November 5, 2024 • 31 mins
In our second episode of the Borderline Personality Disorder (BPD) series, we discuss how this condition manifests in relationships and clinical practice. We explore the pervasive patterns of instability, fear of abandonment, and the role of attachment theory in understanding BPD, while also touching on psychosis and dissociation. Our conversation highlights the challenges faced by individuals with BPD in their relationships and the dynamics that arise in therapeutic settings. We further emphasize the importance of understanding the multifaceted nature of BPD and the need for compassionate approaches in treatment.
Chapters
00:00 Borderline DSM Symptoms Overview 04:09 First Signs and Symptoms in Treatment 07:45 Fear of Abandonment and Its Impact 09:56 Attachment Theory and BPD 16:58 Fear of Abandonment and the Dynamics of Therapy 24:39 Episodes of Psychosis and Dissociation in BPD 30:43 Conclusion
Book Referenced:
- 1984 Borderline Book- John Gunderson, M.D.: https://www.amazon.com/Borderline-Personality-Disorder-John-Gunderson/dp/0880480203
Other Resources:
- BPD: https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
- BPD: https://www.nami.org/learn-more/mental-health-conditions/borderline-personality-disorder
- BPD: https://www.borderlinepersonalitydisorder.org/
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Welcome to the Personality Couch Podcast, where we discuss all things personality andclinical practice.
I'm your host, Doc Bok, and I am here with my co-host, Doc Fish.
We are both licensed clinical psychologists in private practice.
And today we will be continuing our series on borderline personality disorder and what itlooks like in relationships and in
(00:29):
clinical practice.
So let's get right to it.
Last week, we brought in the DSM definition of BPD, which then we broke down into kind offour main chunks.
But When talking about personality pathology, we first have to look at is this a pervasivepattern?
(00:54):
Has this been going on for a while?
Is this more than just someone's bad day
or a bad season?
But this has been present sometimes even as early as childhood you can see the beginningsigns and then adolescence.
And definitely by early adulthood and it's persistent.
So it's across multiple contexts.
(01:17):
With BPD also comes significant impulsivity as well, which is one of the main pieces ofBPD.
And then the criteria in the DSM actually break that down further about what impulsivitylooks like.
And then the four things that we summarize, Instability.
(01:39):
So in sense of self, unstable moods, especially intense anger or rage, unstablerelationships.
The second part is fear of abandonment.
Third part, self-harm or suicidal threats
or behaviors, and then impulsivity shows up again.
(02:00):
And we also talked about the movement.
This isn't just a static categorical description.
There's movement back and forth.
And with that, we sometimes see more of the out of touch with reality symptoms.
So sometimes psychotic symptoms, sometimes dissociation or out of body experiences andphenomenon, sometimes paranoia,
(02:26):
all of that.
But we also talked about The three different contexts for instability, right?
So the self, relationships, and mood.
Unstable sense of self, right?
We have that empty spot inside, just like this constant feeling that we're bad.
And that can be kind of even look like taking other people's identities on in order toconnect with them, in order to like fill that empty spot, to try to
(02:54):
to maintain or develop a sense of self.
The unstable relationships, right?
We talked about idealization versus devaluation.
In other words, like, I love you, I hate you.
It's a push-pull.
Quick attachment, but then also super quick distancing if scared or threatened.
Then we have the unstable mood, the mood swings that can occur within hours, never rarelymore than a few days.
(03:20):
There's often a baseline though of like the
the depressed mood, the low mood, but that'll be disrupted by really intense emotions suchas panic, despair, anger.
Anger's not an unhealthy emotion in itself, right?
But we're talking about developmentally inappropriate anger, right?
(03:41):
Like really intense anger that's difficult to control that can be outward, like outbursts,but it can also be kind of directed towards the self.
Right?
Confirming, I'm bad, I'm bad.
And it can result in treating yourself meanly, really, in thoughts.
(04:02):
Could be in actions as well.
But it results in depression.
I'm curious, what do you feel like of these different characteristics that we've talkedabout so far, What do you feel like comes up in treatment the most often?
That is, that's a hard question.
(04:24):
I think I'm have to go with the unstable relationships because I think that is whatprompts treatment.
There's so much distress there.
It's work relationships.
It's gonna be affecting your job, right?
It's often a significant other.
It can be parents, it can be friends.
(04:45):
It can be an array of all, but I think that is really
what I see the most is that unstable relationships.
That is so interesting.
I didn't expect you to say that, actually.
I thought you were going to say impulsivity.
Yeah.
But I can see that because that the unstable relationships really is often the catalystfor people to come to treatment, especially with BPD.
(05:15):
But relationships in general, relationship problems, conflict
can often lead the person to seek out treatment.
And with BPD, then the person coming in, you know, may have really unique issues aroundthose relationships, often kind of the ups and downs, the volatile.
(05:37):
You can almost see the push pool in the relationships that they're describing.
So that makes sense.
That makes sense.
I think the first thing that came to mind for me was in
In psychological testing, it's often a little different.
think what presents first in the data for me is probably the empty spot, the unstablesense of self.
(06:02):
Yeah, when they are explaining their story, we're going through what's called the socialhistory.
