 Hi everyone. Have you ever wondered what is borderline personality disorder? What is the process of getting treatment like and what are some possible coping strategies? Well, that's today's topic for our Ask an Expert series, an interview series where we chat about mental health topics with experts. So think clinicians or those with lived expertise. I'm Monica and I study medicine. I'm really keen to make psychiatry accessible for everyone. So I really like hosting these bi-weekly sessions where we sit down with experts or those with lived expertise to really chat about any mental health topics that you might be interested in. So if you yourself would like to be featured or if you have any feedback or questions, then please consider to check out the contact description box below. And with that, I would love to introduce you to our wonderful guest today, Dr. Ali. Welcome. Hi, it's like to go. What's up? What's up, Monica? How's it going? I'm so happy to get to chat with you today. How are you? I am good. I am good. I am well caffeinated. I feel, I feel ready, excited. Yeah, things are good. Good. So let's just jump right in. I think it'd be great for us all just to get to learn a bit about you and the kind of work that you might do. Sure. Yeah. Well, I'm clinical psychologist by training. My area of focus has been anxiety disorders and anxiety related disorders. So social anxiety, panic, OCD, all that sort of stuff. In grad school, I studied hair pulling disorder, skin picking disorder and those types of body focus repetitive behavior problems. And then on my postdoc is when I started doing a lot of work with borderline personality disorder and I got trained in a treatment. Well, I'm sure we're going to talk about, which is dialectical behavior therapy. And I just really, this became one of my favorite things to work with for a wide variety of reasons. So that's me. I did that for a long time at Columbia University. I was an assistant professor there. And I've been working much more in the media space for the past few years. I've got a YouTube channel, The Psych Show, where I try to make psychology fun and easy to understand. So we definitely share that mission, Monica, not only with yourself but with Psych2Go and the whole community here. And I just want, I want to make this knowledge, this information, everything I have learned through my professional work, my personal life when it comes to mental health. I want to make this stuff really fun, really easy to understand. I want to share it with everyone because mental health information can be so hard to access and understand and all that sort of stuff. And I think it should be, it should be freely, readily, easily available. So that's who I am. Thank you so much for sharing. I absolutely agree. I feel like there's so much information out there sometimes be so difficult to understand what is fact and what exactly is fiction. So I thought it might be just great to jump right in and to talk about what are the signs and symptoms of BPD. Yeah, it's, I'm really glad you wanted to tackle this topic because borderline personality disorder is there's a lot of myths around it. And those myths continued to exist in the professional healthcare world for a very long time. We thought that this was a very extremely rare problem and, you know, a little over 1%, about 1.4% of the United States population experiences borderline personality disorder. But we used to think it was much more rare than that. And it was highly stigmatized people who had this disorder were thought of being as really emotional that they really overreact and that they, they were seen as being very manipulative that they manipulate relationships to their benefit. And there was a lot of, a lot of Hollywood depictions of this type of problem that really weren't, weren't that great that perpetuated a lot of these stereotypes that people would get really manipulative when they thought their relationship was going to come to an end and they'll do whatever it takes to kind of keep it going. And then there is a wonderful person named Marsha Linehan who herself was struggling with this problem and she was very, very much experiencing some of the symptoms we're going to talk about. She was chronically suicidal. She tried to get a lot of help. This is back in the 70s. And while she had access to a lot of the best healthcare at the time, the best mental healthcare at the time, none of it was working. And so she basically decided I am going to go get a doctorate myself and I'm going to create a better treatment for this. And a lot of what we know about borderline personality disorder, what it really is comes from a lot of the work that Dr. Linehan has done and the treatment that she's developed. What we do know about it is there's these core problem areas. And I should say it's a personality disorder. Personality disorders, how they're different from other things like I talked about, I've treated a lot of anxiety and anxiety related problems. Those tend to be either more focused in what the problem is. So for example, if you're someone who has social anxiety disorder, it's a problem that exists in very specific types of situations, social situations where you feel like you're being judged or evaluated. Or maybe you might be experiencing depression and it's only gone on for a certain period of time. Personality disorders are different because they tend to be a bit more broader in what, in how they impact you, they impact many areas of your life, and