Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners.
This episode covers the diagnosis of borderline personality disorder with expert guests:
Dr. Robert Biskin, Associate Professor in the Department of Psychiatry at McGill University, psychiatrist at the Borderline Personality Disorder Clinic at the McGill University Health Centre, as well as inpatient psychiatrist at the Jewish General Hospital.
Dr. Ronald Fraser, Associate Professor in the Department of Psychiatry at McGill University, Adjunct Professor at Dalhousie University, head of the Inpatient Detoxification Services and Addictions Unit, as well as director of the Extended Care Borderline Personality Disorder Clinic at the McGill University Health Centre.
By the end of this episode, you should be able to…
List the DSM-5 diagnostic criteria of borderline personality disorder.
Recall the epidemiology of borderline personality disorder.
Consider the risk factors and posited causal mechanisms for borderline personality disorder, including developmental and neurobiological mechanisms.
Discuss the clinical presentation of borderline personality in different clinical settings, including the Emergency and Outpatient settings.
Recognize the differential diagnoses for patients presenting with borderline personality disorder.
List the common comorbid psychiatric and general medical conditions with borderline personality disorder.
Discuss the common diagnostic challenges and pitfalls.
Explore the stigma surrounding the diagnosis of borderline personality disorder, and discuss a therapeutic approach to providing psychoeducation to patients with this diagnosis.
Guests: Dr. Robert Biskin and Dr. Ronald Fraser.
Hosts: Dr. Sarah Hanafi (PGY3), Dr. Nima Nahiddi (PGY3), Audrey Le (CC4).
Audio editing by Audrey Le.
Show notes by Dr. Nima Nahiddi.
Interview Content:
Introduction – 0:00
Learning objectives – 2:03
DSM-5 definition of personality disorder, and borderline personality disorder (BPD) – 3:00
Other associated features of BPD – 4:36
Distinguishing BPD from other psychiatric and co-morbid conditions – 5:55
Epidemiology of BPD – 13:48
BPD over the lifecycle – 18:05
Explanatory models for the development of BPD – 21:20
Differences in the presentation of BPD – 26:00
Approach to a BPD diagnosis in the emergency department – 31:05
Stigma surrounding BPD diagnosis and disclosure of diagnosis – 33:51
Clinical pearls for screening of BPD – 41:11
Evidenced based screening tools or scales for BPD diagnosis – 46:22
Closing – 48:40
Resources:
Articles: Diagnosing borderline personality disorder | CMAJ
References:
Biskin, R.S., Paris, J. (2012). Diagnosing borderline personality disorder. CMAJ. 184 (16), 1789-1794.
Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R., & Chauncey, D. L. (1989). The revised Diagnostic Interview for Borderlines: Discriminating BPD from other Axis II disorders. Journal of Personality Disorders, 3(1), 10–18.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.
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PsychEd+Episode+32+-+Diagnosing+Borderline+Personality+Disoder+with+Dr.+Robert+Biskin+and+Dr.+Roland+Fraser.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Dr. Hanafi:
Welcome to PsychEd, the Psychiatry Podcast for Medical Learners by Medical Learners. In this episode, we'll explore a topic that I'm certain will be of interest to many of you. Borderline Personality disorder or BPD. In the first part of this episode will touch on diagnosing borderline personality disorder and in part two will review treatment. I'm Sarah Hanafi, a PGY 3 at McGill University, and I'm joined by Nima Nahiddi (PGY3), a fellow PGY 3 McGill.
Nima:
Hi, I'm Nima.
Dr. Hanafi:
We're also joined by Audrey Le, a fourth year medical student at McGill. Everyone, we're very grateful today to have our guests, Dr. Robert Biskin and Dr. Ronald Fraser, to share their expertise. Dr. Biskin, why don't you introduce yourself?
Dr. Biskin:
Hello. My name is Rob Biskin. I'm a psychiatrist. I work mostly at the Jewish General Hospital, as well as at the McGill University Health Centre. I'm an associate professor at McGill, and I work mostly in personality disorders, as well as the general inpatient setting.
Dr. Hanafi:
And Dr. Fraser, why don't you introduce yourself to our listeners?
