David Baxter PhD
Late Founder
An Interview with Joel Paris, M.D. on Treatment of Borderline Personality Disorder
by David Van Nuys, Ph.D., MentalHelp.net
Dec 15th 2009
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Joel Paris, MD. on Treatment of Borderline Personality Disorder (BPD). BPD involves a chronic pattern of unstable relationships, impulsivity and emotional instability often accompanied by cutting (self-harm behaviors) or suicide attempts. The causes of BPD are not completely understood, but likely involve a complex inter-relationship between inherited biological vulnerability and life circumstance. Dr. Paris' message is one of optimism: Good treatments specifically targeted to BPD now exist that been demonstrated effective with clinical trials. Dialectical Behavioral Therapy (DBT) is one, and Mentalization Therapy is another. These treatments involve talk-therapy with a strong educational componant (designed to help patients learn coping skills), the validation of patients' inner experience, and a push to engage work and social relationships. Drugs are not generally helpful when treating this diagnosis and in some cases can be harmful. Most people who receive these treatments will experience an improvement in their functioning within a year, and across the lifespan, many people with BPD tend to improve with age anyway.
David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show (download mp3 podcast here), we'll be talking about the treatment of borderline personality disorder with my guest, Dr. Joel Paris. Joel Paris, M.D., is a research associate at the Sir Mortimer B. Davis Jewish General Hospital in Montreal. Since 1994 he's been a full professor at McGill University and served as chair of its Department of Psychiatry from 1997 to 2007. He has supervised psychiatric evaluation with residents for over 30 years and has won many awards for his teaching. Dr. Paris is a past president of the Association for Research on Personality Disorders. Over the last 20 years, he has conducted research on the biological and psychological causes and the long-term outcome of borderline personality disorder. Dr. Paris is the author of 135 peer reviewed articles, 11 books, and 25 book chapters. He's also editor-in-chief of the Canadian Journal of Psychiatry. Most recently, he's the author of the book, Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice.
Now, here's the interview.
Dr. Joel Paris, welcome to Wise Counsel.
Dr. Joel Paris: Thank you very much.
David: Well, I'm happy to have the opportunity to speak with you. I've been reading your book, Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice, and I'm finding it full of fascinating and useful information.
Dr. Joel Paris: That's great.
David: Yes, and as I was reading it, I was gratified to see that I've interviewed a lot of the people that you cite, for example, Marsha Linehan, Jeffrey Young, John Clarken, and Otto Kernberg.
Dr. Joel Paris: Yes, there's about a hundred of us working on this, I would say.
David: Oh, my goodness.
Dr. Joel Paris: So we all know each other.
David: Yes, I bet you do. Well, to get started, perhaps we should have you tell us a bit about borderline personality disorder, understanding that we have some professionals who listen to the show and probably even more lay people.
Dr. Joel Paris: Right. Well, a personality disorder is something which starts when you're young, usually in your teenage years. It's not an episode like depression or a panic attack; it's a continuous problem that affects you over a long, long time, and the way it affects you is in your emotional life, your relationships, your ability to work, to some extent the way you think, your ability to control your impulses. So it's a very broad concept, but it explains problems that go on in a fairly severe way for years and years.
Now, borderline personality disorder is the type that we see most often in a clinical setting, and these patients are best known for two things. One is that they cut themselves quite often to relieve tension, and the second is when things go bad for them, they'll take overdoses of pills, and although they occasionally do commit suicide, the usual result is they end up in the emergency room having to get their stomach pumped.
So these behaviors indicate that they're quite impulsive, and behind that impulsive tendency is what Linehan calls "emotional disregulation": their emotions are very unstable; when they get upset, they can't calm down. And this is not manic-depression or bipolar disorder, which it's often mistaken for, because this is not a situation where somebody stays in the same mood for days or weeks at a time. The mood shifts around from hour to hour, from event to event. The patients tell you they're on a rollercoaster.
So between this emotion disregulation and impulsivity, they're really quite troubled, and their relationships really suffer. Some of them are able to hold a job and go to school and function well in a structured environment, but most of them have trouble with intimate relations, where they get overly attached, overly disappointed, things break up quite rapidly, there's a lot of storm and stress and arguments, and this often leads to other difficulties. Some of these patients also have what we call cognitive symptoms, where they feel a sense of unreality about the world, and some of them will also hear voices from time to time when they're under stress although they know that that's not real. So that's the clinical picture.
David: Wow. It certainly is a complex picture.
Dr. Joel Paris: Very complex.
David: Yes, and you've sketched it out for us really well. Personally, I've always been bothered by the designation "borderline personality disorder." Like borderline between what and what?
Dr. Joel Paris: Yes, well, it's a bad term, but there's a whole bunch of them in psychiatry like that. Schizophrenia means a split head and it doesn't mean anything, but we're sort of stuck with it. Borderline is based on a theory that goes back 70 years that these patients were somewhere in the middle between a neurosis and a psychosis.
David: Yes, I think that's what I learned when I was in graduate school not quite 70 years ago. But they were still saying it.
Dr. Joel Paris: That was the border they were talking about, and it's really not a good term, but the reason why many experts have resisted changing the name is because all the names that have been suggested instead make assumptions about the nature of the problem which may or may not be correct. So if we called it emotional disregulation disorder, that wouldn't really cover all the bases that I've just described, and so we're waiting to understand this better or maybe eventually it might be divided into subtypes. If you don't know a better choice, you're probably better off sticking with the one you have.
David: Well, that's interesting because somebody I interviewed - and I don't remember who it was - when I raised my discomfort about the term borderline personality disorder, they had suggested that there was another name in the offing that was being considered by the latest DSM group, but it sounds like maybe that's not going to happen.
Dr. Joel Paris: I don't think so. There's going to be? they're talking about all kinds off changes in DSM V, but my sources tell me the word borderline will still be in there somewhere, for better or for worse. By the way, if we changed the name, the stigma attached to the disorder wouldn't go away.
David: Yes, that issue of stigma - there is always that problem of stigma that attaches to psychiatric diagnoses and this one in particular. Certainly, psychotic and schizophrenic - those are pretty heavy. Does anybody ever come in with a self diagnosis and saying, "Doctor, help me. I have a borderline personality disorder"?