So asking about their, their mood, how long that's been going on for.
their medical history, family history, trauma history, educational history.
(06:22):
In all those different questions that we ask, we're piecing together a narrative.
And sometimes I can start to see, you know, in the descriptions of things that there'snot, perhaps not a stable sense of self, or to your point, in those descriptions of
relationships, you can see the push-pull.
(06:45):
By the time that we actually get the data, I can start to see there is really, really lowself-esteem.
There appears to be an empty spot that either the person is running from or trying tofill, but it becomes pretty apparent when looking at all the different domains of
(07:05):
functioning like we do in our deep dive evaluations that we do in our private practice.
It becomes pretty clear.
Okay, we need to look at potential borderline because of that empty spot.
That makes a lot of sense, especially even just the difference between testing and therapytoo, right?
(07:27):
Testing is the deep dive and you get the whole, well, attempt to get the whole picture atonce, right?
It's like a snapshot.
Therapy is a long-term process of working through layers, like peeling back the onion.
I wonder, so...
We talk about relationships, but how does that tie into fear of fear of abandonment?
(07:49):
So now we're getting into some of the things that we didn't get to talk about last time.
But fear of abandonment is pretty hard to miss once we know what we're looking for.
There may be clues that come up relationally where if there's even the hint of leaving,
(08:12):
the individual has a huge reaction.
So not even just the act of leaving, but the possibility of leaving.
So an example might be an accidental pocket dial.
That can become a personal affront because, you didn't actually want to talk.
(08:35):
So do you really love me?
There's that fear.
Like, it is so easily triggered.
by the most sometimes benign things, sometimes not so benign, like pushing on a bruise insome regard.
Another, I guess, more overt example is a partner walking out the door, right?
(08:56):
Maybe they're walking out the door after a major conflict.
Maybe there was a heated argument about something and the partner just needs to take abreak, get their thoughts, cool their head, cool their heads prevail.
They walk out the door to go for a drive or to go get some, I don't know, burger and friesor something.
my goodness.
(09:17):
An individual with BPD may feel really threatened when that person leaves.
The feeling of this person leaving even just for a timeout in the middle of conflict feelslike they are never coming back.
And if they're never coming back, where does that leave me?
(09:39):
because I am intertwined with this person.
Who am I outside of this relationship and outside of this person?
And as I'm talking about that, this is a bit of a tangent, but it reminds me of what welearned kind of early on with attachment theory and the concept of object permanence.
(10:02):
You can see it in object relations theory, is psychodynamic.
thinking to like develop mentally with like developmental psychology in children orinfants.
I think the easiest way I like to explain Object permanence is at some point, infants, ifyou have a toy right in front of them, you put it away, like put it behind your back.
(10:25):
They don't know it exists.
right?
It's either there or it doesn't exist.
They either see it or it is not anything.
Eventually,
a child is able to understand and remember that, the toy exists even though I don't seeit.
(10:47):
So if we translate that and we put that on attachments, or relationships, when this personleaves, the relationship doesn't exist.
That's pretty powerful, right?
So if that's not developed, right?
If it is developed, it's OK.
(11:07):
I know the relationship exists, even though that person's going out the door after afight.
There's a timeout.
We need to cool down.
It'll be OK.
They'll come back.
The lack of object permanence is like, they leave.
They're not going to come back.
They're never going to come back.
(11:28):
Who am I?
What do I do?
All of those emotions is
probably not the first time that somebody has left and actually not come back.
So that bruise that you were talking about, that is painful.
I love how you brought up object permanence.
like that.
Yeah.
Yeah.
I was just thinking about it as we were discussing this fear of abandonment.
(11:51):
And it makes sense when we think about just child development or just human development,that there's a skill that we
learn or a milestone, I don't really know quite the right word for that.
That seems to somehow be lacking in individuals with BPD or it's deficient.
(12:13):
Maybe I should say it's deficient.
if we're going into attachment theory, the Inconsistent attachment to a primary attachmentfigure, right?
So like, as a kiddo, you need mom, mom comes sometimes.
But other times she doesn't, right?
So you never know what you're gonna get.
(12:33):
So even if you know in your head that that person might be coming back, it may not evenfeel like it because like, is this the time that they're gonna come back or is this the
time they're not gonna, they're not going to, right?
Are they gonna meet my needs or are they not?
So this fear of abandonment oftentimes has its roots in early attachment.
(12:55):
Research tells us that there is a genetic loading
for personality disorders.
So most likely there's something close in the genetic line and how someone perhapsattaches to their child can then in turn affect how that child attaches to other people.
(13:18):
So there can be kind of a ripple effect when there's dysfunction in personality ordysfunction in attachment.
So it can also look a little less overt.
So I've also seen this fear come up, perhaps people that are more reserved, keep more tothemselves.
(13:42):
Perhaps they don't want to share anything or certain parts of themselves for fear that itwill lead to abandonment.
So for example, I am not going to open
up that closet with those skeletons, because I don't want you to leave.
(14:03):
And then when those skeletons come out, and then a loved one or partner finds out, andit's like, well, why didn't you tell me?
Or once things start surfacing, it can really impact the relationship lead to sometimeseven a blow up, because parts were concealed because of that fear.
