Transcription
[Music] Hi, I'm Kyle Kiddleson with MedCircle, joined by clinical psychologist Dr. Romney. Love seeing you again today.
Thank you so much for having me, Kyle. Where you've talked about Borderline Personality Disorder in the past, and if you're watching this right now and want a general overview of BPD, use the links below to access that content. Because right now, we're gonna dive into the four subtypes. Dr. Romney, let's start with the high-functioning, high-functioning, internalizing/quiet subtype of BPD.
So, Borderline Personality Disorder, sort of again, in its wider spectrum, is a very, very heterogeneous personality disorder, which is why it's so tricky. Even people out there experiencing borderline personality will say, "How come my experience is so different than other things that I've read about borderline personality?" What is heterogeneous? Different. It's different. It's so scattered. Like, it's, it's not just one thing. It's almost like saying, "I want cereal." I'd be like, "You're a granola person? You're a Cheerios person?" Like, what are we talking about here? Borderline personality is that mixed up in a way. And because we have this one umbrella term that's used, but these four subtypes are very different, so it's important for us to distinguish.
So, as we start with the high-functioning, internalizing, sort of quiet borderline, to me, this is something we could almost term as a more pure borderline personality in this way. That this is a style of borderline personality where we see a tremendous amount of despair, of, of fragility, of, you know, tremendous abandonment crises. When, when there is an, when there is a trigger or an activation, such because of an abandonment crisis or a triggering of a prior trauma or a stress that feels that it can't be managed, the person will rage it themselves, right? So they will internalize it. They will talk about themselves horribly. They might even have suicidal thoughts about themselves, believing passively the world will be better off without them.
But the key piece in this quiet borderline distinction is that they are high-functioning. Many people who fit this high-functioning, internalizing, quiet borderline descriptor have very high-power jobs. They're often in jobs where they're giving to others: nursing, teaching, mental health. So there's a natural draw of this particular style of borderline personality to a helping profession, to give to others. Where they might get challenged in a professional arena is that if they even make a small error, and I mean, it could be small, they will have a very strong reaction to it. And that strong reaction will be very self-blaming and sometimes even self-harming.
So the person who presents with quiet borderline personality styles or disorder is somebody who's much, much more likely to have co-occurring depression or an anxiety disorder. That also makes the symptomatology almost sometimes feel worse because there can be this real, these, these negative mood states that accompany this particular style. In fact, many mental health practitioners may miss the borderline piece and focus more on the depression or the anxiety piece in treatment until over time they see that the patient's sort of style of self-talk is so self-harming. And that individuals with quiet or this sort of high-functioning, internalizing borderline personality, while they are high-functioning, it's not a very stress-resistant pattern.
So when there is stress, something shifts at work, something shifts in a relationship, there is a, um, a tremendous difficulty in being able to tolerate the distress associated with those times. But that distress, instead of lashing out and yelling at somebody else or making that kind of a gesture, they're very quick to almost rage quietly at themselves, self-harm, self-destruction. People might starve themselves, may not get enough food, may try to almost break themselves trying to maintain a household or be all things to all people. So it's a very self-destructive disorder, but it's done in such a quiet way that a lot of people don't even identify it classically as Borderline Personality Disorder, which is traditionally thought of to be as a much more chaotic, externally dysregulated pattern.
Are these subtypes in the DSM and recognized in the mental health community, or is it just what laymen have come up with?
In the DSM, they have not recognized the subtypes. These subtypes represent a mashup over the years of different sources of research. Theodore Millon was a major player in coming up with these subtypes of borderline personality. In fact, his scale, the Millon Clinical Multiaxial Inventory, which is a personality assessment tool, he, I give you, if you're more expert in scoring it, you can actually look at the scoring and sort of break some of that down. And he has opined on these sorts of subtypes of borderline personality. It's absolutely a, anyone who's in practice who's ever worked with somebody with borderline personality knows that this is, it is, it's like a stone with many facets, right? When you tell me somebody's got borderline personality, I'm saying, "That's not enough. You got to give me more. Tell me a little bit more about this client," because I am going to have an incredibly different treatment approach or recommendation based on the kind of subtype. But no, this has not officially elevated itself into the diagnostic manuals.