Dr. Joel Paris: Well, actually, some people do.
David: Really?
Dr. Joel Paris: Yes. Now, I must tell you, the diagnosis itself does reflect a certain unpopularity among psychiatrists and psychologists who are afraid of these patients because they're often threatening to kill themselves. They can be suicidal for years, and they can leave your office and say, "I don't know if I'll see you next week," and it's scary. So a lot of people have trouble with these patients, but recently there's been a movement on for education, and the National Institutes of Mental Health supported a program in which educational events were held all over the United States and in other countries to raise public awareness about borderline personality disorder, and the US Congress determined that May 2009 was Borderline Personality Disorder Month, which reflected, I think, the parent of a patient who knew a congressman or something.
David: Did you say that's May?
Dr. Joel Paris: May, this May, May of this year.
David: Oh, my God. That's my birthday month. Oh, no.
Dr. Joel Paris: Yes, mine too. What I find now with patients is that we used to be afraid of giving them this diagnosis and, in fact, patients feel better to have a diagnosis because it means that the doctor knows something about it; there's a literature out there; there's research; we can predict how things are going to turn out; we have specific treatments now which are mainly for this disorder. And so a lot of us now explain the disorder to the patients; we encourage them to go to the web, read up on it - there's a number of good, reputable websites - and most people are happy to hear this because it's good news. They've been given much worse diagnoses: they've been told they have bipolar disorder, which has a much worse prognosis, or sometimes even been told they're psychotic. So, in fact, when they realize that there's something out there that describes their problems fairly accurately, they like that; they feel better.
David: That's fascinating, and that really does sound like a sea change.
Dr. Joel Paris: It is.
David: A lot of clinicians kind of resist giving diagnoses, maybe because of the stigmatizing and so on, or they feel that it's not going to really change what they do. But you feel that diagnosis is very important and particularly for this disorder. Maybe you can say something about that.
Dr. Joel Paris: Well, yes. Well, the reason for that is that what we've discovered in recent years is that there are specific types of therapies - talking therapies, psychotherapies - that work for this disorder. So if you don't recognize it, you won't order them. In fact, two big mistakes are made: first of all, the patients may be seen by physicians who see the patients are chronically depressed and pump them full of antidepressants and other drugs which don't work very well, and the research shows that. The other mistake is they get a kind of generic, non-specific psychotherapy - "How was your week?" "Hope things aren't going too badly for you" - which isn't very effective. But in the last number of years, we know that specific programs, well structured programs which target the emotion disregulation and impulsivity, work.
Now, Marsha Linehan - you said you interviewed her - she was the pioneer. She had the first one way back in 1991, and that's still going well. There's a second one that was developed in London, England, called mentalization-based therapy which has several clinical trials behind it, and there's a few competitors as well which don't have quite as much research behind them.
But what these methods have in common is you don't just sit there and listen, you go after the specific problems that these patients have. It's really a kind of a teaching procedure where you're helping them to learn more life coping skills, and the research is very encouraging. The problem is where do you find the money to pay for treatments that require going regularly for months at a time. So that's another issue.
David: Yes, well, maybe we'll drill down into treatment a little bit more down the line.
Dr. Joel Paris: But that's why diagnosis is important, because if you don't recognize what's going on, you won't be able to direct patients to the proper treatment.
David: And yet the diagnosis, to me, seems like it would be very challenging because, as you point out, there is what you describe as the co-occurrence of multiple symptoms: for example, cutting and suicidality - which you've already mentioned - hearing voices, and so I would think that issues of differential diagnosis? I assume that there are other reasons why people cut themselves or attempt suicide. So how do you make this diagnosis?
Dr. Joel Paris: Actually, the repetitive cutting is - this is the first thing you think of when you see it in a young person. The suicide attempts, of course, can be all kinds of other things, too. That's correct. In fact, it's like everything else in medicine: if you see a typical case, you can make the diagnosis in five minutes, and the challenge only comes when you have some features and not others, and there are always marginal clinical pictures which are more difficult and more challenging. I'd say 90% of the time, there's really no problem in diagnosis once you get the idea of what this thing is about, when you've seen a lot of these patients.
David: Interesting.
Dr. Joel Paris: I've trained non-psychiatric physicians and psychologists to pick up the diagnosis rapidly, and it's really not that hard.
David: Yes, well, one of the things that I was fascinated to read because not only would clinicians sort of flee working with these people for fear that they might commit suicide, but it just does have the reputation of being very difficult to treat, yet you cite recent research - evidently a very large-scale research - that shows that, on the whole, these people get better.
Dr. Joel Paris: Yes, well, in fact many of them get better even with time. This is part of some research that I've been involved with myself. The longer you follow them, the more likely they are to have recovered. You don't see many middle-aged or older people with this problem; this is a problem of youth. Although some of them do commit suicide, the vast majority of them don't, and by 40 or 50 for sure they're much better - many are better by 30. And so it's a bumpy ride, but a lot of people do well. One of the things that you see when you practice medicine is that the worst cases keep coming back, and the ones that get better sort of disappear, so it gives you the wrong impression about prognosis.
David: Yes. How did you get into this area of specialization in the first place?
Dr. Joel Paris: Well, I was a young psychiatrist, and I become interested in people who were suicidal because I thought that if they were suicidal, I could tell whether they were alive or dead at the end of the treatment and whether I was making a difference. And I also found it very interesting to try to understand why people felt that way. I wrote a book about this. I quoted John Keats and called it Half In Love With Death. It's like they're fascinated with dying, and they need that exit door in order to keep on living, so it's a very interesting relationship between life and death. I've talked to some of my colleagues about this, and we agree most of us are pretty straight arrows and we find these people kind of fascinating and it's a challenge, and as a medical specialist, I should be treating pretty sick people.
David: So somehow your interest in suicide, then, led into this?
Dr. Joel Paris: That's right.
David: And you got very involved with research. It's really, I guess, both a clinical and a research career that you've had.
Dr. Joel Paris: That's correct.
David: Okay, well, how has our understanding of the underlying causality and dynamics of borderline personality disorder evolved over time?