(14:24):
But then it's a self fulfilling prophecy where
It actually leads to distrust and perhaps the person actually leaving because trust hadbeen eroded.
Right.
And I wonder if it's not even just information, but also like parts of yourself.
Right.
So I'm not going to act in this way that is natural to me because I don't want them toleave.
(14:50):
I'm going to try to be absolutely the best that I can.
Right.
But we're human.
I think that overlaps with like unstable sense of self too, right?
Like you try to fit in a picture of what is wanted so you can keep somebody.
That makes sense.
It's like there's this ever shifting sense of self and a presence of, what do you want meto be?
(15:14):
Right, exactly.
Okay, I'll be this.
I'm a shape shifter.
Okay, I'll be this.
Okay, I'll be really involved in these activities.
I'll dress this way.
I'll do this for you.
to keep the attachment while the core pieces of who you are, your interests, your likesare kept under wraps because to actually reveal that would mean the loss of a
(15:37):
relationship.
Separation in general, any separation, that's going to be a threat to abandonment orelicited fear of abandonment, right?
So I was thinking even like trips.
For example, like a work trip.
So a significant other goes on a work trip.
There's fear of abandonment, right?
(15:58):
Yeah.
Let's see, like at a really unhealthy level, right?
Maybe the person with BPD, you know, gets drunk, puts themselves in unsafe situations,calls the significant other, right, to save them so that they come home, right?
There's like a save me, save me, save me.
(16:19):
Like, need to come back, I need you.
But it could also look not so dramatic, perhaps, right?
Just like separation anxiety, right?
If your significant other goes on a work trip, you make it like pouty, right?
Like, I don't really want you to go, but like, I guess you have to, right?
(16:41):
They could be overly communicative.
So like they're on their work trip and they're texting every five minutes.
Right.
And that might look more like instead of like a save me, like love me, love me, right.
Love me, love me, love me.
Come back.
I think clinically too, in the context of trips, when the therapist takes time off,there's an attachment break.
(17:10):
Is my therapist going to come back?
Why did my therapist leave?
probably more common, I would think in more severe cases of BPD, though maybe not.
Maybe it comes up in different ways, but that, you know, it could be bit of poutiness orattitude towards perhaps your treatment provider who's taking some time off or has to go
(17:39):
on medical leave, whatever it is, all the way across the continuum to
some pretty significant drama to try to keep perhaps even the therapist staying and notleaving.
(17:59):
So that's such a good example.
I was thinking, you were talking about that, right?
That it can sometimes be even like unconscious, right?
So provider takes time off.
All of a sudden the next week, client forgets they have an appointment, even thoughthey've never forgot before.
(18:23):
And literally, they literally forgot.
So it can be an unconscious thing.
It's not necessarily malicious, still data.
Or it could even be a punishment of the provider.
Like, how dare you leave me?
I'm not going to show up.
And it could end up never showing up again.
(18:43):
So I'm going to leave you before you leave me.
Right.
Or I'm going to do to you what you did to me.
Exactly.
Exactly.
Because I'm mad.
It could also be redirected towards the self, right?
We talk about anger, that anger can be outward or inward.
All of a sudden, we're engaging in impulsive, regressive behaviors.
We're hurting ourselves because we must be so bad because therapist doesn't love us enoughto never take time off.
(19:11):
So regressive is just like a backslide.
It can be a backslide of behavior, emotions, and development.
Maybe a simple example, if you're having a bad day and you're really tired and somethinglike really makes you irritated, right?
That little child temper tantrum you might have, right?
(19:33):
That could be a regression.
We all regress.
But usually it doesn't, we don't maintain it.
Got it.
So perhaps in therapy, the progress that you've made in treatment can sometimes benegated.
or there's some backsliding that happens.
(19:54):
I think this is also where borderline particularly has or can have a bit of a bad rap intherapy for reasons like this, unfortunately.
And because it is a lot, that is a lot to manage as a treatment provider who has, youknow, typically a whole caseload of other people that they're helping as well.
(20:20):
And it's normal to need time off.
That's part of being human, is needing to take a break from the work that we do.
But when there's pools, or when time off gets muddied with perhaps drama, or unhealthy, orlike you said, regressive behavior, as perhaps a pool to come back, don't leave, rescue
(20:47):
me, see I'm hurting myself.
You should care enough.
I'm pooling.
That is a lot.
That is a lot to manage for any relationship, any relationship, whether it's a loved oneor a professional.
This, like I said, this is where I think borderline can get kind of a bad, unfortunately,a bad rap because of the pool.
(21:15):
and the toll it can take interpersonally, even with professionals who are trying to workthrough this with the patient.
I guess this is maybe a good time to say, spoiler alert, therapists are humans too.
Like we do feel for the people that we see, and we can very much get pulled into dynamicsthat involve personality.
(21:39):
Absolutely.
It takes.
practice and study and awareness to be able to unhook.
Yeah.
And I want to also say that this isn't every case with borderline.
every single person with this condition is going to test the limits of the therapeuticrelationship to that degree that time off becomes a big drama.
(22:07):
However it can and it has, it's definitely happened to me.
think probably most therapists have received some type of pool in their career from somepersonality dynamic, whether they realize that's what it is or not.
