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1. 00:02 Today we're going to discuss two clinical constructs which are related to borderline personality disorder but are not the same. The first one is borderline pattern first described in the 11th edition of the international classification of diseases the ICD
2. 00:20 published in 2022. And the second construct is the borderline personality organization
3. 00:27 first proposed by who else? Otto Kernburg in 1967.
4. 00:33 The pattern and the organization are not the disorder. Stay tuned. The
5. 00:39 distinctions are fascinating. My name is Sam Baknin. I'm the author of malignant self- loveve narcissism
6. 00:45 revisited. I'm also a professor of psychology in various sunundry universities.
7. 00:52 Okay, let's start with a fact. There is no diagnosis of borderline personality
8. 01:00 disorder in the ICD11. None. There is no substitute for such
9. 01:06 diagnosis. There's no no borderline personality disorder by another name.
10. 01:12 None. Self-start experts who tell you otherwise have no idea what they're talking about. Instead,
11. 01:19 the International Classification of Diseases, the ICD, introduced a new construct, the
12. 01:26 borderline pattern. And I would like to read to you what it says. But before I
13. 01:32 go there, borderline pattern can be diagnosed together with highly specific
14. 01:40 trait domains and highly specific dysfunctions. As you may recall from my previous videos, the ICD is not like the DSM. Whereas the DSM provides essentially bullet a list of bullet
15. 01:52 points called diagnostic criteria. The ICD is much more fluid and allows the
16. 01:59 clinician allows the therapist and the psychiatrist and the psychologist allow them allows them to construct a
17. 02:06 composite a composite picture using a variety of trade domains, a variety of dysfunctions, clinical ratings and so on so forth. The clinical picture emanating from the ICD is much closer to reality, much more factual.
18. 02:22 And so a clinician may uh assign certain trait domains to a
19. 02:29 client upon presentation, then analyze the client's various dysfunctions,
20. 02:36 rate the client clinically, and tack onto add onto all this the borderline
21. 02:42 pattern specifier. And here is what the borderline pattern specifier in the ICD11 has to say.
22. 02:50 The B I'm quoting the borderline pattern specifier may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern
23. 03:01 of instability of interpersonal relationships, self-image and effects and by marked impulsivity as indicated by five or more of the following. Number
24. 03:13 one, frantic efforts to avoid real or imagined abandonment. Number two, a
25. 03:19 pattern of unstable and intense interpersonal relationships which may be characterized by vacasillations between
26. 03:26 idealization and devaluation typically associated with both strong desire for
27. 03:33 and fear of closeness and intimacy. Number three, identity disturbance
28. 03:41 manifested in marketkedly and persistently unstable self-image or sense of self. known as self-concept.
29. 03:49 Number four, a tendency to act rashly, recklessly in states of high negative
30. 03:56 effect leading to potentially self-damaging behaviors. For example, risky sexual behaviors, reckless
31. 04:04 driving, excessive alcohol or substance use, and binge eating or binge eating.
32. 04:11 Number five, recurrent episodes of self harm. Example, suicide attempts or
33. 04:17 gestures, self mutilation. Number six, emotional instability due to
34. 04:24 marked reactivity of mood. Fluctuations of mood may be triggered either internally by one's own thoughts, for example, or by external events. As a
35. 04:35 consequence, the individual experiences intense dysphoric mood states which typically last for a few hours but may
36. 04:43 last for up to several days. Next, chronic feelings of emptiness.
37. 04:50 Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper, yelling or screaming, throwing or breaking things, getting into physical fights and
38. 05:01 so on. And finally, transient dissociative symptoms or psychotic-like
39. 05:08 features, brief hallucinations, paranoia in situations of high effective arousal.
