BPD-related cognitive-perceptual difficulties and challenges in their diagnosis and treatment

I'm going to keep my presentations minimal so we can be sure to hear the most from our speakers, so I'll invite people to look in

their

course book, which has biographies of our presenters. I'll say I do. It is my privilege to work side by side with our next expert in our Yale program in our adult day program. I invite Dr. Gabriela Balf to come to the podium and join us to discuss how to introduce ourselves to borderline personality disorder, but also allow us to hear about the

challenges

that can arise when working with psychotic experience.

Thank you Dr. Boff. Thank you very much sir. Good morning, keep this in mind because I will ask you later as a complete disclaimer. Everyone has to make

their

own disclaimers. I'm not a great researcher, the people who came before me, the people who follow me, are. I'm not. Dr. Axelrod asked me to come here and speak from my experience as a doctor, so please keep your questions in this area. I was quite lucky. having heard a lot of stories that people told me, I prescribed a lot of medications, had good luck, bad luck with some and then heard the stories that people told me about it, so this is the position I'm talking about.

Since the first time I realized that

cognitive

problems can be a problem, it was a strange episode years ago, I won't say how many, when I was still an internist and there was a nice lady that I really liked and she liked me. I, who came to the office, was extremely upset and made my things miserable. She praised me. She said that I am the best doctor she has ever seen in her life, but that she will no longer come to this office because she was too angry. things and we talked a lot, we settled some things and on the next visit I was surprised to see that she didn't remember much of the upset I had about her comments, she honestly did not, so this is the first time I realized that intuitively it's not worth talking a lot when people are very upset, yes, imagine, and then, in my residency in Psychiatry, I learned to strike the iron when it's cold and that made sense, then I got very interested when Seth proposed this topic I said Yes, so this is what I learned about it.

I'll tell you everything I know about borderline personality. about why this

diagnosis

is so challenging. why primary care doctors don't formulate it. why don't we do it. in emergency rooms and why don't we explain what this problem is with

cognitive

problems, some

challenges

that I encounter when treating people and also some good news, so let's move on, there are several ways to think about borderline personality. The official form is the DSM, this is our Bible and next week, next Sunday, it will be the 5th edition and by the way, the criteria for borderline personality will not change from the previous TR 4th edition, so by the way for some reason, he said there are five criteria out of nine um I don't know what happens when you have four criteria out of nine and these four seem important like self-harm or feeling empty or angry or dissociated nobody knows um on the other hand this What makes me angry about research is that it can be arbitrary and can be based on previous research that could have been flawed, which is why one of the Psychiatry News reporters tracked down the person who was part of the first working group that participated in the first writing of the DSM. and I asked you about the criteria for depression which, as you know, is still five out of nine, how did you come up with five out of nine, what kind of curves and what kind of curves does Roc use to figure that out?

And that person said well. It seemed like a true story, we'll talk about it later. Dr. Linehan's model made a lot more sense to me and she is so pragmatic that this lady identifies some areas that have problems, this area of ​​dysregulation, such as interpersonal cognitive emotional, and proposes some solutions. For that, in my school you have to learn about the psychodynamic model and, in fact, it makes sense to think about how people think about themselves, how they perceive reality and what they do when they are stressed, how they cope with stress. and finally, Dr. Hermann and Dr.

Van Der kok talk about borderline personality as a complex post-traumatic stress disorder, so the DSM talks about these nine criteria about abandonment, about these stormy relationships, about problems, thinking about oneself as a soul person, about being impulsive, sometimes suicidal. be emotionally unstable feel empty sometimes angry and also like my wife then I realized she must have dissociated, I honestly didn't remember anything that happened on that visit well these were too many lines to remember so I'm a very pragmatic person and I prefer mnemonics like Dr. Linehan would and this is what I have for you. I'm suicidal and this is how I can remember the criteria that have to do with abandonment, mood swings, suicide, unstable relationships, difficulty controlling anger, emptiness, you have them all, so now. do you remember the three words remember the song this is to help me remember things and what I realized is that songs have a lot to do with unstable emotions, very intense emotions and this song in particular that I love has all the criteria from the DSM because there's a song about relationships, okay, it talks about abandonment, it talks about emptiness, about impulsivity and substance abuse, such risky behaviors, some paranoid ideas, self-harm instead of feeling numb, okay and a sense of identity, let's move on to Dr.

