Okay, welcome back to the podcast. I am joined today with Dr. Michael Cummings. He is a psychopharmacologist. He is someone who's been on the podcast many times at this point. Hello, I'm happy to be back.

Today we're going to be talking about borderline personality disorder and medications and what we know, what we don't know, what is helpful, what is not so helpful.

So maybe we can start out and you could just kind of define how do you define borderline personality disorder.

Okay, this is a disorder, which I'll start with a disclaimer at the beginning. I don't like the present name of the disorder in the DSM.

It's a holdover from psychoanalytic theory in 1938, which saw this disorder as being in a borderland that was between psychosis and neurosis.

These individuals are thought to be bordering on psychosis due to recurring dissociation or minor episodes of psychosis related to affective distress.

But in many ways, the term is far out of date. I think a term that I've seen that I like better is emotionally unstable personality disorder, because over time it's become clear, at least to a number of authors who write about personality disorders, that the heart of this disorder is an inability to modulate often very intense.

Effective states, for example, martial in a hand has one of the major workers in this area has described people with this disorder as for ordinary person might experience annoyance.

These people experience rage where a typical person might experience sadness. These people will experience despair and hopelessness.

I think the DSM criteria are fairly accurate in their description that is these people are prone to intense emotional states.

They often are engaged in frantic efforts to avoid what they perceive as emotional abandonment. They're also very prone to black and white thinking, meaning they tend to view the world as either being ideal or terrible.

That includes interpersonal relationships in which they often either idealize the other person along the lines of oh, you will be perfect, which of course the other person never is, which then sets them up to switch to your terrible.

So the alternate between idealization and devaluation, they often also feel an internal sense of emptiness, a lack of coherent self-identity, and often engage in very impulsive, often self-destructive behaviors in an attempt to escape from what they find to be intolerable negative affective states.

Yeah, so we've talked about this in episode 115, which is one of our most popular episodes.

We talk about the prevalence somewhere around 1.4%. There's about a three to one female to male ratio.

Previously we've also talked about temperament from birth and in a New York longitudinal study from 1956 to 1988.

Research has evaluated 138 infants and categorized them into three categories, easy, which was about 40% of them, which were generally cheerful, quickly established, sleeping patterns, not much affective arousal to novel stimuli and quickly adapted into a routine. So that was the easy.

There was about 15% that were slow to warm up. They had lower activity level withdrawal on first exposure to new stimuli, and there were 10% that were categorized as difficult, which, quote, often irregular in feeding and sleeping are slow to accept new foods and take a long term to adjust new routines or activities and tend to cry a great deal.

And so of the 141 children, they followed 42 had behavioral problems. The difficult children accounted for the largest proportion of these cases.

About 70% of the difficult children developed behavioral problems. So in a previous time where we discussed this, you know, you mentioned that this was probably temperamentally leading to some of the issues later on that lead to borderline personality disorder.

Yes, indeed, you know, the data that's out there suggests that temperament plays a large role in the evolution of borderline personality disorder. And indeed, although we don't know much about the genetics of the disorder, it is clear that having first degree relatives who suffer with this disorder leads those families have a higher overall prevalence of this disorder.

This temperament, the temperament is thought of as then perhaps giving rise to some of the unstable social interactions that may then worsen the person in the direction of developing borderline personality disorder, environmental things that have been associated with the development of this include things like physical and sexual abuse, neglect, unstable chaotic family.

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