Dr. Joel Paris: Yes, well, you're asking me what's behind this. I wish I knew.
David: Yes, we had earlier conceptions about what's behind it, and maybe we have some new ones now that are better informed.
Dr. Joel Paris: Well, we don't. I think the short answer is that we mostly don't understand this very well. In the days of psychoanalysis, they had very firm ideas that this was caused by problems early in childhood, but in fact, most of these people are normal, fairly normal - not all of them - but a lot of them have fairly normal childhoods, and all hell breaks loose at puberty.
So some of them come from terrible families with alcoholic fathers - this is fairly common - but not all of them. Some of them have histories of physical and sexual abuse, but many of them don't. Now, there are genetic studies which suggest that there's something, some heritable vulnerability for this disorder, and we know that people who suffer very traumatic life experiences don't always get sick.
So there's a combination of a biological vulnerability and difficult life experience, but you can't assume that every one of these patients necessarily has had a terrible childhood. More of them do than the average person, and more of them do than a lot of other patients we see, but it's not a one-to-one correspondence. So this is really what makes it complicated.
David: Yes, you indicated that, to some extent, there's a hereditary component. I would think that maybe that would have something to do with the emotional disregulation that you talked about earlier?
Dr. Joel Paris: And the impulsivity, both, yes. There's some evidence that the impulsivity is related to disordered serotonin metabolism, but it's a little vague at this point.
David: Yes, I was going to ask about brain correlates. With all the brain imaging that's going on today?
Dr. Joel Paris: Yes, it's been done. Certainly we know, for example, that - just to give an example of their emotionality - their amygdala, which is kind of the alarm bell in the brain, goes off quite easily and is hyperactive. There's some evidence that in the prefrontal areas, which control judgment and reasoning and where you keep your impulses under control, that there may be something defective there. It isn't very specific, and I'd say we're just at the beginning.
David: Okay, when you talk about the amygdala and so on, and earlier you made a reference to pharmacology, to drugs, and I know in your book you say that drugs are overused and often do more harm than good in relation to this disorder.
Dr. Joel Paris: Yes. This is not because I'm one of these psychiatrists who hates drugs. I don't feel that way at all, but in this particular population, because they have so many symptoms and because psychiatrists these days rely mostly on drugs and maybe also some of these patients are being treated by general doctors who do the same, I think there's a tendency to push the drugs too hard, and they're actually overrated. Many of these patients - the sicker ones - you'll see around four or five different pills, and this is a real problem because some of them do have serious side effects, particularly the antipsychotics - the antidepressants I don't think really do much harm. And so I think these patients are being over medicated, whereas the evidence as I read it for psychological treatment is much stronger, the problem being where are you going to find it? Who's going to do it and who's going to pay for it?
David: Yes. I sort of go, "Yay!" when I hear about the effectiveness of psychological treatment - being biased as a psychologist.
Dr. Joel Paris: Right.
David: Now, as I mentioned earlier, the subtitle of your book is A Guide to Evidence-Based Practice. Perhaps you can take our listeners a bit through the evidence based movement.
Dr. Joel Paris: Well, some people are surprised to hear that medicine isn't always evidence based, but I must tell you I'm old enough to remember a time when there was very little evidence and when everything was based on clinical experience and what the white-haired senior doctor said based on what he had seen over the course of his career. The problem is you can be white-haired and senior and be completely wrong.
So evidence based medicine is a movement within medicine which developed in Oxford, England, and also in Canada to base medical treatment as much as possible on research. And that research often consisted of randomized clinical trial, where you give a treatment and randomly pass the patients something else or a placebo or something like that. And you should have a lot of evidence to prove if you have one? Sometimes doctors read one study and they run with it, and that's a big mistake because you need lots of research, which is consistent, to prove things.
Now, the problem is, in medicine, there's a lot of things which we don't have evidence one way or the other, so we're stuck with our clinical judgment. Nevertheless, as time goes on, particularly in the younger generation - and I think the same movement has moved to psychology in terms of evidence based practice - as time goes on, there's more and more respect for data, and clinicians are reading more research. So that's the idea. And the idea of the book is to say this is not just another book saying I treated 100 patients and here's what I think - God knows there've been a lot of books like that. This is a book which says I have read all the research, and this is how I put it together, and this is the state of our knowledge as of now. So that's the approach.
David: And one of the beauties of your book, I might add, is that you summarize that evidence, you summarize all of that research, in sufficiently clear terms that I think any intelligent layman could benefit from reading it.
Dr. Joel Paris: Thank you, I certainly hope so. I tried hard.
David: Yes, and I've also been impressed? in these interviews, I've discovered that what you say is true, that younger clinicians are more familiar with research, I think, than they used to be; that they actually are reading the research and applying it to their work, which I don't think was so much the case when I was coming up.
Dr. Joel Paris: No, it certainly wasn't true in the '60s and '70s.
David: Yes, that's when I was coming up.
Dr. Joel Paris: We're the same age, then.
David: Now, the "mind" is so complex. I understand the impulse behind the evidence based movement, but I'm wondering if you see any danger that the insistence on rising to that standard might jeopardize approaches whose subtlety might not be easily measured.
Dr. Joel Paris: Well, yes, I think there's something to that. The problem is not so much the evidence based approach. The problem is everyone wants to make things simple, and the simplest things in my area, which is medicine, is to write a prescription. And so I don't think that clinicians take the time to understand people as much as they used to, and I've written a couple of books about that too.
Certainly in borderline personality disorder, at the very least you have to take the time to go over the complex symptom picture and to get a proper life history. And it really isn't that difficult, but you have to know how to talk to people, and you have to be sensitive to the patients. And some of the stuff that I learned when I was young, it wasn't evidence based, but there's a kind of quality of humanism that is required to work with people who are constantly thinking of killing themselves. So, yes, I think I agree with what you're saying.
David: So I believe you propose a treatment model that integrates a number of approaches, and you started to talk about that before, and you actually in the book succeed in summarizing it fairly succinctly. Maybe you can take us through that.
Dr. Joel Paris: Yes, well, what I say in the book is that the best evidence is for psychological treatments that are designed for this particular population. And these treatments have a large educational component; they're very well planned and structured; they don't leave patients hanging and blowing in the wind; they are really worked out.