Dr. Fraser:
Thank you for the kind of invitation. I'm Ronald Fraser. I'm also a psychiatrist like my colleague, Dr. Biskin. I split my time, half time work as an addiction psychiatrist, running the withdrawal management unit at the Montreal General Hospital. And the other half of my time is leading a team that treats severe and persistent treatment resistant borderline personality disorder. And I'm an associate professor here at McGill and adjunct professor at Dalhousie University in Halifax.
Dr. Hanafi:
During today's episode will touch on several learning objectives. One list the DSM five diagnostic criteria of Borderline personality disorder or BPD, two recall the epidemiology of BPD, Three Consider the risk factors and posited causal mechanisms for BPD, including developmental and neurobiological mechanisms. Four discuss the clinical presentation of BPD in different clinical settings, including the emergency and outpatient settings. Five Recognize the differential diagnoses for patients presenting with BPD. Six, List the common comorbid psychiatric and general medical conditions with BPD. Seven, Discuss the common diagnostic challenges and pitfalls. And finally. Eight, Explore the stigma surrounding the diagnosis of BPD and discuss a therapeutic approach to providing psychoeducation to patients with this diagnosis. Now let's get started.
Dr. Le:
Before we dive into things. I thought it may be helpful for our listeners if we first defined what a personality disorder is per DSM five or the Diagnostic Statisticians Manual. A personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture and is inflexible and pervasive across a range of social situations. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders. Now, in the DSM five, Borderline Personality disorder specifically is described with nine diagnostic criteria, of which at least five must be met to make the diagnosis. These criteria include frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, identity disturbance, including a persistently unstable self image, impulsivity, and two or more areas such as spending, substance use and sex, recurrent suicidal behaviour, gestures, threats or self mutilating behaviours, affective instability, chronic feelings of emptiness, inappropriate and intense anger, and finally transient stress related paranoid ideation or severe dissociative symptoms. So with that, I think it would be helpful for our listeners to understand whether in practice there are other associated features that are typically found. Maybe, Dr. Biskin, if you could speak to this.
Dr. Biskin:
Sure. The DSM obviously gives a good presentation of the main symptoms. And we have a lot of research that's developed over the years to kind of that really gives a clear picture that it is a unitary construct, BPD and all the symptoms really kind of go together. But one of the things that it really doesn't capture adequately is to some extent the the just negative affective states how unwell people with BPD often feel. So if you look in the appendix of the DSM five, you'll see that they include an alternate model for personality disorders. And one of the nice features about that alternate model that's not captured in the current model that we use now is to some extent the amount of just angst, anxious mood, depressed mood and those sorts of components that are just really prevalent for people with BPD, they just feel unpleasantly bad a great deal of the time. There are moments when they feel better, but I think that those dysphoric states are really one of the associated features that's not fully captured.
Dr. Hanafi:
So I think that one thing that many learners, including myself, struggle with, is trying to distinguish BPD from other conditions, such as primary mood disorders, post-traumatic stress disorder, or other personality disorders. Could you perhaps share with our listeners how you approach making this diagnosis and how you differentiate between BPD and other conditions with overlapping features?
Dr. Fraser:
So maybe I'll tackle that one. It's an excellent question, Audrey, And it's not just about differentiating it from other conditions, but also trying to determine what, if any, co-morbidities they may have. And it's not unusual for people to have comorbid conditions. So. So, for instance, you might see somebody in the emergency room and either withdrawing from substances or intoxicated on substances, and their presentation may resemble a great deal of personality disorder. But you have to try and tease out and determine, is that a state feature of of either the withdrawal or the intoxication or is it a trait? And it's a more persistent thing. So it can be difficult to tease out all these things. And that's where it's really important to try to resist looking at things. Cross sectional, see what's happening in the moment and try to have, if at all possible, a more longitudinal perspective. And that can be certainly easier said than done in many instances. If it's the first time you've ever met an individual or assessed an individual. But if you've had the opportunity to follow people over time, often that will certainly clarify itself. Oftentimes what I see people for the first time, I may have a lot of uncertainty as to what the exact diagnosis is. Human beings are fairly complex systems and creatures. Sometimes collateral history can be tremendously informative if that's available. But often what you want to try to do is get from the patient themselves sort of what's happening in the here and now, but also try and contextualize that by having a sense as to the more longitudinal history, which often sort of goes back to adolescence and getting a sense as to are these isolated issues or have these been really quite longstanding. And I think that can be tremendously helpful because many of the symptomatology can be somewhat non-specific. So, for example, if you look, the DSM five doesn't actually have complex PTSD as a formal diagnosis. But if you look at the proposed criteria for complex PTSD, it's pretty much the same criteria as borderline personality disorder. It's problematic when you have two conditions with the exact same criteria. So it can be really difficult to determine how you're going to conceptualize something. But I think if you take a careful history, if you have some humility about the fact that you may not have all the answers in the here and now and work collaboratively with the patient to try and tease out what is going on. And often my experience has been if you review the diagnostic criteria of borderline personality with an individual, a lot of it will often profoundly resonate with them and be in fact extremely validating. And they'll say, Wow, you know, is my picture in there or something to that effect? And sometimes they're right, and sometimes it may resonate with them, and it still may in fact not be the correct diagnosis. So you have to be prudent about that. But I think those is sort of the general approach as to how we try to tease these things out.
