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Dr. Sarah Hanafi (PGY3): [00:00:09] Welcome back to Psyched, the psychiatry podcast for medical Learners By medical learners.In this episode will actually continue exploring a topic that I'm certain remains of interest to many of our listeners. Borderline Personality Disorder. In the first part of this episode, we reviewed the diagnostic considerations of the gist of this disorder, and the second part of this episode will touch on management of borderline personality disorder.
Audrey Le (CC4): [00:00:34] During today's episode, we'll touch on several learning objectives. One understand the frame and principles of care for the treatment of individuals with borderline personality disorder or BPD. Two, to explore the approach to the treatment of individuals with BPD, including the presentation in crisis to the emergency department, the inpatient psychiatric admission, and finally the context of psychiatric outpatient care. Three understand the use of psychotherapy in the treatment of individuals with BPD, and four understand the use of pharmacotherapy in the treatment of individuals with BPD. Now let's get started.
Dr. Nima Nahiddi: [00:01:17] I think it would be a good idea to start off with describing the general principles of care for treatment of individuals with borderline personality disorder.
Dr. Ronald Fraser: [00:01:26] As Dr. Biskin mentioned sort of in the first podcast, there's a lot of different frames, a lot of different theoretical perspectives on the treatment of borderline personality disorder. I think the one thing that most have in common is that they're psychotherapies. So the most robust evidence for treatment of borderline personality disorders is psychotherapeutic rather than pharmacological and. You know, obviously they have other commonalities. But personally, Dr. Baskin may disagree about this. Personally, I think the thing that's most important is just having a frame, like just having a conceptual framework that that you have confidence in as a therapist. And from my perspective, it's always been important to me to be part of a team and that the team share the same basic conceptual framework. I think that provides a grounding which is particularly useful when situations get challenging or if there are clinical situations that are difficult for the team or for the individual or for the patient. I think having that framework to structure the work is very grounding for everybody involved. And for me, I think that's the the essential ingredient. I have no doubt that the various disciplines of various schools of thought would disagree with that, and they would say that, no, no, no, it's super important that you do X, Y, and Z. I'm not so convinced that that's true. Now, I'm biased because when I put together, along with a team, a framework for our program, we consciously decided to go with a trans theoretical approach where we basically stole components of all kinds of different schools of thought that we thought would best serve our patients. And and I think that has served us and served our patient population well.
Dr. Robert Biskin : [00:03:54] I would I would actually completely agree with what what Dr. Fraser said, that the framework and the structure is probably the most important part of treatment for people with BPD. It highlights one of the challenges in terms of treating people with BPD in an outpatient setting versus other settings. There's a lot more variability in teams and structures in both the emergency room and the inpatient units. So having a consistent team with the same theoretical framework, the same approach to treatment is is extremely important. There was an interesting paper actually a number of years ago that looked at many of the different specialised types of psychotherapy for people with BPD, and it highlighted that the use of a team, the use of a consistent theoretical model, consistent frame force for treatment, the use of psychotherapy and particularly obviously looked at psychotherapies and particularly the use of multiple different types of psychotherapies, often with different treaters providing different parts of the therapy are some of the elements that are really essential or consistent across many different many of these different theoretical models, many of these different specialised treatment programs, which again kind of highlights what Dr. Fraser was saying about how no matter what type of psychotherapy that you choose to employ, there's many different tools from different approaches that can kind of be brought in and are probably very useful for treatment of people with BPD so that those structural elements are probably extremely important. So that would be what I would focus on as primary principles.
Dr. Nima Nahiddi: [00:05:40] Can you discuss what you both mean by the idea of the therapeutic frame?