Linehan's model, this is this piece. been here before Cairo Vangelder, she is extremely talented and can explain things in a way that I can always understand and remember forever, so I borrowed one of her slides that has to do with explaining what borderline personality is all about and she identifies The first three areas of this regulation that Dr. Linehan indicates impulsive emotions, impulsivity in relationships and adds self-image and cognition now Dr. Linehan is very pragmatic, she invented this phenomenal method of treating people that works with electrical behavioral therapy and suffice it to say we are very good at that, Dr.

Axelrod can say a lot more about it, let's move on to my school's model and this actually made a lot more sense to me than the DSM because you really can't Label people, describe them and put them on. the shelves put them in pretty shoe boxes and say here this your desk your blue your green your size is 14 whatever so more like people function through a Continuum and I agree that we are all crazy sometimes I am more than others and the question is how severe the nutty flavor is and in what flavor, so this is how these people explain it and the best way to say it.

I really like the images. I think we convey 80% of information through images, so see how I think about it. You have these healthy, neurotic people who are very structured and very organized here, and then you have here the psychotic people who are flexible, whose boundaries are very, very flexible, very fluid, for example, here, a healthy neurotic individual would say: Well, Seth is pushing me, sometimes it sounds like that. my father, who is pushing me, but he is a very good mentor and I am going to accept this challenge and do something about it here, ah, Seth, he is my father, uh, I am just going to disintegrate, I can't stand this kind of things. of Challenge and I'm going to this is a loose sense of self of loose boundaries where I am and where Seth begins and this is the limit level organization of personality where you can have parts of you that are very, very organized and very structured, you seem very competent . and parts that are looser and then come the flavors, so here you have the depressive people, so this is me on a good day, then you will have paranoid people, here you have the head of the CIA, who else, let's see the sociopaths, here are some famous ones.

CEOs here and here and then you have obsessive compulsive and so on, so this actually makes a lot more sense to me, that people would have different degrees of functioning, they wouldn't be able to keep their lives together, they would have a lot of struggles. with that and suffer a lot and the people who could um are luckier and have it easier this is how Nancy McWilliams writes about this and writes about the sense of identity this is basically where I stop and Seth begins this is this defenses that the mechanisms of coping that people use and that's how I see reality, Seth is really mad at me because he didn't tell me that my slides are fabulous, no, he didn't have time to tell me that my slides are fabulous types of primitive defenses, this is an area Fascinating, so I was always impressed with how what people use in interactions and, for example, one of the main coping mechanisms that people with borderline personality use is splitting.

You've heard about it right now. This is not the split I heard in the morning team briefing that, oh, this person splits all the time, it's not about how people who have a borderline personality see the world, so when I have a borderline personality I can't keep in my head the idea that my mom may have some good parts. and the bad parts or like Dr. Balf can be phenomenal and know all these medications and she can be late, she has some flaws, so the idea is that if you think about children, they have the same problem and they can't keep it in their head the idea that people can be good and bad and you see this in fairy tales, in fact in fairy tales you have the stepmother and the good mom who is usually dead anyway, but here you have the stepmother who is all bad, the good mother is all good and they cannot coexist, but in reality they are the same person as the mother but children need the division to understand that is why people with limits cannot perceive in a moment the people can be very good or very bad there is nothing in between now the last model that I am going to talk about briefly is the complex model of post-traumatic stress and it depends on when the trauma occurred, the abuse in life, it can be a trauma with Big T like horrendous sexual abuse or it can be a little tea trauma, as Francine Shapiro would say, it can just be bullying, just being invalidated. all the time so here it is after hurricane Irene in my backyard these are the trees you have some branches here and they are broken but these trees are standing and this happened late in their development what is this?

This is a tree that has an identity. the trauma is bent all the time by this continuous pressure from the outside this has entered into your identity the trees above are ordinary trees that are trees in my backyard this is the dvdv3 in Aruba so this is your identity it is bent forever because the wind always blows in the same direction, so another way to think about it is how you grow with the trauma and with these cognitions, these ideas that you have about yourself and that were introduced from outside, you see how they grow inside you and if the You separate very quickly. and without preparation, guess what happens now how many people are we talking about, they said in the clip before 50 million, this is very, the answer depends basically on what sample you use, this is a very large community sample, this is 35,000. people and whose results were published in February, this is in the general population, basically, three out of every 100 people will have a borderline personality.