All personality disorders create drama and there can be pools.
(22:32):
certainly when you are sitting in that therapist chair,
You are getting fooled.
I thinking, so I was even reading this book, this is 1984.
Okay, so that's right after the criteria was developed for borderline in the DSM.
And it states that the history, some of the history behind that are individuals that werein inpatient, like in a hospital that weren't responding.
(23:04):
to treatment that usually works for psychotic individuals.
Makes sense because it's borderline, right?
We don't stay in psychosis.
There's that movement.
It specifically states about all of the pulls from the staff.
They didn't want the staff to leave them, right?
So upon discharge or the threat of discharge, all of a sudden they got worse.
(23:28):
But if they weren't getting better, whose fault is that?
Right?
Not theirs.
And this is an inpatient setting, right?
So I think that speaks to your point.
This is not every person, right?
There's a whole severity.
But I think that even perhaps the history of this diagnosis is where the stigma started.
(23:49):
That's really unfortunate because really what is happening is like, we don't understandit.
We still don't, but we definitely didn't understand it then.
And that's when it started.
That reminds me of the severity, right?
Like the inpatient level of severity.
It reminded me of one of the criterion that we had discussed about the movement ofborderline, where in extreme periods of stress, usually, often in response to like a
(24:22):
threat of abandonment, there can be like dissociation symptoms, paranoid ideation.
psychotic like symptoms, right?
Cause we're sliding into that psychosis stage.
It is really interesting.
There is this disintegration or regression is the term that we use today that can happenwhere we start with Individuals with BPD will start backsliding into sometimes stepping
(24:55):
out of reality.
And with that, I've seen
a of different presentations of it.
But some of the most striking presentations are individuals that are generally prettyfluid.
You talk with them, they're able to describe, at least to some degree, even if they'reusing maybe nondescriptive language, they're able to tell you that they're distressed.
(25:21):
They're able to tell you what they did.
They're able to tell you sometimes even, hey, I think I stepped out of reality.
And that's the piece that separates this from being true psychosis and neurosis.
This is exactly why it's in that borderline or borderland area.
(25:42):
Most people who are out of touch with reality are just out of touch with reality.
To go out of touch with reality and be aware of it, those two things don't typicallycoexist, but they do in borderline.
So you can have this really interesting presentations, conversations with people who livethat, who live in that world and can say, yeah, I had this episode of paranoia where I was
(26:15):
afraid for my life and thought someone was hunting me down.
And, you know, I ended up, I don't know, selling all my possessions and moving to adifferent country.
Sure.
Right?
Well, what?
Right.
Because maybe their coworkers or something like were mad at them.
(26:35):
Right.
But that's not the case.
They weren't hunting them down.
They were mad or angry.
But the interpretation of those things sometimes in those transient or temporary states ofpsychosis or out of body phenomenon, they
(26:57):
can sometimes interpret things in such a way that are out of touch with reality.
Like, my coworkers were actually planning a surprise party for me, but I thought they weretalking bad about me behind my back.
And I created this whole narrative about what happened.
(27:17):
And I believed that they were plotting to harm me.
And so I fled the country.
Right.
Like that's.
This is not out of the realm of things that happen with individuals with BPD.
And sometimes it can be seemingly the most fluid, high functioning sometimes even,individuals that will backslide so significantly and have these episodes where they are
(27:48):
not themselves.
Sometimes it can lead to memory problems too, or dissociation.
So that's when you're out of body experiences, of yourself in third person or in slow-moor of derealization, meaning feeling like things aren't real.
(28:09):
And sometimes that can even mean that there's memory lapses because I was not fullypresent.
And other times I've...
talk to patients who have these real kind of backsliding episodes into psychosis andthey're aware of it.
So it can be the full spectrum of things.
(28:33):
Dissociation is a key word I love, dissociation, right?
So it's a defense mechanism, right?
It's protective.
You shut down at least part of yourself, your emotions, your...
brain, right?
So you're not fully present.
I've seen that anywhere from, you know, like zoning out, right?
(28:55):
Daydreaming, technically is a dissociation to even just an extreme fragmented sense ofself where there's different parts.
So everyone has parts, right?
Like there's usually like an inner child in you or like your work self versus your homeself, right?
(29:15):
It is all the same person.
It's just a different presentation.
If that slides into maybe like an unhealthy disintegrative state, those pieces canfragment.
I would say this would be individuals who may think they have even multiple personalities.
(29:36):
There's a specific part of them that comes out when they're threatened.
There's a specific part if they're triggered in a certain way.
It's the same personality.
They're aware of it.
So it's very, it is actually very different than multiple personalities or dissociativeidentity disorder.
It's very different, but it's still that sliding into the psychotic state, right?
(30:01):
And that dissociation, like this part of me functions to keep me safe at this moment intime.
And I have to separate that from the rest of me.
It's powerful how our brains.
can work and how we can protect ourselves.
I imagine it's super scary as well, especially if you don't know anything about it.
(30:22):
Like that's scary.
Complex, complex.
Borderline is complex.
I think that's the bottom line here.
There's so many different flavors and ways that it can present and we humans are complex.
This condition is especially complex.