Before we move on to the second subtype, how prevalent is BPD?
Prevalent? The prevalence of BPD is widely disputed. Okay? So the estimates of BPD in the population range probably, I've seen estimates anywhere from two to six percent, two to seven percent, that kind of thing. Part of the reason it's, there's so, so much variation is that it's not easy to assess. Many clients who present with borderline personality disorder in, sort of, non-research studies, like, just sort of in traditional clinical evaluation, what they show, how they show up in, sort of, chart data at clinics or hospitals, is they're often more likely to be diagnosed with mood disorders, anxiety disorders, bipolar disorder, but not borderline personality disorder. Part of that is a training issue. People are less likely to give that diagnosis out. They want to subsume it under, under other things. Part of it is a, I guess, I don't know how we call it, sort of a marketplace issue. Borderline Personality Disorder is viewed as something that's difficult to treat and takes a very long time to treat. And because of that, just to not get pushed back from insurers or spaces like that, there may be more of a tendency to use some of the neighboring or co-occurring symptomatology in that person. Oftentimes, the way these patterns are medicated or similar, there's no pill for borderline personality per se. You're often sort of working on it symptomatically. So I think that we still haven't seen that study that gives us the optimal prevalence number. If I were to spitball a guess, I would say it's probably somewhere between three and five percent.
Tonight, we'll be having a live panel with Dr. Romney and other MedCircle doctors. It's a great chance for you to ask questions directly to these doctors. It is not treatment or therapy, it is education and a great chance for you to really understand whatever mental health topic you need clarification on. You can sign up to join us tonight or get the replay sent to you at a later date using the links below this video.
Dr. Romney, what is the second subtype of BPD?
The second subtype has been termed petulant or histrionic. I don't like the term histrionic as a feminist. I don't like that term because it really carries this implication. It builds on the term hysteria, and the term hysteria is really sort of pathologizing of female sexuality. So let's stick with petulant. But just so people know, because this term histrionic is thrown around, histrionic means somebody who is very superficially attention-seeking and emotionally dysregulated. So a person who's like almost seductive in their presentation, they are, they will be almost coy and little girl, and it's very, it's very female-oriented to get attention, um, but it's very much an attention-seeking kind of a pattern, very, and very a socially immature pattern.
But if we focus on the petulant piece associated with that, the petulant part is again, it's this sort of acting out, "If I don't get my way." And so a petulant person can be experienced as manipulative. They could be experienced as a victimized. Um, petulant people will have a, they'll be a sort of a little bit of a through-note of entitlement. In fact, there's a fair amount of overlap of what we call covert narcissism and what we, some of the patterns we see in petulant borderline personality. And here's where borderline personality gets super, super tricky. We've talked about this on MedCircle before, and I know we have a series on Cluster B personality disorders. There are multiple personality disorders in that set. Borderline and narcissistic are two of that set.
When we look at some of the theorists who've studied personality disorders, Otto Kernberg being one of the most primary, what we see there is that there is a view of borderline and narcissistic personality disorder as almost being slight variations on a theme. So it's no wonder that at times they overlap. We just talked about the quiet, high-functioning, internalized borderline person. There, we see very few, almost no narcissistic personality whatsoever. In fact, the people in that quiet borderline group really don't have a lot of ego strength, which is why they tend to devalue themselves and really fall apart and can't tolerate in the stress in their lives, especially around abandonment, because there's almost no sense of worthiness.
But when we slide over into spaces like the more petulant, traditionally called histrionic, now we're looking at more the attention-seeking. Now we're seeing the sense of some sort of passive, low-grade entitlement. "Why am I not getting my way? I'm going to get my way." And if I don't get my way, I can't tolerate the abandonment feelings and the stress feelings that come out of that disappointment. So people might experience a sort of petulant borderline pattern as one that's more of sort of an attention-seeking, acting out kind of a pattern, and will feel that this is somebody who throws tantrums a lot. It'll have that kind of flair in a very dysregulated way. But as I said, here now you're in an area of the borderline personality where we're seeing an overlap with narcissistic personality. If you want to view it this way, they sit right next to each other. So one is going to bleed over into the other, just like I'd argue in covert narcissism, some of that borderline symptomatology has bled over into there. So these are things that sit right next to each other, and things that sit next to each other are going to be, we're going to see observe, observe similar patterns in them.