Now, what I also say, though, is that you shouldn't throw up your hands if these specific treatments are not available in your community. One often hears people asking, for example, for dialectical behavior therapy - that's been around for almost two decades - and where can I find it, and it's not available in many places. It's not available in my city, either, because it's very expensive and uses up a lot of resources.
So what I recommend in the book, which is primarily addressed to practicing therapists, is that they adapt some of these ideas into their normal practice, and instead of looking to send patients for some expensive referral, to try to apply some of these ideas in their own work, which is more or less what I've done. I have learned from my colleagues, many of whom are working in the field and have terrific ideas about how to treat these patients, and I've tried to develop my own personalized way of doing things.
And I also advocate trying to get these patients back on their feet as rapidly as possible and not expecting that it's going to take years to treat everybody because I think that's kind of negative and demoralizing. A lot of these patients can be gotten better in a few months, some of them in a year or so, and it's only a minority that are going to haunt the clinical system for years to come. So I advocate an optimism and also, on a very practical level I think, you have to help these patients get back to work or go to school. They can't be sitting around collecting a welfare check; it's murder for them.
David: Yes, I was struck by your down-to-earth approach, and you advocate that they need to get a life.
Dr. Joel Paris: That's right. I think that's the central point.
David: Yes, and often that's really a challenge. I'm wondering - talking about the social factors right now - unemployment is very widespread. This could perhaps be an aggravating factor.
Dr. Joel Paris: It is an aggravating factor, although I think that it's not so bad that people who are motivated can't find something or can't go back to school to prepare themselves for something. The programs that I'm involved with are all very much oriented towards getting people back into the world, and we're not looking at a Great Depression; we're looking at a higher level of unemployment. But the fact is that these patients, if they really want to, some of them will take jobs that other people might not want to take. I tell them it's part of their treatment.
David: Yes, the things that you emphasize, I seem to recall three points stuck out for me that you found as being in common to the successful approaches, and one was validating their experience - I guess that's accepting what they're describing as their inner world - and in developing some kind of capacity for self observation, and then finally this third stage of working on getting them engaged in work and relationships.
Dr. Joel Paris: That's a very good summary. These ideas are not totally original with me; therapists have talked about them for a long time. Marsha Linehan has talked a lot about these ideas, so has Anthony Bateman, the British psychiatrist who has a different method. But I think these are the essentials; yes, I think that's a good summary.
David: Okay, do you have any sense of the recovery rates that are more promising than we might have guessed? Do you have any numbers?
Dr. Joel Paris: Yes, I do. I followed a large cohort, and basically by age 40, 75% had recovered and by age 50, 90% had recovered. Now, you might say, "Do I have to wait till I'm 40 years old to feel better?" And I would say "not necessarily." There are some more recent studies which use what we call the "perspective method," where you take a bunch of patients, and you sign them up, and you follow them for 10 years. So these studies have found that people stop cutting and overdosing often within two or three years, many of them, but they continue to have a lot of trouble functioning for a longer time. But in the end, most of these patients are working and having some kind of a social life by 5 to 10 years after diagnosis. And so I think the prognosis is actually pretty good, and I don't think not all my clinical colleagues understand this and have the message, especially when they prefer to diagnose conditions which have a worse prognosis.
David: I was going to ask you if the Canadian government gave you several millions of dollars for future research, how you'd want to spend that, but I get the impression that, really, maybe what's needed is not so much more research as more educational outreach to therapists.
Dr. Joel Paris: Well, I think both are needed. I very strongly believe that research is just beginning. It's been pointed out by several experts in the field that the prevalence of borderline personality disorder is about the same as schizophrenia, maybe even a little higher. It's about 1% of the population in most studies. and yet 10 to 20 times the money is spent on schizophrenia research as is spent on research in borderline personality disorder. We haven't cracked the schizophrenia problem either, but I think we do need research money and support to understand where this thing comes from so as to make our treatments more specific. So I very passionately believe that the researchers are going to come up with answers. I wish I could live another 50 years to find out what they're going to be.
From what we already know, we do need to get a message out to clinicians and to the general public that this is a big problem, but a treatable one, and that clinicians shouldn't be afraid of it. You know, many people have relatives with this condition, and some of them have even formed a national organization to increase general knowledge about the condition, so I think this idea is coming of age, and I think it has a certain momentum behind it, and I feel fairly optimistic that we're going to get somewhere.
David: Well, that feeds into one of my last questions here, which was to ask your advice for families that may have someone who suffers from borderline personality disorder.
Dr. Joel Paris: Well, there are all kinds of groups that help people. In the United States, NAMI has done a wonderful job.
David: That stands for National?
Dr. Joel Paris: National Association for the Mentally Ill. I'm not sure, I think that's them.
David: I think you're right.
Dr. Joel Paris: And they have now recognized that borderline personality disorder is part of their mandate as well because they had started only with the psychoses, and they're now extending that. There's a lot of information available on the web, but these support groups exist. I think there's probably something in all of the major cities in North America of that nature. And I know that I've been involved in some of the events which have taken place to publicize this and to get that message out.
David: Oh, that's great. Dr. Joel Paris, thanks so much for being my guest today on Wise Counsel.
Dr. Joel Paris: Thank you very much for having me. Thank you for reading my book and preparing so well for this interview. You did a great job.