Dr. Biskin:
If I can, I would just add to what Dr. Fraser says, that I completely agree with his points and working on an inpatient unit. One of the things that that I'll often see is that when you take that cross sectional approach, you'll often see patients that look like they have a lot of symptoms of personality disorders, be it narcissism, borderline personality disorder, antisocial. And just based on that cross sectional presentation, you might be misconstruing a manic episode or a psychotic episode. Sometimes people have worked with people who have very severe depressive episodes and they look quite dependent. But again, that longitudinal history and kind of exploring how people change over time really with those symptoms that go back to adolescence is is really very crucial. I would also add that there's a few little tidbits that are sometimes a bit helpful in distinguishing some of the disorders. So, for example, sometimes I would find that people with bipolar disorder, they often report a lot of. Manic episodes. There's a great deal of elation for people with BPD. It's tends to be less likely. Elation does occur, but it's not as present. It's not present for as long. And when the mood shifts happen, that is characteristic for both disorders. The mood shifts in BPD tend to alternate between a lot of sadness, anxiety, anger. Again, much more of those dysphoric states in terms of, I guess, even some of the elements of PTSD, the chronicity and the timeline of the symptoms is something that's quite important as well. And it becomes much more this is true for all personality disorders, that it's global across multiple domains. So having symptoms with just one particular type of situation or one particular environment is less likely to be associated with a personality disorder, whereas people with personality disorders do have problems in many areas of their life that cause them difficulty. So that chronicity and the kind of global nature disorders, this is one thing that I find distinguishes it from some other disorders.
Dr. Fraser:
Sort of to to add on that. One of the things you noticed, particularly in my line of work in addiction psychiatry, is you'll see somebody that meets all the diagnostic criteria for personality disorder. But if you treat the underlying condition effectively, the the other psychiatric conditions, suddenly those features will all disappear. So you may have somebody who has a severe opioid use disorder who engaged in all sorts of anti-social behaviours because they have a four or $500 a day habit. You put them on methadone or Suboxone or some appropriate treatment for their opioid use disorder, and they no longer have to support that habit and all those antisocial behaviours go away. And then there's other individuals, you treat them with methadone and they continue to engage in all those antisocial behaviours. And so that can really be essential in trying to determine what you're observing and whether it's an underlying personality disorder that requires treatment or this other condition. If it's effectively treated, then those other features effectively resolve.
Dr. Hanafi:
Thank you for both of your very thorough answers regarding my question. My next question was, you know, who typically suffers from this disorder? Or in other words, what is the typical epidemiology of BPD?
Dr. Biskin:
So typically the epidemiology for BPD, it's common. It's about 1 to 2% of the population. And there is some variation between different parts of the world. So certain areas, for example, East Asia might have a slightly lower rates than certain parts of Europe and North America. But in general, North America, it is about 1 to 2% of the population, North America and most of Europe. It despite what we see in clinical practice, where in general women present for treatment more frequently than men in the population, the prevalence is approximately equal. And in terms of other aspects of life, socioeconomic status and things like that. People with BPD, it's across the spectrum. So anybody can have BPD.