they also persist for a long time. You have that in other things like depression can persist for a long time, social anxiety can persist for a long time, there's bipolar disorder, yes, there's all that sort of stuff. But personality disorders in general, very broad, they continue for a long time. And we also tend not to diagnose them until you're an adult. So even though some of the symptoms I'm about to talk about, they can exist if you're a teenager. People are very hesitant to make any type of diagnosis and we're really not supposed to until you're older because we need to see a long period of time that you've been experiencing this. Before I go into symptoms, let me check in Monica, I was just talking like I feel like forever. Great information here. I just wanted to pick on one of the points that you said kind of about diagnosing in adulthood rather than in adolescence. Is this just for borderline personality disorder or kind of personality disorders in general? Personality disorders in general, and there's a few different reasons for that. One, we know that your brain is it's still developing until your mid 20s. I think around 25 is when your frontal lobe is finished developing a lot of your values and your sense of self are still developing to long into your 20s. And the big personality stuff, it's not totally solidified when you're a kid, when you're a teenager. So anytime we're looking at any of the personality disorders, there's narcissistic personality disorder, there is obsessive compulsive personality disorder, OCPD, which is different than OCD obsessive compulsive disorder. Those kind of things, any of the personality disorders, we don't want to make that diagnosis until someone is more developed as the person they're going to be. But that's a really good question. Okay, wonderful. I think that's good for now. I'm following, I'm following. If anyone else is having questions as well, just put in the chat. I'm also following those and I'll kind of flag any ones that I think are especially relevant for the community. Yeah, so the main problem areas of borderline personality disorder, the first one is something called identity confusion. And people who have borderline personality disorder struggle to understand who they are and how it's different from other people. And this can get really confusing in relationships. Sometimes you might feel a certain way in one relationship, and if that relationship is coming to an end, you might not really know, well, who am I if I'm no longer with this person. Sometimes it can be hard to know kind of where your identity ends and someone else's begins. Your identity can change and shift a lot over time. And so that's one of the main problem areas. The next major problem area is related to impulsivity and impulsivity. I don't really like that it sounds so technical and harsh, but basically what it means is sometimes it's really hard for you to put on the brakes. So if you are experiencing an emotion or a thought, it's very easy for you to act on it, and it's very hard for you to put the brakes on it. And we can see this in a few different ways with borderline personality disorder. One of the ways is with anger. And this is something that particularly happens with a lot of people who identify more as masculine or male. So you might get angry and then you quickly react to that, maybe you throw something, maybe you break something, stuff like that. With people who identify more feminine, more as a woman, we see it act differently. It tends to be more about self-injury or about self-injury, which might mean cutting yourself, burning yourself, things like that. But in pulsivity, it doesn't have to be about aggression or about hurting yourself. It can also be about you have this thought about, like, I really should say this to that person and then you send that text without really thinking about it. And maybe it causes problems later on. So doing things really quickly without sort of thinking about them. This is something that some other disorders share. ADHD is another one where impulsivity is common. Here, with ADHD, it's more like thoughts enter your head and you might say those things. You might do some of those things. It's hard to control your body. Here, it's more with borderline personality disorder. You're kind of emotional. You have this thought. You kind of react to it. So that's the impulsivity piece. And then related to that is your emotions can feel like they're going up and down. And it's hard to sort of make them feel more mellow, make them feel more in the middle. One of my supervisors described it as people who have borderline personality disorder. Their emotions quickly charge up and they're very slow to come down. It just takes a lot longer to feel more kind of in the middle and to feel more like yourself, which contributes to that identity confusion. It contributes to the impulsivity. All these problem areas sort of impact each other. And because of all of this stuff, you see a lot of problems with relationships with your friends, with your family, with romantic relationships. It can feel like there's a lot of conflict with the people you're close to in your life. Friendships can feel like they come. They're really intense. They're really close. And then they just sort of end and it feels like a complete disaster. A lot of young people who have some of these problems, they might experience a lot of conflict with their family. It just really seems like your family doesn't get it. And