40. 05:16 The borderline pattern specifier continues to say, "Other manifestations
41. 05:23 of a borderline pattern, not all of which may be present in a given individual at a given time, include the
42. 05:29 following. A view of the self is inadequate, bad, guilty, disgusting, and contemptable. An experience of the self
43. 05:36 as profoundly different and isolated from other people. A painful sense of alienation and pervasive loneliness,
44. 05:44 proness to rejection, hyper sensitivity, problems in establishing and maintaining consistent and appropriate levels of
45. 05:51 trust in interpersonal relationships, frequent misinterpretation of social signals. So this is the foundation of the clinical assessment of a
46. 06:02 borderline pattern in patients which otherwise possess trait traits unrelated
47. 06:10 to borderline. So you could present for example you you could enter therapy as a
48. 06:16 client and the clinician would know not notice that you have negative effect you
49. 06:22 are dissocial you are antagonistic you are unencancic you have obsessive compulsive features and so on but at the same time you have a borderline pattern. So the clinical
50. 06:36 interviewing um is may lead to a kind of compounded
51. 06:43 diagnosis without labeling. There's no label there
52. 06:49 but capturing the essence of what's going on in the in the client's mind, the client's psyche, client's emotions, client's cognitions. The ICDbased
53. 07:00 assessment is very versatile, versatile, very flexible and very factual and I
54. 07:07 like it a lot much more than the DSM based questionnaers and and so on so forth. Um today we diagnose borderline
55. 07:16 personality disorder using the um what we call the Xan Zan BPD Z an BPD which
56. 07:27 was first proposed by Zaharini and others in 2006. Some clinicians are still using
57. 07:33 Gunderson's work, the DIIB, the diagnostic interview for borderline
58. 07:39 patients, but it's it's going out of fashion. Today, the ZAN BPD is is mostly
59. 07:45 used. And the rating of Zan BPD is a threshold for diagnosing borderline
60. 07:51 patterns or or even borderline personality disorder under the DSM.
61. 07:57 The ZAN BPD assesses borderline personality disorder
62. 08:04 but can be applied to the identification and delineation and description of the
63. 08:11 borderline pattern specifier under the ICD because the ZAN BPD is very
64. 08:18 flexible. The elements in the ZAN BPD, this test proposed by Zakarini in 2006, the
65. 08:25 elements include the assessment of anger, especially specific or different
66. 08:31 content areas, frustration, irritability, intense anger, mildly
67. 08:37 angry acts, intense angry acts of verbal nature, intense angry acts of a physical nature and so on. So there's a lot of attention paid to anger, aggression, internalized or externalized. Number
68. 08:49 two, the assessment of effective instability, volatility, liability,
69. 08:56 uh including again different content areas um somewhat or substantially out of proportion relative to the severity of life circumstances and triggers and other parameters, other delineators. There's also an assessment of chronic
70. 09:12 feelings of emptiness and again it's divided to different content areas and there's an assessment of serious identity disturbance including different content areas such as mild identity
71. 09:24 disturbances serious identity disturbances and so on. So the ZAM BPD
72. 09:32 captures the quiddity the very core the very essence fluctuating essence
73. 09:38 unstable essence of borderline. Other emphasis in the ZAN BPD to remind
74. 09:44 you it's a test for borderline personality disorder that is currently uh the dominant test. Other elements
75. 09:51 include the assessment of stress related paranoid ideiation or dissociative symptoms. And again the it's divided to different content areas. Mild feelings
76. 10:03 of distrust, unreality, sense of unreality, intense feeling of distrust or unreality, depersonalization, derealization and so on. There's an assessment of frantic
77. 10:15 efforts to avoid feeling the feeling of being abandoned or being rejected
78. 10:21 and overt or covert efforts to manage these fears. There's an assessment of self-destructive behaviors including suicide threats, suicide gestures and
79. 10:32 suicide attempts, different types of self mutilation, scratching, punching oneself, cutting, burning. Um and they
80. 10:42 these are all divided into minor or more serious and severe. There is an assessment of impulsive behaviors which is divided to 12 content areas. It's a very powerful test. And
81. 10:55 then there's an assessment of pattern of a pattern of unstable and intense personal relationships.
82. 11:02 areas that alternate between idealization and devaluation, dependency, fleeing from intimacy,
83. 11:08 engulfment anxiety, and having stormy relationships marked by arguments and breakups. So, a clinician under the ICD is
84. 11:19 perfectly authorized feel should feel comfortable to use the ZAN BPD test.
85. 11:27 Although albeit the Zan BPD is associated mainly with the DSM, it's
86. 11:33 still very good at spotting and feriting out borderline patterns.