Native Americans more Asians Less in a hospital, two in five, so what's the problem? Why do you get so upset about not diagnosing it properly and thinking about it and treating it sounds so simple because it doesn't overlap with so many things. This is the problem that I haven't studied as well because they usually select the population that is relatively free of overlapping problems and here you have depression, you have bipolar substance abuse, as mentioned above, you have anxiety disorders and post-traumatic stress disorder. It's one of them and you have psychosis. These are the numbers and, again, I'm not the number person who can tell you, for example, impress you. and say, oh look, mood disorder, you're 14 14 times more likely to have a mood disorder or can I shock you and say, look at antisocials or schizophrenics, how many times more likely to have a comorbid condition with that? , but I am a visual person, so look what I prepared for you from the same community example, you will have a lot of substance abuse. 78.2 percent of people were found to have substance abuse problems.

Do you know why just because they want to not? treat a condition actually here is the mood disorder here is the anxiety remember some of it is post traumatic stress then in other studies it all depends on the studies you are looking at you will find ADHD and here comes the overlap with the cognitive problems that we How much is the association? How much is post-traumatic stress where people can't focus because of trauma and anxiety? How much is a true attention deficit? Then you have the learning disability and Dr. Zanarini three years agoI was talking about A lot about eating disorders here also overlaps a lot with access, so here's your paranoid, your antisocial, your narcissist and when you see so much overlap, doesn't my watery example make more sense where you have different degrees of organization and different flavors I put it only because regardless of what we talked about before this is the admission

diagnosis

guess what I have to write when I admit you to the hospital otherwise the insurance will not pay me anything the truth is it is a psychotic disorder per se it has only a one percent overlap with borderline personality, but this can be accessed because otherwise the hospital is not paid.

If you think about it, you can stretch out and say well, this makes sense, sometimes people don't have a good reality. prove that his moods fluctuate he must be schizoaffective then you may think well but why not just bipolar and Gunderson and atlasco? I would say maybe it is a mild bipolar spectrum disorder with extremely rapid cycles however people who have limits tend to fluctuate in the negative, think negatively about them and don't have this oh, I feel good, I'm the best kind of feeling that people with mania feel an emptiness that prevails that taste of depression and they don't feel so guilty and embarrassed and the mood this comes from outside some are extremely reactive it is as if they have a third degree burn on their skin and everything hurts, it hurts immensely and in fact this The intensity of the pain is a good indicator.

This is what Zanarini says about the pain of being borderline. I greatly respect and admire the people who had the courage to explain to me what this pain means and how they feel worthless, abandoned, enraged and how. They feel misunderstood, so as treaters, keep this in mind: This is complex PTSD. Well, neuroimaging could say that definitely, if you look at the volumes, measure and die with certain colors, it can definitely look like complex PTSD, so let's talk about this cognitive problem. that fascinates me and again a slide by Kyra van gelder where she puts all the main ones here you have your thinking in black and white here you have your paranoid thinking here you have seeing people all good or all bad when I read a post-traumatic stress books, the association books, this is what I came up with and this is one of the main problems that appear, the cognitive distortions that go from the beginning, so this is the black and white thinking, the denial, this is not happening to me to me, the projection, oh.

Seth is mad at me it's not that I'm afraid he's mad because of dissociation, this is what happened to my lady and it can be a primary dissociation contained with nightmares and flashbacks or you can have this out of body experience when you look at yourself . When something bad happens and you know you don't want to experience it yourself or when it's very severe and the trauma happened very early, you'll see people develop Alters Multiple Personality Disorder, some people at my school may say I don't think so. In that, I have known, they exist because they are multiple and psychoses, so here is the problem with psychosis, what I understand and from my conversations with Dr.

Hoffman, who is my partner at iob and who is an expert in psychosis . and schizophrenia, psychosis and borderline personality are all about splitting, you can't admit that these negative thoughts are yours, so they are from outside and there is something different about their taste, they don't come from somewhere in a room, so people with the borderline because they won't be tempted to turn around and say, oh, who's in the room with me? No, they usually hear it in their head and it's usually a familiar voice. People they know. Parents in psychosis. They may be familiar people, but they may be others. around or strangers who say negative things and you actually turn around to see as if their voices are coming from outside your head.

I got the best explanation for these cognitive-

perceptual

disorders from a person I'll call Stacy again. I appreciate you taking the time to explain to me that we had a coaching call one night and I poured out so much wisdom that I had so many good ideas and what to do and um, Seth would have been so proud of me the next day. The next day she comes over, she hadn't done anything we talked about, she didn't remember talking to me on the phone, so what's going on and then she explained this to me and I'm forever grateful to her, so she said see you later. reality is like this and she draws a straight line for me reality is like this and she draws these interrupted lines so if you catch me in the middle I can't remember and suddenly the light bulb goes off you know so this is really and truly what happens when you're dysregulated, you can, you don't have good contact with previous memories, this is mood-dependent memory, people can't access their memories of the other person, um, about arguments, and here is my favorite song again, you have these. memories but they are scattered they are not united with each other and this is true it is actually in people's heads this is a famous experiment with faces and the reactions they have in normal controls and borderline people do you see the difference?

