New “Asterisk” Medicine: Borderline Personality Disorder as a Case Study

By Kaz J. Nelson (@KazJNelson)

I noticed two people in the front row, frequently making eye contact with one another, exchanging concerned and knowing expressions. As often happens following my presentations on the topic of the clinical assessment and treatment of borderline personality disorder (BPD), these two individuals caught my attention during the break and asked if they could discuss a personal circumstance. They shared with me the story of their close friend, Chuck, who had endured years of psychiatric turmoil and pain, which had impacted every aspect of his life and, at times, had nearly reached the point of fatal crisis. “Based on what you described in your talk, we think Chuck might have BPD.” This was followed by a question that seems obvious at face value but is actually debated within the medical community: “Should we tell him about this diagnosis and that he might have it?”

More is known now about the clinical entity of BPD than ever before. While it is not as often studied compared to other psychiatric illnesses, important work elucidating the epidemiology, heritability, pathophysiology, natural course and treatment has materialized over the past 20 years. The emerging picture is different from what most healthcare professionals have been taught about this disorder.

BPD has long been what I refer to as an “asterisk” disorder.

We tell patients when they meet criteria for a medical diagnosis*

We provide education and disorder-specific resources to patients about their condition*

We show compassion and non-judgmentalism to patients*

We do not discriminate against patients*

We do not refer to patients by their disorder*

We encourage learners to pursue practice in the care of complex and serious illnesses*

*Except for people living with Borderline Personality Disorder

Our new conceptualization of BPD is opening the door for empathic, compassionate, patient-centered care. What we are finding is that people living with BPD have learned from an early age, through complex interactions of heritable factors and their environment, that interacting with people is generally “unsafe” (regardless of the circumstance) and thus a “fight, flee, or freeze” response is generated based on these interactions, rather than a response which benefits from more rational and reasonable brain activities. This proposed pathophysiology explains the sometimes seemingly irrational behavior we observe (and tend to judge) in the context of clinical care. New evidence-based treatments which account for these physiologic processes and promote understanding (rather than stigmatization and discrimination) of this phenomena have shown remarkable promise in facilitating interpersonal responses which better match the circumstances.

Through understanding these phenomena, adopting a non-judgmental stance, and fostering hope for our patients, we not only improve patient care and outcomes, but we benefit as providers through the cultivation of the qualities which brought us to medical training in the first place. Judging, or even hating, the historically “difficult” behavior of patients takes its toll on us and decreases our capacity to care for others.

These caring friends called Chuck and shared with him what they had learned. He had never heard the term “BPD” despite being in his mid-sixties and having been cared for by multiple therapists and physicians. Over his lifetime, he had been given several diagnoses, medications, and therapies. When he read the criteria, he knew immediately that this was the constellation of symptoms which had plagued him since his early college years. He sought further education and specific treatment for BPD. While he continues to experience stress related to his symptoms, he is empowered with enhanced insight, understanding and self-compassion–which have naturally made a significant difference in living with this disorder.

Our calling is to do this work and identify the “asterisks” which surround us and rob us of our capacity to care. The story of BPD is a notable example. What asterisks do you see?

Featured image from Wikipedia

Kaz J. Nelson, MD
Program Director, Psychiatry Residency
Vice Chair for Education, Department of Psychiatry
Chair, Scientific Foundations Committee
Chair, Graduate Medical Education Committee
Associate Designated Institutional Official
University of Minnesota Medical School