David: I hope you learned as much from this interview with Dr. Joel Paris as I did. If you're a therapist, I'd say his book, Treatment of the Borderline Personality, is a necessary addition to your library. It's very clearly written, summarizes a vast amount of research in a most readable way, and is filled with case vignettes and down-to-earth practical advice. If you or someone you know suffers from borderline personality disorder, this is clearly a heartening interview. It's good news to learn that the prognosis is far more positive than was previously believed. If you wish to get more depth on this topic, you might wish to listen to the previous interviews I cited at the beginning of our conversation. Those were interviews with Marsha Linehan, Jeffrey Young, John Clarken, and Otto Kernberg. If you missed them, you'll find them on this site.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
Dr. Paris' book, Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice, providing a comprehensive overview of the current research relating to the treatment of Borderline Personality Disorder, is available from amazon.com.
by David Van Nuys, Ph.D., MentalHelp.net
Dec 15th 2009
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Joel Paris, MD. on Treatment of Borderline Personality Disorder (BPD). BPD involves a chronic pattern of unstable relationships, impulsivity and emotional instability often accompanied by cutting (self-harm behaviors) or suicide attempts. The causes of BPD are not completely understood, but likely involve a complex inter-relationship between inherited biological vulnerability and life circumstance. Dr. Paris' message is one of optimism: Good treatments specifically targeted to BPD now exist that been demonstrated effective with clinical trials. Dialectical Behavioral Therapy (DBT) is one, and Mentalization Therapy is another. These treatments involve talk-therapy with a strong educational componant (designed to help patients learn coping skills), the validation of patients' inner experience, and a push to engage work and social relationships. Drugs are not generally helpful when treating this diagnosis and in some cases can be harmful. Most people who receive these treatments will experience an improvement in their functioning within a year, and across the lifespan, many people with BPD tend to improve with age anyway.
David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show (download mp3 podcast here), we'll be talking about the treatment of borderline personality disorder with my guest, Dr. Joel Paris. Joel Paris, M.D., is a research associate at the Sir Mortimer B. Davis Jewish General Hospital in Montreal. Since 1994 he's been a full professor at McGill University and served as chair of its Department of Psychiatry from 1997 to 2007. He has supervised psychiatric evaluation with residents for over 30 years and has won many awards for his teaching. Dr. Paris is a past president of the Association for Research on Personality Disorders. Over the last 20 years, he has conducted research on the biological and psychological causes and the long-term outcome of borderline personality disorder. Dr. Paris is the author of 135 peer reviewed articles, 11 books, and 25 book chapters. He's also editor-in-chief of the Canadian Journal of Psychiatry. Most recently, he's the author of the book, Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice.
Now, here's the interview.
Dr. Joel Paris, welcome to Wise Counsel.
Dr. Joel Paris: Thank you very much.
David: Well, I'm happy to have the opportunity to speak with you. I've been reading your book, Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice, and I'm finding it full of fascinating and useful information.
Dr. Joel Paris: That's great.
David: Yes, and as I was reading it, I was gratified to see that I've interviewed a lot of the people that you cite, for example, Marsha Linehan, Jeffrey Young, John Clarken, and Otto Kernberg.
Dr. Joel Paris: Yes, there's about a hundred of us working on this, I would say.
David: Oh, my goodness.
Dr. Joel Paris: So we all know each other.
David: Yes, I bet you do. Well, to get started, perhaps we should have you tell us a bit about borderline personality disorder, understanding that we have some professionals who listen to the show and probably even more lay people.
Dr. Joel Paris: Right. Well, a personality disorder is something which starts when you're young, usually in your teenage years. It's not an episode like depression or a panic attack; it's a continuous problem that affects you over a long, long time, and the way it affects you is in your emotional life, your relationships, your ability to work, to some extent the way you think, your ability to control your impulses. So it's a very broad concept, but it explains problems that go on in a fairly severe way for years and years.
Now, borderline personality disorder is the type that we see most often in a clinical setting, and these patients are best known for two things. One is that they cut themselves quite often to relieve tension, and the second is when things go bad for them, they'll take overdoses of pills, and although they occasionally do commit suicide, the usual result is they end up in the emergency room having to get their stomach pumped.
So these behaviors indicate that they're quite impulsive, and behind that impulsive tendency is what Linehan calls "emotional disregulation": their emotions are very unstable; when they get upset, they can't calm down. And this is not manic-depression or bipolar disorder, which it's often mistaken for, because this is not a situation where somebody stays in the same mood for days or weeks at a time. The mood shifts around from hour to hour, from event to event. The patients tell you they're on a rollercoaster.
So between this emotion disregulation and impulsivity, they're really quite troubled, and their relationships really suffer. Some of them are able to hold a job and go to school and function well in a structured environment, but most of them have trouble with intimate relations, where they get overly attached, overly disappointed, things break up quite rapidly, there's a lot of storm and stress and arguments, and this often leads to other difficulties. Some of these patients also have what we call cognitive symptoms, where they feel a sense of unreality about the world, and some of them will also hear voices from time to time when they're under stress although they know that that's not real. So that's the clinical picture.
David: Wow. It certainly is a complex picture.
Dr. Joel Paris: Very complex.
David: Yes, and you've sketched it out for us really well. Personally, I've always been bothered by the designation "borderline personality disorder." Like borderline between what and what?
Dr. Joel Paris: Yes, well, it's a bad term, but there's a whole bunch of them in psychiatry like that. Schizophrenia means a split head and it doesn't mean anything, but we're sort of stuck with it. Borderline is based on a theory that goes back 70 years that these patients were somewhere in the middle between a neurosis and a psychosis.
David: Yes, I think that's what I learned when I was in graduate school not quite 70 years ago. But they were still saying it.
Dr. Joel Paris: That was the border they were talking about, and it's really not a good term, but the reason why many experts have resisted changing the name is because all the names that have been suggested instead make assumptions about the nature of the problem which may or may not be correct. So if we called it emotional disregulation disorder, that wouldn't really cover all the bases that I've just described, and so we're waiting to understand this better or maybe eventually it might be divided into subtypes. If you don't know a better choice, you're probably better off sticking with the one you have.
David: Well, that's interesting because somebody I interviewed - and I don't remember who it was - when I raised my discomfort about the term borderline personality disorder, they had suggested that there was another name in the offing that was being considered by the latest DSM group, but it sounds like maybe that's not going to happen.
Dr. Joel Paris: I don't think so. There's going to be? they're talking about all kinds off changes in DSM V, but my sources tell me the word borderline will still be in there somewhere, for better or for worse. By the way, if we changed the name, the stigma attached to the disorder wouldn't go away.
David: Yes, that issue of stigma - there is always that problem of stigma that attaches to psychiatric diagnoses and this one in particular. Certainly, psychotic and schizophrenic - those are pretty heavy. Does anybody ever come in with a self diagnosis and saying, "Doctor, help me. I have a borderline personality disorder"?