Dr. Fraser:
I think it's to touch on the point that Dr. Biskin had. The vast majority of patients that we see are women. And to some extent, that's because depending on gender, these patients tend to have different trajectories. So female patients with BPD often are in the health care system, male patients with BPD who may have the exact same behaviours or struggles often end up in the legal system. And often the women are in hospital and the men are in prison. A given behaviour society reacts very differently based on what your gender happens to be. It's also important to realise the vast majority of people with BPD we never see. So if it's 1%, let's say it's 1% of the population. That means in Montreal there are 30,000 people with borderline personality disorder. We see a tiny fraction of that. So basically it has the same prevalence as as individuals with schizophrenia. And certainly we we don't see anywhere near those sorts of numbers. So the vast majority of people don't seek treatment. And I don't know about Dr. Baskin's experience, but my experience is unfortunately, the clinical population that we treat. Does not represent the diversity of the city. So we're not seeing the sort of diversity of different cultures and ethnicities that we would anticipate when we look at the demographics of a city like Montreal. And I think that is worrisome. And that's something that where we need to make greater inroads.
Dr. Biskin:
I don't have I don't have the numbers to say exactly about the diversity in terms of the clinical population that we see. But I can say that there is a fair degree of diversity, probably not fully representing the the the full diversity accurately of the city. But I would say that there is a fair degree of diversity. One other thing that I would probably add as well is that BPD, although it is occurs across all ethnicities and socioeconomic backgrounds, it is more likely because of family history and genetic risk to be more commonly associated with people in lower socioeconomic statuses as well. And it is quite likely that people with BPD or it is known that people with BPD do tend to have kind of that same downward drift that we see with other psychiatric disorders that they tend to have more difficulty with occupational functioning, be more likely to require financial assistance and things like that. But yes, I'll completely agree with Dr. Fraser that more inroads with communities is always a good thing.
Dr. Hanafi:
Going further with that. How would you say the epidemiology evolves over a patient's life span? Or in other words, how does it change as they age?
Dr. Fraser:
So maybe I'll tackle that one first. So. In general. This is a disorder that has a relatively good prognosis in that it tends to improve with age, which is not necessarily the case for the vast majority of DSM five diagnoses. So it tends to have onset in adolescence or early adulthood. Many people seem to begin to develop the disorder around puberty, and as you age, many of the symptoms actually diminish and improve. And often by the time you're sort of in your thirties, you often no longer meet the diagnostic criteria. Now, the problem can be, however, you may not meet the diagnostic criteria, but you may still have residual symptoms that are subthreshold but still contribute to quite significant disability. Also, something that's problematic for many of my patients that no longer meet the criteria during the more acute phase of their illness, when they are much more symptomatic, often as a result of a variety of things. They've burnt many social bridges and are often unfortunately estranged from either their children or their extended family, have really have significant academic sequelae and have not been able to complete their educations. They've had significant occupational consequences. And so there can be significant disability even with remission. The other good news is, though, once you remit, you tend not to relapse. So it tends to be quite consistent. Once your symptomology has improved, it tends to stay improved.
Dr. Biskin:
I have very little to add. I completely agree with Dr. Fraser, of course, again. And just to provide some numbers to that. If you look at like 20 year data sets of longitudinal follow ups, over 95% of people will have periods of remission from the diagnosis where they don't meet criteria anymore. But again, as pointed out, the functional problems remain notable and only about 60 or well, frame it positively, 60% of people do have good functioning. When you look at follow up 20 years later, so that's more than half. But there's still a large amount of people who do have functional problems. And trying to find ways to continue helping those people and improving their functioning is, in my opinion, a very important area for treatment.
Dr. Hanafi:
I guess looking more at early in life, what are some explanatory models for why someone develops borderline personality disorder?