(30:43):
So we are going to wrap up for today.
You don't want to miss next episode.
are going to get more into suicidal thoughts, behaviors, gestures, self harm, selfinjurious behaviors, kind of all of those things, what it looks like with BPD and also
resources, which again, I'm going to put below so that you guys can access as well.
(31:08):
So that brings us to a close.
Be well, be kind.
and join us for our next episode on the personality couch.
This podcast is for informational purposes only and does not constitute a professionalrelationship.
If you're in need of professional help, please seek out appropriate resources in yourarea.
(31:31):
Information about clinical trends or diagnoses are discussed in broad and universal termsand do not refer to any specific person or case.
Welcome to the Personality Couch Podcast, where we discuss all things personality andclinical practice.
I'm your host, Doc Bok, and I am here with my co-host, Doc Fish.
We are both licensed clinical psychologists in private practice.
And today we will be continuing our series on borderline personality disorder and what itlooks like in relationships and in
(00:29):
clinical practice.
So let's get right to it.
Last week, we brought in the DSM definition of BPD, which then we broke down into kind offour main chunks.
But When talking about personality pathology, we first have to look at is this a pervasivepattern?
(00:54):
Has this been going on for a while?
Is this more than just someone's bad day
or a bad season?
But this has been present sometimes even as early as childhood you can see the beginningsigns and then adolescence.
And definitely by early adulthood and it's persistent.
So it's across multiple contexts.
(01:17):
With BPD also comes significant impulsivity as well, which is one of the main pieces ofBPD.
And then the criteria in the DSM actually break that down further about what impulsivitylooks like.
And then the four things that we summarize, Instability.
(01:39):
So in sense of self, unstable moods, especially intense anger or rage, unstablerelationships.
The second part is fear of abandonment.
Third part, self-harm or suicidal threats
or behaviors, and then impulsivity shows up again.
(02:00):
And we also talked about the movement.
This isn't just a static categorical description.
There's movement back and forth.
And with that, we sometimes see more of the out of touch with reality symptoms.
So sometimes psychotic symptoms, sometimes dissociation or out of body experiences andphenomenon, sometimes paranoia,
(02:26):
all of that.
But we also talked about The three different contexts for instability, right?
So the self, relationships, and mood.
Unstable sense of self, right?
We have that empty spot inside, just like this constant feeling that we're bad.
And that can be kind of even look like taking other people's identities on in order toconnect with them, in order to like fill that empty spot, to try to
(02:54):
to maintain or develop a sense of self.
The unstable relationships, right?
We talked about idealization versus devaluation.
In other words, like, I love you, I hate you.
It's a push-pull.
Quick attachment, but then also super quick distancing if scared or threatened.
Then we have the unstable mood, the mood swings that can occur within hours, never rarelymore than a few days.
(03:20):
There's often a baseline though of like the
the depressed mood, the low mood, but that'll be disrupted by really intense emotions suchas panic, despair, anger.
Anger's not an unhealthy emotion in itself, right?
But we're talking about developmentally inappropriate anger, right?
(03:41):
Like really intense anger that's difficult to control that can be outward, like outbursts,but it can also be kind of directed towards the self.
Right?
Confirming, I'm bad, I'm bad.
And it can result in treating yourself meanly, really, in thoughts.
(04:02):
Could be in actions as well.
But it results in depression.
I'm curious, what do you feel like of these different characteristics that we've talkedabout so far, What do you feel like comes up in treatment the most often?
That is, that's a hard question.
(04:24):
I think I'm have to go with the unstable relationships because I think that is whatprompts treatment.
There's so much distress there.
It's work relationships.
It's gonna be affecting your job, right?
It's often a significant other.
It can be parents, it can be friends.
(04:45):
It can be an array of all, but I think that is really
what I see the most is that unstable relationships.
That is so interesting.
I didn't expect you to say that, actually.
I thought you were going to say impulsivity.
Yeah.
But I can see that because that the unstable relationships really is often the catalystfor people to come to treatment, especially with BPD.
(05:15):
But relationships in general, relationship problems, conflict
can often lead the person to seek out treatment.
And with BPD, then the person coming in, you know, may have really unique issues aroundthose relationships, often kind of the ups and downs, the volatile.
(05:37):
You can almost see the push pool in the relationships that they're describing.
So that makes sense.
That makes sense.
I think the first thing that came to mind for me was in
In psychological testing, it's often a little different.
think what presents first in the data for me is probably the empty spot, the unstablesense of self.
(06:02):
Yeah, when they are explaining their story, we're going through what's called the socialhistory.
So asking about their, their mood, how long that's been going on for.
their medical history, family history, trauma history, educational history.
(06:22):
In all those different questions that we ask, we're piecing together a narrative.
And sometimes I can start to see, you know, in the descriptions of things that there'snot, perhaps not a stable sense of self, or to your point, in those descriptions of
relationships, you can see the push-pull.
(06:45):
By the time that we actually get the data, I can start to see there is really, really lowself-esteem.
There appears to be an empty spot that either the person is running from or trying tofill, but it becomes pretty apparent when looking at all the different domains of
(07:05):
functioning like we do in our deep dive evaluations that we do in our private practice.
It becomes pretty clear.