87. 11:41 Now the problem with borderline any type of borderline borderline personality organization, borderline
88. 11:48 pattern, borderline personality disorder. The problem with all these borderline aspects of the personality is
89. 11:56 that borderline is often comorbid. It's often diagnosed with other mental health
90. 12:02 issue and these other mental health issue offiscate offiscate and cloud the picture. They contaminate if you wish the purity the unadulterated nature of
91. 12:13 the borderline construct and they raise multiple major issues.
92. 12:19 The ICD provides differential diagnosis in a variety of areas and we will discuss them in a minute and they all attendant upon they're all extensions of the borderline pattern in the ICD.
93. 12:33 Now the ICD mentions the issue of co-orbidity or co-occurrence
94. 12:39 in um in um border in the borderline pattern and it it touches on a wide
95. 12:47 range of symptoms what what is called internalizing features depression anxiety post-traumatic stress disorder externalizing features substance abuse suicidal behaviors self harm
96. 12:59 selfmutilation eating disorders attention deficits and interpersonal features which is a domain of what the
97. 13:06 DSM calls personality disorders. personality disorders in the DSM especially cluster B they are relational
98. 13:13 they have to do with interpersonal relationships but in borderline there's also a co-occurrence co-orbidity of
99. 13:20 psychotic features uh transient hallucinations extreme dissociation paranoid uh trends
100. 13:28 dissociation when I say dissociation I mean insomnia derealization depersonalization so this there is a huge overlap The the overlap is extremely unusual
101. 13:41 and when patient present the patients present they can be misdiagnosed with a mood disorder or an anxiety disorder or
102. 13:48 a substance use disorder or impulsive disorder or psycho or even psychosis
103. 13:54 when actually the problem is borderline features a borderline pattern or a borderline personality organization. There have been attempts actually to
104. 14:06 redefine borderline personality disorder as a mood disorder or as a mode of emotion dysregulation or as an impulsive disorder or as an interperson interpersonal disorder or as a complex traum trauma disorder post
105. 14:21 post-traumatic disorder. And for those of you who want to see all these a review of all these attempts, please see
106. 14:28 the work of Paris P A R I S Especially the articles he published in 2020. She
107. 14:34 published in 2020. So um there are major issues with the coherence and validity of the borderline construct. I'm not denying this.
108. 14:47 But it seems that the same problem exists with other mental health disorders. And we have to balance
109. 14:56 between lack of clarity, doubts, co-orbidities and co-occurrences on the one hand and on the other hand how useful the construct is. Does it allow
110. 15:09 us to identify and and the patient to profile the patient in a way which recommend itself
111. 15:17 to highly efficacious treatments? If the answer is yes, then we would rather keep
112. 15:24 the psychopathological construct even if it's a bit fuzzy and this is exactly
113. 15:31 what the ICD committee and the DSM committee have decided to do.
114. 15:37 Let's start with a few of the co occurrences and coorbidities. Depression is the number one. Depressive symptoms
115. 15:43 are actually the main reason why borderline pre uh patients seek treatments or present themselves.
116. 15:50 Um there are studies that show that all borderline patients at one time or
117. 15:58 another uh suffered from depressive disorders or depressive episodes or depressive
118. 16:04 symptoms. all there there's no exception
119. 16:10 and the crucial issue when we discuss the coorbidity of depression and BPD or
120. 16:16 borderline pattern in the ICD the crucial issue is of course stability versus instability
121. 16:24 borderline patients describe an unstable mood that is highly sensitive to interpersonal conflict real or anticipated and also reactive to stress. Stressors generate anxiety and depression in
122. 16:41 borderline patients much more than in in the general population or in patients with other issues.
123. 16:48 Um, and so this is what we call emotion
124. 16:54 dysregulation and it's pro probably a trait. So it's
125. 17:00 likely heritable, hereditary, genetic. Uh there's work by Linham as early as
126. 17:06 1993 alluding to this. And so this problem with regulating emotions
127. 17:13 explains why so many patients are chronically suicidal
128. 17:19 and um even when they're not depressed.
129. 17:25 Whereas a depressive person, pure depression may possess suicidal
130. 17:31 ideiation during the depressive episode. Borderline this is basically background noise. It's constantly there. It emerges all the time. Um I will not go into it right now but this is one coorbidity.
