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Frank Yeomans, M.D., Ph.D. explains how borderline personality disorder can be overcome

frank-yeomansDr. Frank Yeomans was a recent guest on the “In Your Right Mind” radio program March 5, 2017 episode discussing the diagnosis and treatment of borderline personality disorder (BPD) with hosts Kristina Kuestner, Drs. Tonmoy Sharma and fellow guest commentator Anthony Mele.

BPD is caused by a combination of inherited and environmental factors, and can be moderate to severe. In contrast to people with antisocial personality disorder, who often cause harm to others, people with BPD tend to cause problems for themselves.

Dr Yeomans now joins us for a follow-up Q & A to share valuable insight and direction for those with BPD and their loved ones.

Q : Thank you so much for your time and insight, Dr. Yeomans. In your recent interview on “In Your Right Mind” you shared that BPD as a condition characterized by chaotic emotional states and relationships, impulsiveness, risky behaviors and an unclear sense of self-identity, including a sense of profound emptiness. Living with BPD sounds like a real challenge, but as you stressed, specialized treatment can help. What are the goals of treatment?

A : The goals are, first, to get the symptoms under control and delve into the deeper issues of self-perception and interpersonal relationships. Frequent symptoms that need to be addressed are depression, anxiety and self-destructive behavior. As these begin to improve, patients start to feel well enough to participate in, and benefit from, psychotherapy at a deeper level. They begin to develop a better sense of who they are, to find satisfaction in their love life and other relationships, and find enjoyment in activities and success in their work life.

Q : As psychiatry shifts toward measurement-based care, are there any specific tools that can be used to measure clinical improvement in patients with BPD?

A : Yes, there are so many – first, there are symptoms scales, such as those that measure depression and anxiety. Aggressiveness can be part of the condition and we have scales for that. In terms of quality of life, there is the Social Adjustment Scale. We also have a structured interview that assesses personality organization. The interview measures personality integration in contrast to a fragmented or contradictory sense of self, which is a critical element in BPD. Those are just a few tools that we commonly use and are very relevant for most patients, but there are many others available, depending on patient presentation.

Q : Interesting. In terms of therapeutic strategies, how does transference-focused psychotherapy (TFP) help patients with BPD?

A : Basically, we understand that BPD is rooted in both neurobiology and personal development, and is related to a lack of communication between two different parts of the brain. The brain is the biological driver of what we feel and how we react. The workings of the mind are a higher level of organization that involves how we perceive and understand things – the meaning we assign to things. Positive emotions and negative emotions come from separate brain centers that need to be linked for normal cognitive function. But patients with BPD tend to perceive things as all good or all bad. Because of that, TFP focuses on building the missing link to connect the two areas. So, when a patient comes into a TFP session, we help them see how they transfer their internal perceptions of themselves to external experiences and relations. We help them move beyond their gut level of perception, and teach them how to reflect on their environment and connect to it.

To illustrate my point, let us take, for example, a patient with BPD who sees the therapist looking at the clock and interprets it through the lens of exaggerated negative feelings of neglect and rejection. The previously calm patient may become intensely hurt and angry and accuse the therapist of wanting to get rid of him. The therapist’s role would not be to “talk him out” of his perception, but rather to engage the patient in observing the perception and being curious about it. With the therapist’s help, the patient can get to know and understand his extreme perceptions and reactions, and how he may not be clear about which feelings originate in him, and which come from an accurate observation of the world around him.

In a nutshell, we help patients distinguish better between the images in their internal world and the surrounding external reality. We help patients to see what they transfer from their internal world, which may exaggerate or be inaccurate, to the external reality. We create a setting where we help patients to integrate their extreme negative and positive experiences as a cognitive exercise, while engaging their natural emotional responses as they arise in the therapy.

Q : How does TFP fit in with other forms of psychotherapy for patients with BPD?
A : We use dialectical behavior therapy, which is a form of cognitive behavioral therapy developed specifically for treating BPD, is very helpful for patients and helps them to function better. Many of my patients who have had this type of therapy says it helps them to control their behavior. TFP, however, goes to the next level and improves how patients think and feel, creating more positive emotions about themselves and others. It engages the mind to integrate the positive and negative emotion centers in the brain.