Okay, we need to look at potential borderline because of that empty spot.
That makes a lot of sense, especially even just the difference between testing and therapytoo, right?
(07:27):
Testing is the deep dive and you get the whole, well, attempt to get the whole picture atonce, right?
It's like a snapshot.
Therapy is a long-term process of working through layers, like peeling back the onion.
I wonder, so...
We talk about relationships, but how does that tie into fear of fear of abandonment?
(07:49):
So now we're getting into some of the things that we didn't get to talk about last time.
But fear of abandonment is pretty hard to miss once we know what we're looking for.
There may be clues that come up relationally where if there's even the hint of leaving,
(08:12):
the individual has a huge reaction.
So not even just the act of leaving, but the possibility of leaving.
So an example might be an accidental pocket dial.
That can become a personal affront because, you didn't actually want to talk.
(08:35):
So do you really love me?
There's that fear.
Like, it is so easily triggered.
by the most sometimes benign things, sometimes not so benign, like pushing on a bruise insome regard.
Another, I guess, more overt example is a partner walking out the door, right?
(08:56):
Maybe they're walking out the door after a major conflict.
Maybe there was a heated argument about something and the partner just needs to take abreak, get their thoughts, cool their head, cool their heads prevail.
They walk out the door to go for a drive or to go get some, I don't know, burger and friesor something.
my goodness.
(09:17):
An individual with BPD may feel really threatened when that person leaves.
The feeling of this person leaving even just for a timeout in the middle of conflict feelslike they are never coming back.
And if they're never coming back, where does that leave me?
(09:39):
because I am intertwined with this person.
Who am I outside of this relationship and outside of this person?
And as I'm talking about that, this is a bit of a tangent, but it reminds me of what welearned kind of early on with attachment theory and the concept of object permanence.
(10:02):
You can see it in object relations theory, is psychodynamic.
thinking to like develop mentally with like developmental psychology in children orinfants.
I think the easiest way I like to explain Object permanence is at some point, infants, ifyou have a toy right in front of them, you put it away, like put it behind your back.
(10:25):
They don't know it exists.
right?
It's either there or it doesn't exist.
They either see it or it is not anything.
Eventually,
a child is able to understand and remember that, the toy exists even though I don't seeit.
(10:47):
So if we translate that and we put that on attachments, or relationships, when this personleaves, the relationship doesn't exist.
That's pretty powerful, right?
So if that's not developed, right?
If it is developed, it's OK.
(11:07):
I know the relationship exists, even though that person's going out the door after afight.
There's a timeout.
We need to cool down.
It'll be OK.
They'll come back.
The lack of object permanence is like, they leave.
They're not going to come back.
They're never going to come back.
(11:28):
Who am I?
What do I do?
All of those emotions is
probably not the first time that somebody has left and actually not come back.
So that bruise that you were talking about, that is painful.
I love how you brought up object permanence.
like that.
Yeah.
Yeah.
I was just thinking about it as we were discussing this fear of abandonment.
(11:51):
And it makes sense when we think about just child development or just human development,that there's a skill that we
learn or a milestone, I don't really know quite the right word for that.
That seems to somehow be lacking in individuals with BPD or it's deficient.
(12:13):
Maybe I should say it's deficient.
if we're going into attachment theory, the Inconsistent attachment to a primary attachmentfigure, right?
So like, as a kiddo, you need mom, mom comes sometimes.
But other times she doesn't, right?
So you never know what you're gonna get.
(12:33):
So even if you know in your head that that person might be coming back, it may not evenfeel like it because like, is this the time that they're gonna come back or is this the
time they're not gonna, they're not going to, right?
Are they gonna meet my needs or are they not?
So this fear of abandonment oftentimes has its roots in early attachment.
(12:55):
Research tells us that there is a genetic loading
for personality disorders.
So most likely there's something close in the genetic line and how someone perhapsattaches to their child can then in turn affect how that child attaches to other people.
(13:18):
So there can be kind of a ripple effect when there's dysfunction in personality ordysfunction in attachment.
So it can also look a little less overt.
So I've also seen this fear come up, perhaps people that are more reserved, keep more tothemselves.
(13:42):
Perhaps they don't want to share anything or certain parts of themselves for fear that itwill lead to abandonment.
So for example, I am not going to open
up that closet with those skeletons, because I don't want you to leave.
(14:03):
And then when those skeletons come out, and then a loved one or partner finds out, andit's like, well, why didn't you tell me?
Or once things start surfacing, it can really impact the relationship lead to sometimeseven a blow up, because parts were concealed because of that fear.
(14:24):
But then it's a self fulfilling prophecy where
It actually leads to distrust and perhaps the person actually leaving because trust hadbeen eroded.
Right.
And I wonder if it's not even just information, but also like parts of yourself.
Right.
So I'm not going to act in this way that is natural to me because I don't want them toleave.
(14:50):
I'm going to try to be absolutely the best that I can.
Right.
But we're human.
I think that overlaps with like unstable sense of self too, right?
Like you try to fit in a picture of what is wanted so you can keep somebody.
That makes sense.
It's like there's this ever shifting sense of self and a presence of, what do you want meto be?
(15:14):
Right, exactly.