So how is this subtype of BPD different than Histrionic Personality Disorder?
In Histrionic Personality Disorder, we won't see the same level of triggered activation in the face of things like disappointment, and especially abandonment. And abandonment and disappointment may be experienced as similar. Like, if a person doesn't get, I don't know, an opportunity, or they don't get to go on a, um, the date gets canceled or something like that, that is a disappointment. But if you perceive it as an abandonment, you can see how the reaction to it would escalate a lot more than just like something, sometimes things don't work out. And what was traditionally termed Histrionic Personality Disorder in the DSM, that's much more of a superficial attention-seeking, um, a superficial attention-seeking style where the person actually becomes visibly uncomfortable if they're not the center of attention. So again, you can see that overlap with the narcissistic style. It's also in Cluster B, the need for attention, the need for validation. But what you don't see in the histrionic personality is as strong a bent and a tendency towards the manipulation. You'll see some of it, but mostly, I would say with the histrionic personality style, it's like a baby and an adult in the same person. That's what that feels like.
Yeah. All right, let's move to the third subtype. That would be what we call the angry, externalizing, impulsive borderline personality. Honestly, this presentation is where borderline personality kind of got its bad name clinically, and it's definitely only a sub, a percentage of people with borderline personality. This is my speculation. This is not an accepted fact. I'm going to share it here. It is my belief that when we see the angry, externalizing, impulsive borderline style, that's likely actually almost a complete overlap of borderline and narcissistic personality. It's probably where those two things almost are 50/50 together. And this is again, which is a bummer, because so much of borderline personality gets its bad name just from this one presentation, and people view this as unhinged and unmanageable.
Now, people who have the angry, angry, externalizing, impulsive borderline presentation are exactly what it sounds like. There is a lot of very dysregulated rage that comes up very quickly that is very discontrolled, which can be very unsettling for people around the person. And it can mean, it can often be triggered by things like abandonment crises or significant, um, significant disappointment. There's major difficulties with distress tolerance. So anything that bad that's happening, can't tolerate the distress. But instead of turning inward, they turn outward. You could be yelling, it could be screaming, it could be breaking objects, it could be blaming other people, but it's very externalized. It's, it's targeted at all the other things and people in the environment.
There's also a lot of impulsivity here. Impulsive acting out that can actually be dangerous. So in the midst of the distress, like I said, instead of it being turning inward and harming oneself, there can be impulsive acting out like using drugs and alcohol, driving dangerously, having dangerous sexual encounters, thing, spending a lot of money, things that could put them in sort of harm's way. That sometimes can get so escalated. It is in this angry, externalizing, impulsive subtype, you can understand why some mental health practitioners would confuse this with mania because it looks so agitated and so acting out. And so in this case, you might see a lot of rage, a lot of, you might even see a lot of manipulation. And the same abandonment stuff is there, as it always been. The same problem, the issues with identity are there, as they always been. All of these borderline subtypes have those same undercurrents. A lot of it is sort of how it's expressed and how the world experiences it.
So this particular subtype of borderline personality is also potentially quite dangerous. I think there's that, that potential for suicidal acting out and suicidal, um, thoughts and, and tragically, suicidal, you know, completion of a suicidal act. You'll see that here too. And it can be in a moment of acting out, like, "I'm gonna go do something dangerous. I'll show you." And then unfortunately, that "I'll show you" can end up in a very tragic place. So all of these threats have to be taken very seriously. But many times, people will get very exhausted or even very frightened by this presentation of so much strong rageful emotion. But the person with this subtype, with the angry, externalizing, impulsive subtype, literally feels out of control with these emotions. They do not know what to do with them. They're absolutely overwhelmed. And, and they, because they don't know, instead of turning in, they turn out. But it's just like with the quiet borderline person, they just don't know what to do with all of this strong emotion.
Yeah. Understood. Let's move into the fourth and final step.