Dr. Joel Paris: Well, actually, some people do.
David: Really?
Dr. Joel Paris: Yes. Now, I must tell you, the diagnosis itself does reflect a certain unpopularity among psychiatrists and psychologists who are afraid of these patients because they're often threatening to kill themselves. They can be suicidal for years, and they can leave your office and say, "I don't know if I'll see you next week," and it's scary. So a lot of people have trouble with these patients, but recently there's been a movement on for education, and the National Institutes of Mental Health supported a program in which educational events were held all over the United States and in other countries to raise public awareness about borderline personality disorder, and the US Congress determined that May 2009 was Borderline Personality Disorder Month, which reflected, I think, the parent of a patient who knew a congressman or something.
David: Did you say that's May?
Dr. Joel Paris: May, this May, May of this year.
David: Oh, my God. That's my birthday month. Oh, no.
Dr. Joel Paris: Yes, mine too. What I find now with patients is that we used to be afraid of giving them this diagnosis and, in fact, patients feel better to have a diagnosis because it means that the doctor knows something about it; there's a literature out there; there's research; we can predict how things are going to turn out; we have specific treatments now which are mainly for this disorder. And so a lot of us now explain the disorder to the patients; we encourage them to go to the web, read up on it - there's a number of good, reputable websites - and most people are happy to hear this because it's good news. They've been given much worse diagnoses: they've been told they have bipolar disorder, which has a much worse prognosis, or sometimes even been told they're psychotic. So, in fact, when they realize that there's something out there that describes their problems fairly accurately, they like that; they feel better.
David: That's fascinating, and that really does sound like a sea change.
Dr. Joel Paris: It is.
David: A lot of clinicians kind of resist giving diagnoses, maybe because of the stigmatizing and so on, or they feel that it's not going to really change what they do. But you feel that diagnosis is very important and particularly for this disorder. Maybe you can say something about that.
Dr. Joel Paris: Well, yes. Well, the reason for that is that what we've discovered in recent years is that there are specific types of therapies - talking therapies, psychotherapies - that work for this disorder. So if you don't recognize it, you won't order them. In fact, two big mistakes are made: first of all, the patients may be seen by physicians who see the patients are chronically depressed and pump them full of antidepressants and other drugs which don't work very well, and the research shows that. The other mistake is they get a kind of generic, non-specific psychotherapy - "How was your week?" "Hope things aren't going too badly for you" - which isn't very effective. But in the last number of years, we know that specific programs, well structured programs which target the emotion disregulation and impulsivity, work.
Now, Marsha Linehan - you said you interviewed her - she was the pioneer. She had the first one way back in 1991, and that's still going well. There's a second one that was developed in London, England, called mentalization-based therapy which has several clinical trials behind it, and there's a few competitors as well which don't have quite as much research behind them.
But what these methods have in common is you don't just sit there and listen, you go after the specific problems that these patients have. It's really a kind of a teaching procedure where you're helping them to learn more life coping skills, and the research is very encouraging. The problem is where do you find the money to pay for treatments that require going regularly for months at a time. So that's another issue.
David: Yes, well, maybe we'll drill down into treatment a little bit more down the line.
Dr. Joel Paris: But that's why diagnosis is important, because if you don't recognize what's going on, you won't be able to direct patients to the proper treatment.
David: And yet the diagnosis, to me, seems like it would be very challenging because, as you point out, there is what you describe as the co-occurrence of multiple symptoms: for example, cutting and suicidality - which you've already mentioned - hearing voices, and so I would think that issues of differential diagnosis? I assume that there are other reasons why people cut themselves or attempt suicide. So how do you make this diagnosis?
Dr. Joel Paris: Actually, the repetitive cutting is - this is the first thing you think of when you see it in a young person. The suicide attempts, of course, can be all kinds of other things, too. That's correct. In fact, it's like everything else in medicine: if you see a typical case, you can make the diagnosis in five minutes, and the challenge only comes when you have some features and not others, and there are always marginal clinical pictures which are more difficult and more challenging. I'd say 90% of the time, there's really no problem in diagnosis once you get the idea of what this thing is about, when you've seen a lot of these patients.
David: Interesting.
Dr. Joel Paris: I've trained non-psychiatric physicians and psychologists to pick up the diagnosis rapidly, and it's really not that hard.
David: Yes, well, one of the things that I was fascinated to read because not only would clinicians sort of flee working with these people for fear that they might commit suicide, but it just does have the reputation of being very difficult to treat, yet you cite recent research - evidently a very large-scale research - that shows that, on the whole, these people get better.
Dr. Joel Paris: Yes, well, in fact many of them get better even with time. This is part of some research that I've been involved with myself. The longer you follow them, the more likely they are to have recovered. You don't see many middle-aged or older people with this problem; this is a problem of youth. Although some of them do commit suicide, the vast majority of them don't, and by 40 or 50 for sure they're much better - many are better by 30. And so it's a bumpy ride, but a lot of people do well. One of the things that you see when you practice medicine is that the worst cases keep coming back, and the ones that get better sort of disappear, so it gives you the wrong impression about prognosis.
David: Yes. How did you get into this area of specialization in the first place?
Dr. Joel Paris: Well, I was a young psychiatrist, and I become interested in people who were suicidal because I thought that if they were suicidal, I could tell whether they were alive or dead at the end of the treatment and whether I was making a difference. And I also found it very interesting to try to understand why people felt that way. I wrote a book about this. I quoted John Keats and called it Half In Love With Death. It's like they're fascinated with dying, and they need that exit door in order to keep on living, so it's a very interesting relationship between life and death. I've talked to some of my colleagues about this, and we agree most of us are pretty straight arrows and we find these people kind of fascinating and it's a challenge, and as a medical specialist, I should be treating pretty sick people.
David: So somehow your interest in suicide, then, led into this?
Dr. Joel Paris: That's right.
David: And you got very involved with research. It's really, I guess, both a clinical and a research career that you've had.
Dr. Joel Paris: That's correct.
David: Okay, well, how has our understanding of the underlying causality and dynamics of borderline personality disorder evolved over time?
Dr. Joel Paris: Yes, well, you're asking me what's behind this. I wish I knew.