so all of these things sort of impact each other. And then when we have borderline personality disorder, someone has all of these problems. They've had all these problems for a long period of time. And it's really making it difficult to live their lives. We might see people being chronically suicidal because of borderline personality disorder. We might see them developing other problems too, like depression or anxiety-based problems. It's these core areas, that identity, confusion, impulsivity, difficulty, managing your emotions, and then a lot of relationship conflicts. And do we often see this being comorbid with other disorders? You mentioned it briefly, but I'm quite curious, like, which ones in particular? It can be so many, Monica. I think depression is very common. Substance use is also a lot of common. That's not how we talk. Substance use is also very common. And I think those things can make sense, because if you keep experiencing a lot of the same types of problems, that can be very depressing. And also if your emotions kind of feel like this, it makes sense that you might use substances to try to help you out with that. So those two things can come a lot. I've also seen a lot of anxiety-based problems with this. I've seen people who struggle with panic disorder. I've seen people who struggle with separation anxiety, because of this, a lot of different problems can develop as a result of this. Okay, so just to summarize, it's like identity confusion, impulsivity, just difficulty performing like emotional regulation activities, just general kind of emotional turbulence almost, and this can present in problems with relationships. So let's say that someone kind of... You said it better than me. I just kind of tried to put all the information together. And let's say there's someone who kind of gets a sense that that's what they're experiencing. They're not quite sure if they've got the disorder. What are their next steps? What could they be looking to do? Yeah, that's a good question. And I should say to some degree, these things that I just described are also pretty common with just being a teenager. So if you look at developmentally what's expected when you're in your teenage and adolescent years, you're going to have some identity confusion. You're probably going to try out a lot of different identities. Your family is probably going to say you're really emotional and you're really impulsive and you're probably experiencing a lot of conflict with your friends, with your maybe trying out different relationships, you're experiencing conflict there. So to some degree, these things are totally expected. But if you're wondering if you have this what to do, there's a few different screening tools online that you can try out. There's a lot of great... This is also coming from Marcia Linehan's, her whole group, and everyone else who's really now focused on this problem. But there's different things you can sort of fill out to get a sense of, do I have borderline personality disorder? The best thing to do is to go talk to a mental health expert because what they're able to do is they're able to separate out what is common and expected and just a normal part of growing up versus something that is now a problem. And the way we define a problem, the way we separate out what's normal and what is less common, less normal, is if it's really getting in the way of your life, if it's really causing you a lot of problems in your life. Because when you have borderline personality disorder, it makes it hard to be in the workplace. It makes it hard to be in school. It makes it hard to sustain relationships. It produces a lot of conflicts in your family and around the people that are close to you. And a mental health professional is going to be the best person to be able to figure out how much of this is expected and how much of this is not really expected. That's good. Yeah, it's definitely good to be able to know and to be able to speak to a professional about this because I often see there's a lot of kind of self-diagnosis which is not very helpful. So, yeah, GPs could be a good first step as well. Though I do know that sometimes it could be very difficult to access primary health care providers and mental health care providers. Yeah, I think this is something that I often talk about is 50% of people who are struggling with their mental health in some way, they're going to probably talk about it with their general practitioner, with a doctor that they trust, that they see regularly. I think that is always a really great place to get started and they might be able to answer some of your questions or at least point you towards the right person. The self-diagnosis thing, I did it myself all throughout grad school in my first few years practicing. I think how can you not, right? Because you hear these things, you're like, wait, wait, wait, I struggle with this. But you don't really have the context of seeing what this is like when it is in a clinically impairing way. What does it look like? And the reality is every mental health problem, including things like schizophrenia, they all exist on a spectrum. If you're at home late at night, there's a rainstorm lightning outside, your power goes out and you hear a sound in your mind. You might start imagining something that isn't quite there. We all do that. It happens a lot in different situations. Well, now you might be experiencing more of a mental illness. Everything in mental health is on a spectrum. It's