Dr. Biskin:
So there's a lot of different models, and it's a difficult question to answer because to some extent the models for the development of BPD depend on your theoretical framework for treatment of BPD. Given that I am more comfortable with dialectical behaviour therapy, I'll give the answer for how BPD develops. So the idea behind how BPD develops is that people are born with a genetic risk for emotional instability or liability. What Linehan would call affective dysregulation so that as a child you might be a bit more difficult to sue, you might be more likely to cry as a baby and. Be more unpredictable in your response. Now, normally parents would be able to adjust or caregivers would be able to adjust and provide a bit more support and reassurance and security in the situation where there is a combination of a child who's difficult to soothe and the parent figures who aren't, who don't have the capacity to provide that support and soothing to help the child learn to manage their emotions. The parents might respond by. Saying that the emotion is not okay, the emotion is not appropriate. In other words, they'll say you're not really sad to the baby or it's not to the child. It's not a big deal what you experience. Don't worry about it. Just keep going. Push through or that often will take much more serious forms where the child would be neglected and completely ignored. They're having emotional difficulties. They could be responded to with physical abuse. If the child is crying too much, they might be hit and this would lead to the child learning that their emotional states are not worth listening to. They're not valid, they're not appropriate. And as the child continues to grow up within the same environment, the emotions continue to be present because there is that genetic risk or genetic component of the unstable emotions. But they they learn that they have to use whatever tools are available to them to help them control how they're feeling. And because the feelings are very intense, you often have to use very intense tools to cope with it. And this is what often leads to some of the impulsive behaviours, like using a lot of substances or alcohol or using very intense emotional tools like self harm, which are meant to kind of often use to help people feel or focus on their feelings or numb their feelings. So a lot of these behaviours arise as a way to control the emotions and this subsequently furthers that sense of invalidation that the patient has that my feelings are not worth listening to. My feelings are not valid. I have to do everything I can to make them go away. So that is often the pattern from a DBT perspective that leads to the development of BPD. To add a little bit more to it, there are neurobiological models or neurobiological findings that are associated with BPD that lends some support to the emotional dysregulation component. So the usual genetic findings of the long arm or the serotonin transporter gene, which is associated with almost every psychiatric disorder, it's also associated with BPD. Certain studies have found dopamine receptor associated or specific subtypes of dopamine receptors associated with impulsivity and BPD. And there's also findings on your imaging that suggest a heightened amygdala activity which might be interpreted as a stronger emotional response or threat response. So certain biological findings, although there's obviously no very consistent single pathway and as mentioned before, a lot of the different psychotherapies have different etiological models for the development of BPD. So for example, mentalization based therapy has a similar style, but uses a language that comes from attachment theory, which basically says that the way that the parents react to the child is often unpredictable. So the child doesn't learn how to predict the responses of the caregiver. And this has a whole series of sequelae for the child as well. So again, there's like a dozen or 20 or so different models for treatment of BPD, and each has their own variation on the similar theme that emphasizes intense emotions and impulsivity, often as core, but not always.
Nima:
Thank you so much for that answer, Dr. Biskin. Going back to something Dr. Fraser had said about how different people may be presenting to the health care system, I was wondering whether there are different presentations for BPD, for example. Have you noticed differences in presentation when people come to the emergency department or whether they may be on the inpatient setting?
Dr. Fraser:
Maybe I'll tell a story. I like to tell stories what I'm famous for. So when I came on staff, I had a number of jobs. One was working with the short term, borderline percentage sort of program led by Dr. Paris was international expert that both Dr. Biskin and I have had the fortune of learning from. And my other job was working in the mood disorder clinic. And each Monday we would have mood disorder assessments with the medical students and the residents. And the first ten weeks, you know, ten assessments and nine of them. Came with the same picture treatment resistant depression. They had failed like 12 different trials of different antidepressants. And you can imagine how discouraging that is as a patient where you've tried X number of medications, none of which have had any real, sustained, significant benefit. As Dr. Biskin mentioned earlier, you're still suffering tremendously. You know, you're not comfortable in your own skin, You're dysphoric, you're anxious, you're distressed. Nothing seems to help even though you're reaching out for help. And nine of the ten all had borderline personality disorder that had that had not been recognized, had it not been diagnosed and it not been treated, and they were all being treated for disorders that they did not in fact have and understandably weren't having great results. It's a little bit like, you know, you go in with appendicitis to the emergency room and all the emergency room physician offers you ventolin puffer, you know, you're not going to have a great outcome. So I think that things are better. But oftentimes you're seeing people by the time they get to us still, when you look at their trajectory through the health care system, they've often been diagnosed with a wide variety of different things, failed a wide variety of treatments from very well intended health care professionals. But it's very discouraging for patients and for their families. It's a bit of a marathon, and that's why it's often so validating for them when you go through the criteria with them and they say, Oh my gosh, and they feel understood, you know, for often the first time in their health care trajectory. So that's certainly one of the ways that you see people is in a variety of outpatient clinics. The emergency room is is another place where you see people I think when you're seeing people in the emergency room, you know, if you're seeing me as a patient in the emergency room, I guarantee you you're not seeing me at my best. So I think it's important to remember that when you're seeing anyone in the emergency room, they're they're struggling, they're in crisis. They're not presenting their best foot forward and it's not representative of who they are. 24/7. And you need to contextualize that. So pass it over to Dr. Biskin as well.