Q : Is there a link between borderline personality disorder and addiction?
A : Yes, in many cases there is a connection. Although one can have an addiction and not a personality disorder, my experience is that addiction is very common in people with BPD. It makes sense, because people with extreme and very uncomfortable emotions often try to self-medicate with alcohol or drugs.

Q : On that note, can TFP be used to help patients struggling with addiction disorders?
A : Yes, we have had a great deal of success with treating those with addictions with TFP. However, there is a difference between substance use and chemical dependency. People with chemical dependency go into withdrawal syndromes when they stop taking their drug of choice. We can only use TFP to help people after they have detoxified and treated for their chemical dependency.

Q : Neurofeedback, which is a type of biofeedback to help patients regulate their brain waves, is effective for treating the impulsivity associated with other conditions, such as attention deficit hyperactivity disorder and substance use disorder. Is there a role for neurofeedback in treating BPD?

A : There are a lot of things that can be used with other BPD treatments, so I wouldn’t rule out biofeedback or neurofeedback. To my knowledge, there hasn’t been a lot of research done on it in this population to date, so until we know more, psychotherapy remains the core treatment.

Q : Are there any medications that help people with BPD?

A : This is such an important question in this day and age because psychiatrists are quick to prescribe medications for their patients. But if you look at the American Psychiatric Association’s guidelines for treating different disorders, BPD is the only one for which psychotherapy is the first-line treatment, not medication. A patient might benefit from medication to treat anxiety or impulsivity, but that would be for use as an supporting therapy, and not the actual treatment per se.

Q : Are there any dietary modifications that can help with the impulsivity, such as a low glycemic index diet?
A : The only research of which I am aware would be the addition of omega-3 fatty acids, which have been shown to be helpful in the management of BPD. Other than that, I am not aware of any studies on other dietary modifications that are particularly beneficial.

Q : Does physical exercise have a role in the management of BPD?
A : Exercise is good. Again, as supporting therapy, exercise can be beneficial for patients with BPD. We need more studies on it, but exercise certainly helps relieve symptoms of depression. In fact, I’ve been told that in the United Kingdom, when patients present with depression symptoms, the first prescription they are given is for exercise. I think exercise could be a very useful part of the whole package, assuming there is no significant individual contraindication.

Q : Thank you again for sharing your wisdom about BPD. I am sure that many people living with the disorder and their loved ones will find hope from learning that it is treatable and that people can move beyond it. Is there anything else you would like them to know?

A : People need to understand they are not alone. BPD affects more individuals than schizophrenia or bipolar disorder yet, for some reason, it isn’t as well known. So, people who are affected by BPD often have their distress compounded by thinking, “I’m the only person with this disorder.” I would encourage patients and their families to research out to the community.

It is very important to tell your listeners about appropriate resources because it can be hard to find accurate information about BPD and where to find treatment. The resources listed below can help patients and their loved ones to connect with people like them, and with helpers, all over the country and all over the world.

Most importantly, I would like people with BPD and their loved one to know three things: They are not alone. There is help. Treatment is a tough road, but it’s worth the effort.

Frank Yeomans, M.D., Ph.D., is a Clinical Associate Professor of Psychiatry at the Weill Medical College of Cornell University, Director of Training at the Personality Disorders Institute of Weill-Cornell, Lecturer in Psychiatry at the Columbia University College of Physicians and Surgeons Center for Psychoanalytic Training and Research, and Director of the Personality Studies Institute in Manhattan. He graduated from Harvard College and went on to obtain his medical degree from the Yale University School of Medicine. He trained in psychiatry at the Payne Whitney Clinic of the New York Presbyterian Hospital-Weill Medical College.

Dr. Yeomans is an internationally recognized expert in the investigation, teaching, and practice of psychodynamic therapy of personality disorders. He has written many important articles and books, including “A Primer on Transference-Focused Psychotherapy for the Borderline Patient, and Psychotherapy for Borderline Personality: Focusing on Object Relations,” co-authored with Drs. John Clarkin and Otto Kernberg.

About the author

Dana Connolly, Ph.D., is a senior staff writer for Sovereign Health, a behavioral health treatment provider with locations throughout the United States. She earned her Ph.D. in research and theory development from New York University and has decades of experience in clinical care, medical research and health education. For more information and other inquiries about this article, contact the author at news@sovhealth.com, visit us at SovHealth.com, Facebook and LinkedIn, or follow us on Twitter.