The fourth and final one is called the depressive. I'm sorry, the depressive. The four, the fourth and final one is called the depressive, internalizing subtype, sometimes called sort of self-defeating and self-destructive. So in this particular subtype, it, unlike that first group, the quiet, high-functioning, internalizing person with borderline personality, here we see an almost uniformly dysphoric and depressive presentation. Because of that, people with this final subtype might not be able to hold and secure employment as well. Whereas in quiet borderline, we'll see people who are often able to stay in jobs for many, many, many years. But whereas with the depressive, internalizing, kind of self-defeating and self-destructive, you might see somebody where that's a lot harder because the depressive, the depressive undercurrents of this form of borderline personality can make it a lot harder to sort of mount the energy and the effort to consistently hold employment or even relationships.
The depressive symptomatology is going to get much more exacerbated again at times of frustration, disappointment, and certainly abandonment. The self, the self-destructive and the self-defeating part can mean that there's a very high risk of self-harm, especially in the face of there being an abandonment or other similar kind of triggering crisis. In this particular case, the depression will often become the central focus of treatment because that's actually what's putting this client at risk for suicidal acting out, suicidal harm, self-harm, you know, or the risk of, of committing suicide. So this is actually a relatively high-risk group. Many times, people in this last group will also sometimes get missed. They'll be, they'll be labeled solely as having Major Depressive Disorder. And then one might say, "So what? So what if they only have Major Depressive Disorder?" It does matter because some of that dysregulated instability can make the lows of the depression even lower.
So it's as though the dysregulation of this particular form of borderline personality, where we're seeing the depressive, internalizing style, is, you might see a typically, sort of, typical dysphoria, and then it'll dip even further down when the person is facing a real crisis. And that can, that can mean that they won't be able to take care of themselves. They won't, they'll neglect themselves. They may neglect others in their care that they may need a lot more support and help at those times. They may not as successfully engage in things out there to help them, like psychotherapy. So there's a real risk in that as well. So this is, this is a particular subtype. And again, we're trying to keep them safe because somewhat similar to the quiet borderlines, they're immediately, they're going to go right to that passive self-harming, "I deserve to die. I shouldn't be alive. I don't even know why I exist. I don't know who I am." That kind of emptiness. They'll go there.
But because the depression is such a central core feature of this presentation, it's harder for them to remain functioning in the world. In the quiet borderline type, one thing that often protects them is because they're in the workplace and functioning quite well there, they may have social supports through that. In this final form of borderline personality, it may be harder for these individuals to access social support because they're so depressed and they may be so isolated as a result.
You know, taking all together, Kyle, as you can see, these are actually four different presentations. So you can see how with a therapist, we're seeing for these four as four different clients, a big four very, very different experiences. And I've actually had the experience of working with all four of these subtypes of borderline personality. They couldn't be more different. You know, I have to say that in terms of how treatment goes, the kinds of outcomes we see, the level of engagement, um, the level of boundary violations in therapy is very, very different. And so I think, though, what happens is that the borderline symptomatology can make cutting through the other symptoms, especially anxiety and depression, a lot more difficult. It creates almost this consistency, if you will. So even as you're getting through the, the issues around distress tolerance, and, and trauma-informed care become really, really important.
But I think that people who are living with borderline personality or are supporters of people with borderline personality, really, it's important for them to understand that this can present very differently because so much of our attention is often on the negative stereotypes of borderline personality as being difficult to manage and deeply dysregulated. I think we're not seeing a full picture of it. And I think there's a real risk in that because I don't think we can care for clients who are living with this, be supporters of people living with this, or even if you're living with this, trying to help you understand yourself and saying, "I'm not those things. Do I not have this? I'm actually the person who turns inward and thinks these self-harming thoughts, but I've had the same job for 25 years." No, it may very well fit that pattern, and that might mean a slightly different approach in terms of how the DBT is used with those given clients.
Excellent. Well, for more information on BPT, BPD, and DBT, the standard therapy for BPD, use the links below this video. Dr. Romney, thank you again for the great information. I'm Kyle Kiddleson. Remember, whatever you're going through, you got this.