131. 17:47 A very problematic co-orbidity or a very problematic differential diagnosis is
132. 17:53 between borderline and bipolar. In many countries, clinicians, mental
133. 17:59 health practitioners and scholars make the egregious mistake of conflating the two. Recently I've
134. 18:08 been to Austria and people there scholars clinicians told me that BPD is bipolar which is rookie rookie mistake. It's mindboggling the level of ignorance
135. 18:21 that would motivate one to to make such a statement. Emotion dysregulation is the feature that distinguishes BPD from bipolar. In
136. 18:32 BPD, mood vacasillations are frequent, but they are short-lived. The mood swings are short-lived. In bipolar, the
137. 18:40 hypomomanic episodes can last days or even weeks. BPD can develop psychosis lasting as
138. 18:47 long as a few days. And these episodes are usually misidentified as mania.
139. 18:55 But again the medications used for bipolar disorders are totally ineffective in borderline. We tried we tried for decades they don't work.
140. 19:07 So this shows that the confusion between these conditions uh is seriously deletterious seriously
141. 19:15 damaging to the patient. There were even scholars who suggested the bipolar spectrum where the mild cases
142. 19:23 are diagnosed in the absence of manic or hypomomanic episodes. And this bipolar spectrum was immediately
143. 19:30 totally mixed with with borderline. It's a mess. It's a complete mess.
144. 19:37 Borderline is borderline. Bipolar is bipolar. They have nothing to do with each other. One is a mood, one is a
145. 19:44 personality disorder or personality pattern, one is a a mood disorder,
146. 19:50 biochemical background, everything is completely different. What about
147. 19:57 complex trauma or even post-traumatic stress disorder? about 25%
148. 20:03 up to 30% of people diagnosed with BPD borderline personality disorder these patients also experience post-traumatic stress
149. 20:14 disorder PTSD not CPTSD PTSD this coorbidity has to do with childhood maltreatment for example incest sexual
150. 20:26 abuse or worse so traum but trauma is not
151. 20:32 In the ethology of borderline personality disorder, trauma is not the main cause of borderline personality
152. 20:38 disorder. Various metaanalysis of studies, Porter,
153. 20:44 for example, did quite a lot of work. They suggest that emotional neglect,
154. 20:50 invalidation is the most important environmental risk factor for the disorder. Not abuse, not
155. 20:57 trauma. on the very contrary being ignored, being neglected. What about hyper um ADHD, attention
156. 21:05 deficit, hyperactivity disorder, it's a disorder that also starts in childhood, very similar to borderline, and continues into adult life, very similar to borderline. But BPD usually starts in
157. 21:17 adolescence, shortly after puberty, while um ADHD starts earlier. Some BPD
158. 21:24 patients of course can be diagnosed with ADHD. But ADHD is overdiagnosed
159. 21:31 and is threatening to replace legitimate legitimate diagnosis. It is metastasizing.
160. 21:38 Uh especially when childhood onset cannot be confirmed, it's probably not AD ADHD.
161. 21:45 When the whole set of symptoms, the symptomatology started in adolescence. It's probably borderline. So there's a
162. 21:52 huge confusion regarding the possible causes of attention problems with a specific diagnosis
163. 21:59 um reserved for medical conditions, stimulants and you name it. So it's a sprawling field and it seems that ADHD is consuming u diagnosis which have nothing to do with ADHD.
164. 22:16 Um BPD is as rare as NPD.
165. 22:23 The community prevalence of BPD is about 2%. But 10% or 9% of all clin of the
166. 22:34 clinical population of all people presenting for treatment 9 to 10% are actually BPDs border lines.
167. 22:41 So that gives the wrong impression that borderline is much more prevalent than it is. Similarly in narcissism about
168. 22:49 1.7% of the general population suffer from NPD and they are they are uh they
169. 22:57 present in therapy only following a collapse or modification and so on. So
170. 23:03 this gives the wrong impression that most narcissists are either covert or that the prevalence is much higher. To this very day, the perception is that
171. 23:16 most uh patients with BPD are women. But recent studies, especially community
172. 23:23 studies, show that there are many, many men with BPD who are undiagnosed and untreated. It's probably because women seek help for BPD much more than men. It's safe to
173. 23:36 say that half of all border lines are men and half of all narcissists are women.
