other hand, I feel I don't want to interfere with what you're busy with.
31:55 Speaker 03 Where does that leave us? In putting your mind on the table like that, in explaining, rather than jumping to conclusions or taking shortcuts, you instill in the recipient of your communication a feeling of being understood. So absolutely, you're absolutely right, Kim, for both for children, but also for adults in our lives, but also therapists. We slow down. It's the only way to go with people with BPD.
32:23 Kim Mills? Last big question. What are the next areas of critical research for BPD?
32:28 Speaker 03 We absolutely have to move the field to the dimensional system. So we have to get away from the categories. And I hope the next time I speak with you, I don't even talk about BPD anymore. And I talk about personality, personality problems writ large, or personality difficulties, or personality challenges, or maladaptive self and interpersonal functioning, rather than talking about BPD. I think BPD has become so stigmatized. We have so many wrong ideas about BPD and people with BPD that... And to understand that all of us have bad self and interpersonal days. None of us can always be perfect
33:11 Speaker 03 in our management of interpersonal relationships. It's our biggest challenge every day. And yes, people with BPD or with personality disorder will have more occasions when they lose it with people. But we all can relate to that. And to put that on the same dimension and to acknowledge the continuum between typical and atypical personality functioning is where we need to go. So I think there's a lot of empirical research in support of these ideas. What we now need is the treatment research that shows that when we use the dimension to identify people into our randomized controlled trials for personality pathology treatment, we have the same effect as when we categorize people into BPD
33:56 Speaker 03 and we enroll them into our treatment trials. So I think the next big step for us is to do randomized controlled trials with alternative model-defined personality disorder and not the old categories. That's definitely the biggest new challenge for us.
34:13 Kim Mills? Well, Dr. Sharp, this has been really interesting. I appreciate your taking the time to talk to me today and to explain this really complicated disorder. Really, thank you so much.
34:24 Speaker 03 Thank you. It was my pleasure.
34:27 Kim Mills? You can find previous episodes of Speaking of Psychology on our website at www.speakingsofpsychology.org, or on Apple, Stitcher, or wherever you get your podcasts. And if you like what you heard, please leave us a review. If you have comments or ideas for future podcasts, you can email us at [email protected] . Speaking of Psychology is produced by Lee Weinerman. Our sound editor is Chris Kundian. Thank you for listening. The American Psychological Association, I'm Kim Mills.
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