very easy to see ourselves in these problems. But a professional is really the one who can figure out, is this to be expected or is this actually getting in the way of your life? This is creating some real problems for you. Let's talk about the best way to get treatment for this. Yeah, I definitely remember in class, there's often that talk about having it be a spectrum rather than it be kind of a yes and no. You have BPD or you don't have BPD. And I know that leaves us tons of possible limitations and chats down a different direction. But yeah, definitely just good. I think if someone is expecting some sort of distress, it's just good to talk to a GP or talk to a mental health professional because it's always good to just know what's happening. Yeah, it's funny you mentioned that, Monica, because one of the common problems with borderline personality disorder is people, when they get really emotional, they see things as all good or all bad or they see things as yes or no. They see things in these absolute categories. So a big part of the treatment for borderline personality disorder is to help people see more of the spectrum and to see kind of the wisdom in how both things can both be true and it doesn't have to be all this or all that. Yes, you mentioned treatments. Just briefly, should we go into more depth about what kind of treatments are available? What help might look like for someone experiencing BPD? Yeah, yeah, I'd love to. I love talking about treatment for borderline personality disorder because a lot of the stuff that we do for borderline personality disorder, I think it could help everyone. There are a lot of really great things to come out of this that I think are just helpful for everyone to know. So for a long time, there wasn't really any treatments that were very effective for borderline personality disorder and now the most studied treatment. There's a few different ones that are effective but the most studied one, the one that you're probably going to hear all the time is something called dialectical behavior therapy. That's a treatment that was originally developed by Dr. Marshall Linehan. It's been, there's just really great research around it. What it means, it's in the family of cognitive behavioral treatments. Cognitive behavioral treatments, what they do is they really help you to learn new ways of approaching your thoughts, of changing your environment, of developing skills to improve the way you're acting in different situations to make it easier to overcome some of these problems. That's kind of broadly how I define CBT. CBT is one of those treatments and the way Dr. Linehan did it is so she defined, okay, what are the core problems of borderline personality disorder? We got those all defined. What are things that help you with those problems? So with BPD, we've got identity confusion and one of the core skill I would say of DBT is, oh man, we could get lost in these acronyms, BPD, DPD. So one of the main problems of borderline personality disorders, identity confusion, one of the main treatments of dialectical behavior therapy is mindfulness. Mindfulness, it's super popular right now. A lot of people think it's about like meditation and being Zen and all of that sort of stuff. Really simply, mindfulness, it's not about feeling better, but it's about feeling more. It's sort of like the pause button that helps you to better understand what's happening around you, what's happening inside of you and to be able to sit with that without reacting, without judging. That's how I like to think of mindfulness. And so mindfulness is a skill to help with identity confusion. Impulsivity, reacting to things without really, with the difficulty pressing the brakes, what helps with that? DBT has a huge skill set called distress tolerance. These are things that help you, like I said before, your emotions get really active really quickly. Distress tolerance skills help them to bring them down to a level so that it's easier to sit with them so they're less overwhelming. So you don't feel that urge to act on them. Difficulty regulating, managing your emotions. DBT has a skill set related to emotion regulation. I think about distress tolerance as stuff you do in the moment to help you feel less intensity, whereas emotion regulation, these are skills that you do right now to kind of set you up for success in the future. So for example, a distress tolerance skill might be like going out for an exercise. My heart is racing, I'm so mad, so I'm going to go for a run. That's distress tolerance. Making sure I get a good night of sleep is emotion regulation because that sets me up for a better day tomorrow. And then there are a whole set of skills related to interpersonal effectiveness to help you deal with all the relationship problems that you might run into. So for example, a lot of people with borderline personality disorder, they have a hard time saying no to someone. So there's a skill called Dear Man, which is all about assertiveness and how do you clearly say no or clearly express your needs. It's a super straightforward treatment, but it's also a lot to learn and there's a lot to do in there. My favorite part about DBT is if you're so lucky to find a full DBT program that does all of this stuff, the coolest part of it is phone coaching. So when you're in an emotional crisis, when your emotions are all revved up, you can actually pick up your phone, call your therapist, or you can text your therapist and they'll get back to you and