Dr. Biskin:
I completely agree with that point. And I think that's one of the the advantages that Dr. Fraser and I have working in a clinic for people with BPD is that we get to see these patients on a regular basis over a longer period of time because many people will present for treatment when they're in by presenting to the emergency room for suicidality or self-harm, and they might not get immediately directed to treatment, which can be quite frustrating. As Dr. Fraser pointed out, it takes an average of about six or so years until people receive a diagnosis of BPD despite symptoms starting earlier. But when we're in providing therapy and treatment for these people, we're able to see them in a different context, which is often a much more, much more stable and easier or much more enjoyable experience to work with these people in a treatment context where we're able to provide a treatment that's designed for them, designed for their disorder and able to help. Because the bias that we might have just relying on people, the presentations in the emergency room is quite striking. So when we see people in treatment, it's a much more positive thing.
Nima:
Both of you have spoken about the necessity. For that longitudinal. Approach. When we speak of borderline. Personality disorder and when we're interviewing patients. As a learner. I see a variety of different practices where some psychiatrists feel that BPD diagnoses cannot be made in the emergency Department when patients. Are in crisis. What do you think about that type of approach? Do you believe that the emergency department is an adequate place to make the diagnosis?
Dr. Fraser:
Well, to take it even one step further, some of my colleagues don't even believe borderline personality disorder is a valid diagnosis, period. So there's. There's some controversy about these things, which is a bit remarkable because it's fairly validated diagnosis. But anyways, I think I think you have to be cautious. Particularly if you're seeing someone in the emergency room for the first time. If you're seeing someone in the emergency room for the 10th time, then you would have ten assessments. And so you have a little bit more context. I think often when we see people in crisis in the emergency room, we many, many people simply defer the diagnosis of what used to be called access to. I think there's also problems with that. I think ideally, if this is in your differential and if you are thinking that this is one possibility, I think it's important to put it as a rule out, right, that it's on your differential that you may not have enough evidence, you may not have as much clinical confidence in the diagnosis as you might ideally want to have, but it's somewhere on your range of clinical suspicions. And I think it's important to reflect that in your consultation. So you may not be able and it may not be prudent to make a definitive diagnosis, but I think it should be mentioned somewhere that, you know, at this point in time, these are the criteria that they meet in this cross-sectional, and we may not be able to comment on whether that is an acute situation or if it's an exacerbation of a more chronic situation, which would be more suggestive that they, in fact, do have the condition.
Dr. Hanafi:
Maybe it's a good time to to touch on the topic of stigma and a misunderstanding surrounding this disorder. You talked about making the diagnosis. Why is it important to disclose this diagnosis to patients? And any practical tips on how to do it effectively and compassionately?
Dr. Biskin:
I would like to just go back for a second because I want to expand on Dr. Fraser's comment. I have a slightly different perspective on it, and I'm much more comfortable making the diagnosis of BPD in the emergency room, assuming that the patient is able to provide adequate history or there's sufficient collateral that I'm able to trust. The real shift, in my opinion, comes in making sure that you're changing and adapting the questions to really get accurate information about the longitudinal history and not just the cross sectional. If you are able to get that accurate history, I think that your diagnosis from an emergency room setting, again, assuming good information is just as accurate as it would be for most other diagnoses. And I guess to touch on your point about stigma. The thought that comes to my mind is that we often assume that when we're making a diagnosis of BPD, it has to be a very firm, stable diagnosis, whereas we often are in the emergency room and will make diagnoses of psychosis and or psychosis unspecified, often for first episode psychosis patients to where we're not making a firm diagnosis about whether they have schizophrenia, bipolar induced or bipolar with a psychotic mania with psychosis. And assuming that we have to have a very, very firm convincing, absolutely correct diagnosis for BPD, whereas we don't require that same level of certainty for other diagnoses. I think that's part of the stigma that is inherent about BPD, that people are much more reluctant to make. The diagnosis of BPD, which is associated with poorer outcomes for our patients, is one of the reasons why it takes so long for patients to receive care for diagnosis of BPD. So I think that in general we should be cautious about any diagnosis that's made in an emergency room, whatever the diagnosis might be. But we should make those diagnoses if the symptoms are consistent with that. I forget the other part of your question.
Dr. Hanafi:
So the other part was just how do you approach it effectively and compassionately when you're speaking with a patient about the diagnosis?