Okay, I'll be this.
I'm a shape shifter.
Okay, I'll be this.
Okay, I'll be really involved in these activities.
I'll dress this way.
I'll do this for you.
to keep the attachment while the core pieces of who you are, your interests, your likesare kept under wraps because to actually reveal that would mean the loss of a
(15:37):
relationship.
Separation in general, any separation, that's going to be a threat to abandonment orelicited fear of abandonment, right?
So I was thinking even like trips.
For example, like a work trip.
So a significant other goes on a work trip.
There's fear of abandonment, right?
(15:58):
Yeah.
Let's see, like at a really unhealthy level, right?
Maybe the person with BPD, you know, gets drunk, puts themselves in unsafe situations,calls the significant other, right, to save them so that they come home, right?
There's like a save me, save me, save me.
(16:19):
Like, need to come back, I need you.
But it could also look not so dramatic, perhaps, right?
Just like separation anxiety, right?
If your significant other goes on a work trip, you make it like pouty, right?
Like, I don't really want you to go, but like, I guess you have to, right?
(16:41):
They could be overly communicative.
So like they're on their work trip and they're texting every five minutes.
Right.
And that might look more like instead of like a save me, like love me, love me, right.
Love me, love me, love me.
Come back.
I think clinically too, in the context of trips, when the therapist takes time off,there's an attachment break.
(17:10):
Is my therapist going to come back?
Why did my therapist leave?
probably more common, I would think in more severe cases of BPD, though maybe not.
Maybe it comes up in different ways, but that, you know, it could be bit of poutiness orattitude towards perhaps your treatment provider who's taking some time off or has to go
(17:39):
on medical leave, whatever it is, all the way across the continuum to
some pretty significant drama to try to keep perhaps even the therapist staying and notleaving.
(17:59):
So that's such a good example.
I was thinking, you were talking about that, right?
That it can sometimes be even like unconscious, right?
So provider takes time off.
All of a sudden the next week, client forgets they have an appointment, even thoughthey've never forgot before.
(18:23):
And literally, they literally forgot.
So it can be an unconscious thing.
It's not necessarily malicious, still data.
Or it could even be a punishment of the provider.
Like, how dare you leave me?
I'm not going to show up.
And it could end up never showing up again.
(18:43):
So I'm going to leave you before you leave me.
Right.
Or I'm going to do to you what you did to me.
Exactly.
Exactly.
Because I'm mad.
It could also be redirected towards the self, right?
We talk about anger, that anger can be outward or inward.
All of a sudden, we're engaging in impulsive, regressive behaviors.
We're hurting ourselves because we must be so bad because therapist doesn't love us enoughto never take time off.
(19:11):
So regressive is just like a backslide.
It can be a backslide of behavior, emotions, and development.
Maybe a simple example, if you're having a bad day and you're really tired and somethinglike really makes you irritated, right?
That little child temper tantrum you might have, right?
(19:33):
That could be a regression.
We all regress.
But usually it doesn't, we don't maintain it.
Got it.
So perhaps in therapy, the progress that you've made in treatment can sometimes benegated.
or there's some backsliding that happens.
(19:54):
I think this is also where borderline particularly has or can have a bit of a bad rap intherapy for reasons like this, unfortunately.
And because it is a lot, that is a lot to manage as a treatment provider who has, youknow, typically a whole caseload of other people that they're helping as well.
(20:20):
And it's normal to need time off.
That's part of being human, is needing to take a break from the work that we do.
But when there's pools, or when time off gets muddied with perhaps drama, or unhealthy, orlike you said, regressive behavior, as perhaps a pool to come back, don't leave, rescue
(20:47):
me, see I'm hurting myself.
You should care enough.
I'm pooling.
That is a lot.
That is a lot to manage for any relationship, any relationship, whether it's a loved oneor a professional.
This, like I said, this is where I think borderline can get kind of a bad, unfortunately,a bad rap because of the pool.
(21:15):
and the toll it can take interpersonally, even with professionals who are trying to workthrough this with the patient.
I guess this is maybe a good time to say, spoiler alert, therapists are humans too.
Like we do feel for the people that we see, and we can very much get pulled into dynamicsthat involve personality.
(21:39):
Absolutely.
It takes.
practice and study and awareness to be able to unhook.
Yeah.
And I want to also say that this isn't every case with borderline.
every single person with this condition is going to test the limits of the therapeuticrelationship to that degree that time off becomes a big drama.
(22:07):
However it can and it has, it's definitely happened to me.
think probably most therapists have received some type of pool in their career from somepersonality dynamic, whether they realize that's what it is or not.
All personality disorders create drama and there can be pools.
(22:32):
certainly when you are sitting in that therapist chair,
You are getting fooled.
I thinking, so I was even reading this book, this is 1984.
Okay, so that's right after the criteria was developed for borderline in the DSM.
And it states that the history, some of the history behind that are individuals that werein inpatient, like in a hospital that weren't responding.
(23:04):
to treatment that usually works for psychotic individuals.
Makes sense because it's borderline, right?
We don't stay in psychosis.
There's that movement.
It specifically states about all of the pulls from the staff.
They didn't want the staff to leave them, right?