I mean, really this is this is real, it's not that people are trying to manipulate us traffickers, this is real, so I chose these images because, again, they are worth a thousand words and we can better understand what is happening, These are structures that are involved and I am going to ask you to remember just three this is the magdala this is our emotional center this is what it tells us this is important I remember this and this is going to trigger many things this is the prefrontal cortex this is what what's going to tell me how much I'm going to act on these emotions this is going to direct my behavior I'm going to be restrained or I'm going to fall apart and this is the hippocampus this is where I store my cognitive map this is how I do I have an idea of ​​what happened before and I can choose to behave accordingly, so this is really the basis.

I'm going to be very simple about it and in Dr. Van de Cox's book, Dramatic Stress, we have this wonderful slide. This is the best slide I actually made. Such extensive literature looks for the hassles first and this is the first slide where they actually show how information flows from one center to another, so let me first give you some good news, the bad news, the guidelines are 12 years old and still in the APA side. we have guidelines dating back to 2001 where they say just treat the symptoms basically, if you have cognitive problems, do this and this and this, they have those in your booklet, if you have emotional disorders, do this and this and this and If you have anger, basically the three sets of symptoms do this and this and this well six years later the World Federation didn't do much better, they were similar in guidelines to the APA and also discouraged benzos so this is my big problem . with benzos because it is a chronic condition and we are creating monsters and in fact it should be used specifically for this disorder, for the symptoms or for self-harm, okay, so what are we supposed to do? 2010 is the last review Cochrane is our most respected guidelines database and they took 10,000 studies that were just well conducted and they came up with these ideas so this is one of the three main slides that I'm going to tell you about. how to treat cognitive-

perceptual

symptoms with two antipsychotics that have proven to be really good: Abilify and Zyprexa Zyprexa I. have a big warning about it uh, we will fall into a second anger and impulsiveness remember Topamax Abilify and Lamotrigine Haldol emotional dysregulation has a little bit of amitriptyline again see your zyprex facial oil Abilify actually this is so benign I said I will implement it for suicidal self harm again you see fish oil and for interpersonal problems again Abilify Topamax there is not enough evidence but they are so benign clonidine for self harm for anger for anxiety and naltrexone basically like one of my mentors told me anything that has to do with pleasure you can block it you can block endorphins with naltrexone so remember the keywords Abilify Topamax clonidine ultrexin fish oil this is what actually happens, not many psychiatrists are addressing borderline personality disorder, so if I'm to remain official and be a blank slate, I would officially lie to you, there is only one study that Gunderson says in 2011 that psychiatrists do not treat borderlands patients and to be very honest this was something that hurt me a lot because I like working with Borderlands, I think they care and I think they are extremely talented and it hurt me to know in my last year of school that when someone came he had a lot success by giving us advice on how to have a successful practice on the border.

Lines really, so I decided to be transparent and tell you what's going on, that's why there are no psychiatrists being hired, so let's get to the medication part, what do we choose? There are some problems with nanoderance, that's why it's not very similar to Lamictal because it takes forever to titrate and people can forget or get too angry to take it. There is a possibility of an overdose and you would say, well, I'm not going to prescribe Elavil, so well, if it's a good medicine, I'll try it. You, as my partner, are an adult, I'm going to tell you not to overdose, but I'll still prescribe it to you because it's good for you, so I trust you and I have clear goals, especially when you have these cognitive distortions that All or Nothing tells you. people would say forever ah I don't feel good, it never worked for me, nothing worked for me, so be clear and I learned from my psychology friends to put numbers to it, however, people end up taking a lot of medications, this is real. list this is real, twenty something medications in this, this is what people end up taking and neuroleptics, these are very dirty medications, they don't go to many receptors and that's why you're going to have such good and bad effects.

You will find in their leaflets how we choose according to the side effects and what to expect. This is a list I put together from Dr. Stahl's psychopharmacology and monographs for each medication and this is a question everyone asked me and myself. I was only able to put it together from dozens of studies and monographs because I wanted to put the first generation and second generation of elliptical machines on one slide, so here's my Abilify. You see it? Remember and that's why I don't like zaprexa. Here it weighs 9.2 pounds. I won in three months if you're lucky and this is Latuda, the newer one, which is apparently more efficient than Geodon, and I'm not sure how much it works.