174. 23:42 What about genetics? Whereas in pathological narcissism, we
175. 23:48 do not have a convincing rigorous body of studies that proves that pathological
176. 23:55 narcissism is genetic. That's not the case with borderline.
177. 24:01 Behavioral genetic studies using community samples of twins have found that nearly half of the variance in BPD is heritable
178. 24:12 is related to genetics. So there are no genetic markers for BPD
179. 24:19 or actually for any other diagnosis in psychiatry. Believe it or not, this myth online propagated and perpetuated by charlatans that the mental health
180. 24:31 disorders are hereditary or genetic. We don't have a single genetic marker
181. 24:39 single for any psychiatric disorder. Yes, this includes
182. 24:45 schizophrenia and psychotic disorders, let alone narcissistic personality disorder and so on.
183. 24:53 It's in se several studies have shown that if BPD is related to is genetically
184. 25:01 determined probably it would involve hundreds or thousands of interacting genes
185. 25:10 which and all these genes put together account for less than 5% of the variance
186. 25:17 in borderline. So there's a heritability gap. There are many interactive pathways leading towards disorder and no they are not genetically determined.
187. 25:32 Most but not all people with borderline with the borderline pattern have been exposed to environmental adversity in childhood. Adverse childhood experiences or trauma or abuse in a variety of ways. Remember, abuse doesn't have to be
188. 25:47 physical or verbal or psychological. A a parent, a mother, a parent who
189. 25:54 instrumentalizes her child, parentifies their child, overprotects the child, spoils the child is abusing the child.
190. 26:01 I've dealt with it in other videos, but most
191. 26:07 uh BPD most uh patients with borderline personality disorder, if not all of them, have been exposed to environmental adversity in childhood and in adolescence. Trauma is pretty common in in the borderline ethology, but it's not the
192. 26:25 main risk factor. The most frequent kind of trauma is emotional neglect as I told or emotional
193. 26:33 abuse. There's a high frequency of dysfunctional families in borderline personality.
194. 26:40 But there are other studies which seem to challenge this. For example, sibling
195. 26:47 studies. Siblings raised by the same parents, even twins, are rarely
196. 26:53 concordant for BPD. In other words, they rarely develop BPD simultaneously. this there is some gene environment interplay or interaction here. There's a
197. 27:05 differential sensitivity to the environment. And so probably we need to develop a
198. 27:12 bioocial theory of borderline. Borderline is also common in developed countries but less prevalent in less developed countries in developing countries. Of course, one possible
199. 27:24 explanation is that traditional cultures offer more resources for emotional
200. 27:30 support and they're protective against against this form of mental disorders. And of course, in le in least developed
201. 27:36 countries, there is no infrastructure to diagnose people. Now, longitudinal studies found that somewhere between 5 and 10% of patients
202. 27:47 with borderline, it's closer to 10%. Sometimes it's 11% in some studies. These patients eventually die by suicide. Suicide is the leading cause of death in borderline personality disorder
203. 27:59 under the age of 70. It is notable that almost all these patients had chronic
204. 28:07 suicidality and all border lines
205. 28:14 chronically all the time contemplate suicide, ideulate suicide, consider
206. 28:20 suicide, even make preparations for suicide and attempt suicide. Yet only
207. 28:26 10% die of suicide. The lifespan of patients with borderline
208. 28:32 is shortened but it's shortened by poor health. So border lines live 10 to 20
209. 28:39 years less fewer years than normal people. It's it's common in most in most severe
210. 28:47 mental health issues psychotic disorders for example. Most patients with
211. 28:53 borderline pattern first develop clinical symptoms during adolescence and the peak of the
212. 28:59 psychopathology tends to be in late adolescence and early 20s and after this stage the disorder tends to remit or
213. 29:07 recede gradually with the vast majority of cases no longer diagnosed by age 35
214. 29:13 to 45. No longer diagnosible disorder just remits spontaneously goes away. the prognosis for borderline is actually
215. 29:24 extremely good whereas in narcissism it's actually extremely bad. Okay,
216. 29:32 that's a picture given to us by the ICD and I would like to compare it to a
217. 29:38 construct proposed by Otto Kberg the one and only the father of the field in 1967. He came up with the idea with the construct of borderline personality
218. 29:49 organization. He suggested there's a level of personality organization which is characterized by instability in ident
219. 29:56 in identity instab volatility of relationships and effect liability and
220. 30:02 effect and as well as the use of what is
221. 30:08 what we call in psychoanalytic literature primitive defense mechanisms such as splitting.