So upon discharge or the threat of discharge, all of a sudden they got worse.
(23:28):
But if they weren't getting better, whose fault is that?
Right?
Not theirs.
And this is an inpatient setting, right?
So I think that speaks to your point.
This is not every person, right?
There's a whole severity.
But I think that even perhaps the history of this diagnosis is where the stigma started.
(23:49):
That's really unfortunate because really what is happening is like, we don't understandit.
We still don't, but we definitely didn't understand it then.
And that's when it started.
That reminds me of the severity, right?
Like the inpatient level of severity.
It reminded me of one of the criterion that we had discussed about the movement ofborderline, where in extreme periods of stress, usually, often in response to like a
(24:22):
threat of abandonment, there can be like dissociation symptoms, paranoid ideation.
psychotic like symptoms, right?
Cause we're sliding into that psychosis stage.
It is really interesting.
There is this disintegration or regression is the term that we use today that can happenwhere we start with Individuals with BPD will start backsliding into sometimes stepping
(24:55):
out of reality.
And with that, I've seen
a of different presentations of it.
But some of the most striking presentations are individuals that are generally prettyfluid.
You talk with them, they're able to describe, at least to some degree, even if they'reusing maybe nondescriptive language, they're able to tell you that they're distressed.
(25:21):
They're able to tell you what they did.
They're able to tell you sometimes even, hey, I think I stepped out of reality.
And that's the piece that separates this from being true psychosis and neurosis.
This is exactly why it's in that borderline or borderland area.
(25:42):
Most people who are out of touch with reality are just out of touch with reality.
To go out of touch with reality and be aware of it, those two things don't typicallycoexist, but they do in borderline.
So you can have this really interesting presentations, conversations with people who livethat, who live in that world and can say, yeah, I had this episode of paranoia where I was
(26:15):
afraid for my life and thought someone was hunting me down.
And, you know, I ended up, I don't know, selling all my possessions and moving to adifferent country.
Sure.
Right?
Well, what?
Right.
Because maybe their coworkers or something like were mad at them.
(26:35):
Right.
But that's not the case.
They weren't hunting them down.
They were mad or angry.
But the interpretation of those things sometimes in those transient or temporary states ofpsychosis or out of body phenomenon, they
(26:57):
can sometimes interpret things in such a way that are out of touch with reality.
Like, my coworkers were actually planning a surprise party for me, but I thought they weretalking bad about me behind my back.
And I created this whole narrative about what happened.
(27:17):
And I believed that they were plotting to harm me.
And so I fled the country.
Right.
Like that's.
This is not out of the realm of things that happen with individuals with BPD.
And sometimes it can be seemingly the most fluid, high functioning sometimes even,individuals that will backslide so significantly and have these episodes where they are
(27:48):
not themselves.
Sometimes it can lead to memory problems too, or dissociation.
So that's when you're out of body experiences, of yourself in third person or in slow-moor of derealization, meaning feeling like things aren't real.
(28:09):
And sometimes that can even mean that there's memory lapses because I was not fullypresent.
And other times I've...
talk to patients who have these real kind of backsliding episodes into psychosis andthey're aware of it.
So it can be the full spectrum of things.
(28:33):
Dissociation is a key word I love, dissociation, right?
So it's a defense mechanism, right?
It's protective.
You shut down at least part of yourself, your emotions, your...
brain, right?
So you're not fully present.
I've seen that anywhere from, you know, like zoning out, right?
(28:55):
Daydreaming, technically is a dissociation to even just an extreme fragmented sense ofself where there's different parts.
So everyone has parts, right?
Like there's usually like an inner child in you or like your work self versus your homeself, right?
(29:15):
It is all the same person.
It's just a different presentation.
If that slides into maybe like an unhealthy disintegrative state, those pieces canfragment.
I would say this would be individuals who may think they have even multiple personalities.
(29:36):
There's a specific part of them that comes out when they're threatened.
There's a specific part if they're triggered in a certain way.
It's the same personality.
They're aware of it.
So it's very, it is actually very different than multiple personalities or dissociativeidentity disorder.
It's very different, but it's still that sliding into the psychotic state, right?
(30:01):
And that dissociation, like this part of me functions to keep me safe at this moment intime.
And I have to separate that from the rest of me.
It's powerful how our brains.
can work and how we can protect ourselves.
I imagine it's super scary as well, especially if you don't know anything about it.
(30:22):
Like that's scary.
Complex, complex.
Borderline is complex.
I think that's the bottom line here.
There's so many different flavors and ways that it can present and we humans are complex.
This condition is especially complex.
(30:43):
So we are going to wrap up for today.
You don't want to miss next episode.
are going to get more into suicidal thoughts, behaviors, gestures, self harm, selfinjurious behaviors, kind of all of those things, what it looks like with BPD and also
resources, which again, I'm going to put below so that you guys can access as well.
(31:08):
So that brings us to a close.
Be well, be kind.
and join us for our next episode on the personality couch.
This podcast is for informational purposes only and does not constitute a professionalrelationship.
If you're in need of professional help, please seek out appropriate resources in yourarea.
(31:31):
Information about clinical trends or diagnoses are discussed in broad and universal termsand do not refer to any specific person or case.
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