David: Yes, we had earlier conceptions about what's behind it, and maybe we have some new ones now that are better informed.
Dr. Joel Paris: Well, we don't. I think the short answer is that we mostly don't understand this very well. In the days of psychoanalysis, they had very firm ideas that this was caused by problems early in childhood, but in fact, most of these people are normal, fairly normal - not all of them - but a lot of them have fairly normal childhoods, and all hell breaks loose at puberty.
So some of them come from terrible families with alcoholic fathers - this is fairly common - but not all of them. Some of them have histories of physical and sexual abuse, but many of them don't. Now, there are genetic studies which suggest that there's something, some heritable vulnerability for this disorder, and we know that people who suffer very traumatic life experiences don't always get sick.
So there's a combination of a biological vulnerability and difficult life experience, but you can't assume that every one of these patients necessarily has had a terrible childhood. More of them do than the average person, and more of them do than a lot of other patients we see, but it's not a one-to-one correspondence. So this is really what makes it complicated.
David: Yes, you indicated that, to some extent, there's a hereditary component. I would think that maybe that would have something to do with the emotional disregulation that you talked about earlier?
Dr. Joel Paris: And the impulsivity, both, yes. There's some evidence that the impulsivity is related to disordered serotonin metabolism, but it's a little vague at this point.
David: Yes, I was going to ask about brain correlates. With all the brain imaging that's going on today?
Dr. Joel Paris: Yes, it's been done. Certainly we know, for example, that - just to give an example of their emotionality - their amygdala, which is kind of the alarm bell in the brain, goes off quite easily and is hyperactive. There's some evidence that in the prefrontal areas, which control judgment and reasoning and where you keep your impulses under control, that there may be something defective there. It isn't very specific, and I'd say we're just at the beginning.
David: Okay, when you talk about the amygdala and so on, and earlier you made a reference to pharmacology, to drugs, and I know in your book you say that drugs are overused and often do more harm than good in relation to this disorder.
Dr. Joel Paris: Yes. This is not because I'm one of these psychiatrists who hates drugs. I don't feel that way at all, but in this particular population, because they have so many symptoms and because psychiatrists these days rely mostly on drugs and maybe also some of these patients are being treated by general doctors who do the same, I think there's a tendency to push the drugs too hard, and they're actually overrated. Many of these patients - the sicker ones - you'll see around four or five different pills, and this is a real problem because some of them do have serious side effects, particularly the antipsychotics - the antidepressants I don't think really do much harm. And so I think these patients are being over medicated, whereas the evidence as I read it for psychological treatment is much stronger, the problem being where are you going to find it? Who's going to do it and who's going to pay for it?
David: Yes. I sort of go, "Yay!" when I hear about the effectiveness of psychological treatment - being biased as a psychologist.
Dr. Joel Paris: Right.
David: Now, as I mentioned earlier, the subtitle of your book is A Guide to Evidence-Based Practice. Perhaps you can take our listeners a bit through the evidence based movement.
Dr. Joel Paris: Well, some people are surprised to hear that medicine isn't always evidence based, but I must tell you I'm old enough to remember a time when there was very little evidence and when everything was based on clinical experience and what the white-haired senior doctor said based on what he had seen over the course of his career. The problem is you can be white-haired and senior and be completely wrong.
So evidence based medicine is a movement within medicine which developed in Oxford, England, and also in Canada to base medical treatment as much as possible on research. And that research often consisted of randomized clinical trial, where you give a treatment and randomly pass the patients something else or a placebo or something like that. And you should have a lot of evidence to prove if you have one? Sometimes doctors read one study and they run with it, and that's a big mistake because you need lots of research, which is consistent, to prove things.
Now, the problem is, in medicine, there's a lot of things which we don't have evidence one way or the other, so we're stuck with our clinical judgment. Nevertheless, as time goes on, particularly in the younger generation - and I think the same movement has moved to psychology in terms of evidence based practice - as time goes on, there's more and more respect for data, and clinicians are reading more research. So that's the idea. And the idea of the book is to say this is not just another book saying I treated 100 patients and here's what I think - God knows there've been a lot of books like that. This is a book which says I have read all the research, and this is how I put it together, and this is the state of our knowledge as of now. So that's the approach.
David: And one of the beauties of your book, I might add, is that you summarize that evidence, you summarize all of that research, in sufficiently clear terms that I think any intelligent layman could benefit from reading it.
Dr. Joel Paris: Thank you, I certainly hope so. I tried hard.
David: Yes, and I've also been impressed? in these interviews, I've discovered that what you say is true, that younger clinicians are more familiar with research, I think, than they used to be; that they actually are reading the research and applying it to their work, which I don't think was so much the case when I was coming up.
Dr. Joel Paris: No, it certainly wasn't true in the '60s and '70s.
David: Yes, that's when I was coming up.
Dr. Joel Paris: We're the same age, then.
David: Now, the "mind" is so complex. I understand the impulse behind the evidence based movement, but I'm wondering if you see any danger that the insistence on rising to that standard might jeopardize approaches whose subtlety might not be easily measured.
Dr. Joel Paris: Well, yes, I think there's something to that. The problem is not so much the evidence based approach. The problem is everyone wants to make things simple, and the simplest things in my area, which is medicine, is to write a prescription. And so I don't think that clinicians take the time to understand people as much as they used to, and I've written a couple of books about that too.
Certainly in borderline personality disorder, at the very least you have to take the time to go over the complex symptom picture and to get a proper life history. And it really isn't that difficult, but you have to know how to talk to people, and you have to be sensitive to the patients. And some of the stuff that I learned when I was young, it wasn't evidence based, but there's a kind of quality of humanism that is required to work with people who are constantly thinking of killing themselves. So, yes, I think I agree with what you're saying.
David: So I believe you propose a treatment model that integrates a number of approaches, and you started to talk about that before, and you actually in the book succeed in summarizing it fairly succinctly. Maybe you can take us through that.
Dr. Joel Paris: Yes, well, what I say in the book is that the best evidence is for psychological treatments that are designed for this particular population. And these treatments have a large educational component; they're very well planned and structured; they don't leave patients hanging and blowing in the wind; they are really worked out.