they'll help coach you through how to use these skills in the moment. And that's where the magic of DBT really, really happens. Another big part of DBT, there's a lot of tracking, a lot of monitoring, a lot of learning how the stuff inside of you is impacting the people around you. Wow, that was a lot of good information. I think it's really nice how it tackles each specific component of BPD. So one for identity confusion, one for kind of managing emotions, one for impulsivities, it's really great to tackle all that. And I'm sure they all kind of work in tandem and they all require the help of a professional. And given that I know professional help is sometimes inaccessible for many people in general, actually. Do you have any thoughts on what someone could do, like even now, what they can do to kind of get started and find a way to cope with BPD? Yeah, I think learning a lot about what the problem is and that's a great starting point. Because I think a lot of people might feel a lot of shame around this and that's common with a lot of mental health problems. Shame is a big problem to overcome to actually getting help. I think it's very common with BPD because there's such a history of ignorance and stigma and misinformation about it even in the healthcare community. And it's only a few decades ago that we really started to define what this problem is. So because of that, anything that you can do to better understand it, I think is going to really go a long way to feeling like, okay, this is just like one thing that I'm experiencing. And I always tell people it's not your fault that you are experiencing this problem. BPD is usually caused by a biological component. Some people just have a stronger emotional temperament. They're just born that way. They're just born with a volume on their emotions turned up. And then maybe they've gone through, they've had some difficult childhood experiences. The more trauma and adverse experiences you have as a kid, whether it's a traumatic thing you went through or a lot of stressful things you went through, maybe you moved around a lot, your parents separated, you had the loss of a parent. So many things can happen. But the more difficult you had as a child, the more difficult it is for you to regulate your emotions. And then people who have that temperament, they've gone through difficult things. They tend to have a bad fit between their family and how their family is interacting to their emotions. So this is not your fault. This is not your fault at all. It is. This is the dialectic here. The D in DBT is dialectic. We understand things in relation to each other and how things are related to each other. It's not your fault. And at the same time, it is your problem. It is something you have to learn about. You have to learn how to overcome all of that stuff. So I'd say anything you can do to understand it better is a really good starting point. And one of my favorite DBT skills is something called chain analysis. Monica, have you ever heard this term before? I've heard it. I think I was reading the DSM, then going down to rabbit hole. I'm not quite sure the details. I'd love to hear from you. I love a good old DSM rabbit hole. Yeah. What I was doing to prep for this, exactly. It's so helpful actually. I feel like it's literally like a Bible of everything I need to know or the starting point of everything I need to know. And then I have to do more Googling. I feel like that's the most psych to go thing that you could possibly be doing is going through a DSM rabbit hole. I love it. So the chain analysis is so, it's such a useful skill. So basically what happens is something's happened in your life. You're not happy about it. Maybe your friend said something. You emotionally reacted back. They said something had escalated and now you said like, I don't want to talk to you. I hate you. You know, you sent them these nasty texts. All that sort of, you're at home. You're crying about it. You're angry about it. And it's still kind of festering the next day. This is a great time to do a chain analysis where a chain analysis is, it's like a bunch of bubbles like chains connected on a piece of paper. And you kind of write down, okay, what's the problem that happened? Problem is that I yelled and said nasty things to my friend. And then you kind of go back and what happened right before that? What happened right before that? What happened right before that? What were you thinking? What were you feeling? What were you doing? And you try to go back to the beginning of the day, the day before, all that sort of stuff. And what we usually find is, okay, you yelled at your friend, but you were also right before that. Maybe you saw your friend hanging out with someone that you're not that close to and you kind of felt really alienated from them. And that whole day you weren't feeling that well, probably because you woke up late, you didn't have your breakfast, you didn't sleep that well. So the whole morning you were not set up to have a good day. And you can go even further back than that as well if you want. And then we kind of identify, there's so many things that probably contributed to this blow up that happened between you and your friend. And so now we got all the chains in order. Then we do a solution analysis. Okay, where might be one place where we could intervene? Where's one place where we could have done a different skill? It was probably not right before you blew up at your friend. It was probably too late then. But