Dr. Biskin:
As Dr. Fraser mentioned, emphasising that the diagnosis of BPD, although it is stigmatised within society. One of the things that most people don't realise, and this includes many health care providers, is that the prognosis is quite good actually. So I will often encourage people not to look on Google, not to look on YouTube because a lot of the images associated with BPD are again based on that cross sectional image of what people imagine, kind of like the worst case scenario would be like. Whereas the reality is much more complicated and there's a lot more fluctuations that you're able to see. And and people are not just identified by one specific difficult moment. So I think providing a lot of information, providing a lot of information that people don't choose this disorder, they don't choose to have the problems that they have. But it developed out of a reason or developed for a reason. And it's often meant internally to kind of cope with the intense, unpleasant experiences they have. And this is the best that they can do, because again, a lot of the difficulties are ways to avoid the one remaining alternative, which is often suicide. So people I often frame it that people are trying everything they can to keep themselves alive and to make their lives as bearable as possible.
Dr. Fraser:
I think the other issue that comes from your point is clinicians, typically, because of the systemic stigmatisation of these patients, have a hesitancy to disclose the diagnosis because there's this either conscious or unconscious fear that there's going to be a bad reaction because the system views the these patients as problematic, troublesome, undesirable. So there's this systemic. The stigmatisation that gets internalised by the clinician that the patient is oblivious of. Like they they have no idea. At this point in their career. Unfortunately, they may become very aware of it moving forward as they have more contact with the health care system. But so we have this fear that they're going to react badly because we're telling them something that's really bad news and it's that internalised systemic stigmatisation. You know, I've had the opportunity to disclose the diagnosis to hundreds of patients, and most people are really relieved to finally have an answer. That makes sense. And their families are relieved to finally have an answer that makes sense. I can only actually think of one person to react badly. And she said Borderline. So you're telling me I barely have a personality? No, no, that's not what I'm communicating here. I didn't do a good job. Let me try again. So. For the most part, it's very well received because these patients have been suffering. For often years looking for answers that make sense, often for years. And finally, you've given them something. So that actually gives them hope. And one of the earlier parts of your question is why is it important to disclose the diagnosis? Because what often happens with teams is teams make the diagnosis, but they never tell the patient. And that's sort of the epitome of internalised stigmatisation. It's important to disclose the diagnosis because that diagnosis informs treatment. So we're not going to continue. To give you a pharmacotherapy for conditions that you don't have. And we're going to try our damnedest to connect you with an evidence based treatment that's demonstrated effectiveness for treating your condition. And, you know, when I started my career, that was not the situation. Right. And when I started my career, these patients were viewed largely as untreatable. And the change. In the clinical circumstances, you know, even in the last 20 years. It's remarkable. We have something to offer people. And when I was a resident, we didn't have that.
Nima:
Thank you for speaking on the piece of internalised stigma. I think it's very important and refreshing to hear, and it's also nice to hear as a learner that there's hope for our patients and there's something that we can do. Do you have any tips or clinical pearls for clinicians who would like to screen for borderline personality disorder?
Dr. Biskin:
I think in terms of the the comments, the tips that I would say really is that emphasis on longitudinal symptoms and don't get stuck with the cross sectional and don't get stuck with just necessarily what's going on right in this moment, but taking that chance to kind of understand the person's life. Where where are they not functioning? Where are they having problems with their emotions, their impulsivity, etc.? One of the other interesting things I've always been particularly interested in the symptom of emptiness in BPD, and I always find it fascinating how people with BPD with that particular symptom, you'll ask people, Are you empty? And that term will resonate with them very clearly. You ask somebody what it means or what it's like for them to experience emptiness and you'll get a whole variety of different answers. But the term that specific word is just so consistent. And if somebody doesn't understand that word when they say, Oh, what do you mean by emptiness? Is there anything else like it? You just move right on to the next question. They definitely do not have that criteria. And anecdotally, I'd say that the chances of them having BPD go down quite a bit at that point. A couple other tips that I would say is looking at how long the symptoms and the problems have been present. And when you ask people, when do they start having difficulties in their life. The earlier the problem started, the more likely it is to be BPD so or any personality disorder. Two weeks ago, very unlikely if it was since they were like early adolescent or childhood, then the chances are much, much higher. Those would be a little bit of the suggestions I would make.