Everyone asked me about weight and you can't predict who will lose weight, who will lose weight. gain a knot who is not the

related

one it is very difficult to lose who had problems with weight gain you can say that this is very difficult to lose they have problems with the heart and I wonder how many of us really check it I do not check ways, that's another disclaimer, but I send people by 30kg and I ask people to come and go to the labs and I ask them to stick their tongues in me periodically. This is the target test that we are doing very loudly with them checking things.

After the guidelines came out, this is how we are doing with the readers, so it is a big clamor for better hours on our part and because this is a discussion between the guidelines and when we know what we have to do or not. we make. because we're part of the equation we might be exhausted too and then we do this thank you so let me tell you the good news and this will be the end of the practical stuff. I'm going to say metformin. It works, metformin is a medication that is initially used for diabetes but it is also used for weight gain in some studies you can even avoid gaining seven kilos and Topamax Works advice about metformin if you start slowly many people tell me no They tolerate it because They start with 500 twice a day, when actually the trick is to start slowly with 250 once a day for a week, then start at 50 twice a day and adjust slowly to avoid diarrhea, if that still bothers you. happens. turn on the extended release and people tolerate it much better.

Topamax really works and the cognitive distortions that may appear are reversible, so it is worth a try. Other medications that we use well are always a problem with co-pays. This is my cheat sheet, this is how I choose my antidepressants. Do you want fewer sexual side effects? I'm going to give you Lexapro, do you want, let's say, more sedation? I can choose between Symbolta and Effexor. Everyone asks me about weight gain, so this. is my answer to that and I can tell you some tips, for example Lamictal, my neurology friends would say 50 twice a day and then 100 twice a day the following week.

Well, Abilify started slowly due to akathesia, what else for theadd comorbidity? Set some goals. not just the general goal just to feel better use the long acting formulation in the morning and then when people get home and have to take care of their children the short acting formulation remember to use some cardiovascular medications my patients know I prefer the stage fright propranolol for anxiety clonidine guanfacine but for people who use cocaine this is a big problem and the way to remember it do not prescribe propranolol for people beta blockers for people who use cocaine because it can cause strokes and heart attacks so the way to remember there's no bee in cocaine it's fine and ECT is always a problem and if you have serious comorbid depression it works measure everything you do put it on a slide don't stop things during the holidays and about sleep , let me tell you about sleep hypnotics, this is a big problem, so Last year in February, this big study came out, so we should be more careful when prescribing because we can trim the years of people's lives, for What everyone should have a schedule, they should limit their distractions, they should remove this TV from the bedroom.

Not my children, my children will never watch television in their room and anyway, what you will see, this is what you will see, exercise spirituality, so please be patient, ask your doctors about the options, educate yourself, consumers, your partners in this, you are my partner, so remember. the keywords Abilify Topo maxclundino clues about fish oil ask your doctor to send you to laboratories to control your weight dear doctor remember where you are from meet people where there are thempay attention to yourself and your family two words family connections these are very good references that I am giving you and thank you all for patience for educating me and my mentors for teaching me that there is always hope, thank you Dr.

Ball. I have two excellent slide words. um we have a couple quick announcements uh to add one is our process for asking questions. I hope people have listened. I should have announced it sooner. It's writing your questions on green cards, passing them to the hallways. One thing to keep in mind. is that in addition to questions that may arise immediately after the presentation, we will have all the panel discussion time, it will also be a time to submit questions that could be directed to individuals or could be directed to multiple people, we will have limited responses to the questions.

It's time to make these first introductions to get us back on track time-wise, but we'll ask Dr. Both a few questions. I also want to mention how this is going if people would be willing to move towards the middle in the seats just because we have had more people coming in and we would like to allow them into the auditorium so I would appreciate if people would be willing to move, um, okay, The first question is, um, could you say a word about how? Do you think a patient, a client with borderline personality disorder, would do that after bariatric surgery and, particularly with respect to issues of poor self-image or instability of sense of self, yes, surgery?

If so, I am doing all the preoperative tests for bariatric surgery in primary care centers and it works you can get rid of diabetes you can improve your self-image I don't see it as a last resort this is after your diabetes there is a lot of rigged hay on your body this is great great option and again be good partners on this, ask your doctor about it, ask them to send them to you because the risks are minimal and the benefits absolutely huge. I don't have any other cards coming to me, possibly because I didn't do it.

Don't make the announcement before. I hope people have questions about this presentation and again, if you write them down or if they come to mind during the day, the discussion board would be a place where we could have more questions right now. t um I'm going to say thank you very much Dr. Balth