222. 30:14 It's a psychoanalytic concept. Um, and it describes the structure of personality functioning that lies between neurotic and psychotic levels. So while borderline personality
223. 30:26 organization is somehow related to borderline personality disorder, it's not synonymous with it. It represents a
224. 30:33 broader spectrum of personality functioning or to be more precise personality dysfunctioning. The key
225. 30:40 characteristics of borderline personality organization are very similar to the borderline pattern. And I
226. 30:47 regret that the ICD didn't bother to credit Ottober with these insights.
227. 30:53 The borderline personality organization includes these features. Identity diffusion, a lack of stable and integrated sense of self with shifting and contradictory self-perceptions.
228. 31:06 unstable relationships, intense but yet unstable interpersonal relationships marked by idealization and devaluation of others. Primitive defenses, immature defense
229. 31:18 mechanisms such as splitting, viewing people as all good or all bad. Projective identification, projecting one's own unacceptable feelings onto others and forcing them to accept this projection. and denial.
230. 31:30 Impulsivity, difficulty controlling impulses leading to behaviors such as substance abuse, reckless driving, or
231. 31:37 risky sexual behavior. Emotional or emotion dysregulation, difficulty managing and regulating
232. 31:43 emotions, often experiencing intense and fluctuating moods, brief psychotic
233. 31:49 episodes, micro episodes. In times of stress, individuals may experience brief periods of distorted reality testing.
234. 31:57 Fear of abandonment, a pervasive fear of being abandoned or rejected, which can lead to clingy or avoidant behaviors in
235. 32:04 relationships, difficulty with reality testing. I want to clarify. People with
236. 32:10 borderline personality organization are not psychotic but they may have difficulty to maintain a stable sense of
237. 32:17 reality particularly particularly when they are stressed or challenged or rejected or humiliated or abandoned or
238. 32:24 engulfed with intimacy. So there's a difference between
239. 32:30 borderline personality dis disorder and borderline personality organization. Borderline personality organization is a
240. 32:37 broad concept an umbrella concept. It encompasses a range of personality functioning levels and personality
241. 32:44 dysfunctioning levels. While BPD is a specific clinical diagnosis, BPD is more
242. 32:50 severe than BO. The disorder is more extreme, more harsh, more severe than the
243. 32:56 organization. BPD is characterized by a greater degree of impairment in
244. 33:02 functioning. A more diagnosible clinical picture and very um conspicuous clinical
245. 33:09 features. Individuals with the organization may not meet the criteria for for the disorder. They display some
246. 33:16 of the core features associated with it but not all. It's very reminiscent of Len Perry's idea of personality styles.
247. 33:25 Sperry suggested that there is a borderline personality style. Borderline personality organization
248. 33:31 represents a level of personality organization characterized by a particular constellation of features and
249. 33:37 defense mechanisms. It provides a framework for understanding and classifying individuals with varying
250. 33:43 degrees of personality difficulties including those who may or may not meet the full criteria for borderline personality disorder. some literature
251. 33:54 um in the description and now you're fully acquainted with the ICD's approach
252. 34:01 to borderline features the borderline pattern having eliminated borderline
253. 34:07 personality disorder and emotional emotional uptake or emotional regulation disorder having eliminated them in the latest 11th edition.
254. 34:18 Borderline personality disorder is still a hotly disputed diagnosis.
255. 34:24 As I said earlier in this video, many scholars are attempting to subsume it under other mental issues or conflate conflate it with other mental issues.
256. 34:37 But I believe that the borderline pattern or the borderline personality or organization is a valid clinical
257. 34:43 construct which captures the essence of some individuals the way nothing else
258. 34:50 can. See if you agree.