maybe we could have started with the morning. Maybe if we do something different with the morning, you're going to have a different afternoon. And what I like about chain analysis, when you kind of lay everything out, it makes so much sense. Like, oh, this is why I did that thing. It's not because I'm like a horrible person. It's because I was really having a bad day and there was a lot of reasons why I was having a bad day. So I love doing chain analysis and they just help you to understand yourself better and they also help you to feel like it's, like you're not a horrible person, but there's reasons behind this stuff. It's probably my favorite DBT skill. So it's really breaking things down and trying to analyze things and making sense of them because once someone's able to kind of identify and understand the motivation behind these behaviors, then they can better apply the techniques to hopefully not repeat the same situation again. Totally, totally. And once you have an understanding of that, then you're better positioned to do some of the other skills that you learn in DBT. DBT is, it's, there's so many metaphors in it, that like is a lot of times we get, I was trying to talking about how people with borderline personality disorder they get all good, all bad, all yes, all no, all black, all white, all that kind of stuff. And one of those, one of those things is getting all emotional or all analytical and a chain analysis, it's really useful when you're very emotional to kind of pull you back into a place where you're kind of thinking about it in a more straightforward way. DBT would call that being in a wise mind. Wise mind is the integration of emotion and sort of logic or rationale and kind of combining the two together. You said it really well. Like once you understand how this came to be, then you're better positioned for the future of approaching it differently. So any other resources that you'd like to think, like to point the community towards for the readings, I feel like there's so much. There's so much. There's so, there's so much. There's a ton of DBT workbooks out there that I think are a really good resource where you can learn some of these skills. But my favorite psych to go, I know you guys have, you all have the most beautiful, amazing animations. I'm always very jealous of your videos for having these really clear cut, simple, easy to understand videos. I love it. What would be a good resource for you all? So I want to recommend Rock Steady. I might even have it here in my, oh no, I don't, do I have, okay. Hey, Monica, check it out. Wonderful. This book I love. It's Rock Steady, Brilliant Advice for My Bipolar Life by Ellen Forney. Now I know it says bipolar life, but basically what this book is, it's sort of like a, it's a graphic novel, how to, of DBT skills. It's awesome. And it's the sequel to a book this, this author wrote called Marbles, which is I think the best depiction of bipolar depression. But she did such an amazing job putting DBT skills together in a book. If you're only looking for like one quick, easy to understand thing, this has most of the, the biggest DBT skills in it, even though it doesn't say borderline personality disorder. So I would pick up Ellen Forney's Rock Steady. I think it's a great resource. And then there are so many, there's so many DBT skills out there. There's so many things you can learn. Let me just kind of mention my favorites really quick. So there's a ton of stuff on mindfulness you can kind of learn about yourself. A lot of great resources on YouTube. My favorite emotion regulation skills. There's the tip skill, which is about temperature, intensity. Is it pressure? I don't know. But there's some like basic things you can do like progressive muscle relaxation, slow breathing, intense physical exercise. And then the dive reflex, really quickly bring your emotions down. I would learn some of those skills. Those are the easiest skills to do when it comes to DBT. And then I mentioned it before, but the Dear Man skill is probably one of the best interpersonal skills about how to assert yourself, what to say. So you're not taking advantage of so that you say no when you want to say no, and that you can get the help that you need when you need it. And that's something you can benefit from and everyone can learn. Thank you so much. And I just wanted to share as well for the Psych2Go community members. I absolutely love your channel. I mean, Dr. Lee, I've followed you for a while and to be able to do this interview is really like a big honor. So thank you so much. The feelings mutual. It's amazing. So yeah, I've left a link down in the description box below for any questions. And then check out Dr. Lee's channel. He's got new videos. Well, tomorrow, is that it? Yeah, I'm dropping. I'm dropping a react video to a YouTube channel that was trying to over. People were trying to overcome their fears doing these like stunts. So I got a reaction video to that. And then my last two videos were on social anxiety. And then next week I've got one of my friends. Yeah, great. So I'm really grateful for the chat today. We've definitely covered a lot from what is BPD to treatment, some coping strategies and some wonderful resources you suggested. So thank you very much. Thanks for having me and thanks for having this conversation. Yeah, thank you so much. And to the Psych2Goers, if you have any other comments or any sort of things you'd like to do in the next episode. Thank you. Bye. Bye, everyone.