Dr. Fraser:
Yeah, I would agree with all of that, and particularly emptiness is is one of the most unique diagnostic criteria for BPD that is not very commonly seen in other conditions. Maybe a couple other personality disorders, but it's really unlike, like, impulsivity. Are you impulsive? That's like spectacularly non-specific. Almost everything in DSM five can have impulsivity as a feature. I don't do this in the emergency room because you sort of have to focus on the crisis and what brought them here. And if you don't, people get upset about that. But when I'm just doing a general assessment, seeing somebody for the first time and they're not in crisis. I often start with the personal history before anything else. And this. This is helpful for a couple of things. So I'm finding out the longitudinal history without them necessarily being aware. I'm looking at the longitudinal history and I'm going to be able to learn a lot about their childhood, their adolescence, their relationships within their family, within peers. I'm going to get that developmental history. So it's super useful for me clinically, but it's also, in my experience, very helpful therapeutically because you give you give the patient the correct impression that you're interested in them as something more than a collection of symptomatology, because eventually I am going to get to sort of a checklist of symptomatology. But by doing that personal, developmental, social history at the outset, you get that context right at the get go and it helps you have a better sense as to when you do get to the FBI and what's been happening more recently. It gives you some some contextualisation of where that fits into the larger picture. And I really do think it helps with the therapeutic alliance. It's not so effective in the emergency room. However, people tend to get frustrated with you because they want to get right to the chase and that's okay.
Dr. Biskin:
Sorry, just to go back, I do need to add, even though I made that comment about emptiness from a very technical perspective, it's not the most reliable or useful diagnostic criteria. It is that the positive predictive value is a little low. If you want to be specific in terms of which criteria is the most useful to screen for, it varies by study that you look at, but the one that's probably the most useful is to look at the chaotic interpersonal relationships in multiple domains. And this kind of touches on the point that Dr. Fraser made about kind of getting that longitudinal history of their relationships. And to kind of add to that one other thing that I particularly find interesting to understand for patients is how they spend their time. Like, what does a typical day look like for them? This is more useful when initiating therapy, but it's it's quite fascinating to some extent how how people spend their time and how much of their time can be consumed by the challenges that they're experiencing or how how much empty time there might be for them to fill.
Nima:
Thank you for those clinical pearls. I'm sure they'll be very useful. Lastly, I'm wondering if there are any evidence based screening tools or skills that you know of or use that could help learners who would like to diagnose BPD.
Dr. Biskin:
I guess I'll answer this one. There's a number of self-report questionnaires that can be used, and depending on which expert you will ask, you'll get different opinions about which ones are the most useful. So one of the ones that I am fond of is called the Borderline Personality Questionnaire. It's a bunch of yes, no questions about 70 or 80. So it's not the fastest questionnaire, but it gives you a with good psychometric properties, it gives you a good chance to make an accurate diagnosis. Obviously, you'll still need an interview. One of the shorter ones is the McClean's, the MSI-BPD. The McClean screening instrument for Borderline Personality disorder, which is nine items that basically takes the DSM questionnaire or the DSM and puts it into questionnaire form, which has okay psychometric properties, but it's much shorter than 70 something questions. One of the tools that we use a lot and sadly seems to have fallen out of favour in the research literature is the diagnostic interview for borderlines where the DIB-Ab are revised version, which is now about 30 years old or so, 25 years old, I think. And it is a semi-structured interview that can take typically about an hour or so to do it. That really covers a wide range of symptomatology. And when you're using the the this diagnostic interview for borderlines, it will kind of select for a more homogenous group of people who have problems, not the standard five out of nine, which creates a rather diverse group of presentations, but you're going to end up with a more homogenous group of people who have a greater degree of symptomatology. But it's good if you want to get very accurate diagnoses. Having said that, most of those are used for research, clinical research and in clinical practice I rely primarily on the interview. The other ones are sometimes used for symptom tracking with so-so data about whether or not they're useful for that.
Dr. Fraser:
I just talked to people.
Dr. Hanafi:
Well, thank you so much, Dr. Biskin and Dr. Fraser, for joining us today. I think we can speak on behalf of all of our listeners that we're very grateful to have had this opportunity. And I think we learned a lot about an important topic in psychiatry. We're looking forward to speaking with you again for part two. So listeners, please stay tuned for the next episode on the management of BPD. Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi, and Audry Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live Music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Roland Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org, Thank you so much for listening.
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