Now, what I also say, though, is that you shouldn't throw up your hands if these specific treatments are not available in your community. One often hears people asking, for example, for dialectical behavior therapy - that's been around for almost two decades - and where can I find it, and it's not available in many places. It's not available in my city, either, because it's very expensive and uses up a lot of resources.
So what I recommend in the book, which is primarily addressed to practicing therapists, is that they adapt some of these ideas into their normal practice, and instead of looking to send patients for some expensive referral, to try to apply some of these ideas in their own work, which is more or less what I've done. I have learned from my colleagues, many of whom are working in the field and have terrific ideas about how to treat these patients, and I've tried to develop my own personalized way of doing things.
And I also advocate trying to get these patients back on their feet as rapidly as possible and not expecting that it's going to take years to treat everybody because I think that's kind of negative and demoralizing. A lot of these patients can be gotten better in a few months, some of them in a year or so, and it's only a minority that are going to haunt the clinical system for years to come. So I advocate an optimism and also, on a very practical level I think, you have to help these patients get back to work or go to school. They can't be sitting around collecting a welfare check; it's murder for them.
David: Yes, I was struck by your down-to-earth approach, and you advocate that they need to get a life.
Dr. Joel Paris: That's right. I think that's the central point.
David: Yes, and often that's really a challenge. I'm wondering - talking about the social factors right now - unemployment is very widespread. This could perhaps be an aggravating factor.
Dr. Joel Paris: It is an aggravating factor, although I think that it's not so bad that people who are motivated can't find something or can't go back to school to prepare themselves for something. The programs that I'm involved with are all very much oriented towards getting people back into the world, and we're not looking at a Great Depression; we're looking at a higher level of unemployment. But the fact is that these patients, if they really want to, some of them will take jobs that other people might not want to take. I tell them it's part of their treatment.
David: Yes, the things that you emphasize, I seem to recall three points stuck out for me that you found as being in common to the successful approaches, and one was validating their experience - I guess that's accepting what they're describing as their inner world - and in developing some kind of capacity for self observation, and then finally this third stage of working on getting them engaged in work and relationships.
Dr. Joel Paris: That's a very good summary. These ideas are not totally original with me; therapists have talked about them for a long time. Marsha Linehan has talked a lot about these ideas, so has Anthony Bateman, the British psychiatrist who has a different method. But I think these are the essentials; yes, I think that's a good summary.
David: Okay, do you have any sense of the recovery rates that are more promising than we might have guessed? Do you have any numbers?
Dr. Joel Paris: Yes, I do. I followed a large cohort, and basically by age 40, 75% had recovered and by age 50, 90% had recovered. Now, you might say, "Do I have to wait till I'm 40 years old to feel better?" And I would say "not necessarily." There are some more recent studies which use what we call the "perspective method," where you take a bunch of patients, and you sign them up, and you follow them for 10 years. So these studies have found that people stop cutting and overdosing often within two or three years, many of them, but they continue to have a lot of trouble functioning for a longer time. But in the end, most of these patients are working and having some kind of a social life by 5 to 10 years after diagnosis. And so I think the prognosis is actually pretty good, and I don't think not all my clinical colleagues understand this and have the message, especially when they prefer to diagnose conditions which have a worse prognosis.
David: I was going to ask you if the Canadian government gave you several millions of dollars for future research, how you'd want to spend that, but I get the impression that, really, maybe what's needed is not so much more research as more educational outreach to therapists.
Dr. Joel Paris: Well, I think both are needed. I very strongly believe that research is just beginning. It's been pointed out by several experts in the field that the prevalence of borderline personality disorder is about the same as schizophrenia, maybe even a little higher. It's about 1% of the population in most studies. and yet 10 to 20 times the money is spent on schizophrenia research as is spent on research in borderline personality disorder. We haven't cracked the schizophrenia problem either, but I think we do need research money and support to understand where this thing comes from so as to make our treatments more specific. So I very passionately believe that the researchers are going to come up with answers. I wish I could live another 50 years to find out what they're going to be.
From what we already know, we do need to get a message out to clinicians and to the general public that this is a big problem, but a treatable one, and that clinicians shouldn't be afraid of it. You know, many people have relatives with this condition, and some of them have even formed a national organization to increase general knowledge about the condition, so I think this idea is coming of age, and I think it has a certain momentum behind it, and I feel fairly optimistic that we're going to get somewhere.
David: Well, that feeds into one of my last questions here, which was to ask your advice for families that may have someone who suffers from borderline personality disorder.
Dr. Joel Paris: Well, there are all kinds of groups that help people. In the United States, NAMI has done a wonderful job.
David: That stands for National?
Dr. Joel Paris: National Association for the Mentally Ill. I'm not sure, I think that's them.
David: I think you're right.
Dr. Joel Paris: And they have now recognized that borderline personality disorder is part of their mandate as well because they had started only with the psychoses, and they're now extending that. There's a lot of information available on the web, but these support groups exist. I think there's probably something in all of the major cities in North America of that nature. And I know that I've been involved in some of the events which have taken place to publicize this and to get that message out.
David: Oh, that's great. Dr. Joel Paris, thanks so much for being my guest today on Wise Counsel.
Dr. Joel Paris: Thank you very much for having me. Thank you for reading my book and preparing so well for this interview. You did a great job.
David: I hope you learned as much from this interview with Dr. Joel Paris as I did. If you're a therapist, I'd say his book, Treatment of the Borderline Personality, is a necessary addition to your library. It's very clearly written, summarizes a vast amount of research in a most readable way, and is filled with case vignettes and down-to-earth practical advice. If you or someone you know suffers from borderline personality disorder, this is clearly a heartening interview. It's good news to learn that the prognosis is far more positive than was previously believed. If you wish to get more depth on this topic, you might wish to listen to the previous interviews I cited at the beginning of our conversation. Those were interviews with Marsha Linehan, Jeffrey Young, John Clarken, and Otto Kernberg. If you missed them, you'll find them on this site.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
Dr. Paris' book, Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice, providing a comprehensive overview of the current research relating to the treatment of Borderline Personality Disorder, is available from amazon.com.