Dr. Robert Biskin : [00:05:45] So the the idea of the therapeutic frame incorporates a few different components, but it's often a very structured approach to the therapy with very clear therapeutic goals, therapeutic steps and therapeutic outcomes or consequences for different sorts of actions. So a lot of the types of treatment will have very specific types of therapy every week. So you'll have a number of different individual sessions or group therapy sessions every week. And oftentimes attendance at these sessions, at these appointments is very, very important. There's often a lot of specific rules that people might have about attendance, about showing up on time, about communicating with the treating team or indoor therapists in between sessions. But in addition to that, there's a more global framework as well in terms of identifying early on specific targets for the treatment. So this is, in my opinion, an area where focusing on functional outcomes actually becomes very important. Having that as an overarching goal, not necessarily the only goal, but one of the goals for for treatment, for example, being able to find a job or look into or be able to develop new friends or relationships as kind of overarching functional goals for therapy is another part of the framework. And finally, another essential component of framework is that therapy must end. And I do believe that having an endpoint that the patient is aware of from the beginning of therapy is one of the important steps for having this consistent approach, not only because it gives patients the chance to recognise when therapy is going to end and they must take those steps to work on their own and learn to trust themselves in the skills that they've developed on their own. But it's also necessary because otherwise we won't be able to continue providing treatment for new people if we're continuing with the same groups of people indefinitely.
Dr. Ronald Fraser: [00:07:49] Yeah, I think all of that is really, really key. I think the only other thing I would add is that there's also a secondary frame for the team itself. And, you know, both the teams that both Dr. Biskin and I belong to meet on a weekly basis that provides our own internal structure. And one of the things that we do is obviously we provide support, peer supervision, guidance. But also, you know, we have a place where we all feel safe enough to ask difficult questions and ask ourselves, what are we doing and why? But also, what are we not doing? And why. And those are really important questions for us to step back and reflect on, because we have to be accountable to the patient. We have to be accountable to the system. We have to be accountable to each other, and we have to be accountable to ourselves. And so there are two frameworks one, the clinical framework for the patient. And then secondarily, but equally important is a clinical team framework that we work with in.
Dr. Sarah Hanafi (PGY3): [00:09:11] So you've both touched on the emergency department as one of these areas where maintaining that frame is perhaps a little more challenging. And I know in the previous episode we talked about how patients can sometimes present in crisis in the emergency department. I'm wondering, can you walk us through an approach to the management of someone who's presenting with BPD in the emergency department and is in crisis.
Dr. Ronald Fraser: [00:09:38] So that can be. Theoretically easy and. Extremely difficult in reality. So one of the advantages that our teams have is team consistency. Emergency rooms sometimes have that where they have consistency of staffing, but most often they don't. So most often there are different psychiatrists on different shifts, different days with different ideas, which is all fine, but different nursing staff and different patient attendants and just different everything. And you can imagine that that doesn't necessarily lend itself to consistent messaging. And that can be problematic because the one thing that these patients do, all patients do well with is consistent messaging and not mixed messaging. So wherever possible. It's important to try to really communicate amongst ourselves within the emergency room of what the plan is. Why that's the plan, What's the rationale? What are the goals with complex patients that may present more often to the emergency room? Often we'll have case conferences with various stakeholders in terms of their outpatient care, their inpatient care, their emergency care, and try to put together treatment plans. So when a patient presents under such circumstances, this is going to be the consistent response. And obviously the patient is involved in that treatment plan so that there's no there's no surprises. And so they understand what the plan is and they understand what the rationale is. The rationale is to do no harm and to hopefully improve the situation. You know, ideally emergency room team sort of come up with consistent approaches of how they're going to manage these patients and how they're not going to manage these patients. So, you know, not using things that are punitive, not we don't have control over what other people do. So we don't have control over what patients do when they're in crisis. But we do have control over how we choose to respond. And that's what we need to focus on is our choices. And our reactions. I think that's really the key starting starting point for any patient that we see in the emergency room in crisis.
Dr. Robert Biskin : [00:12:35] I'll add a few other points as well. It's interesting because for my experience, the way that I work with patients who are in my clinic at the Jewish General Hospital, it's I have the I have the ability to provide care for them in whatever setting they come in. So if they're in active treatment with us, I will be the one who will go down and see them in the emergency room. I will see them when they're admitted on the inpatient unit and I'll follow them as well when they're discharged into the outpatient clinic. So it provides a lot of consistency in that context, but that's not feasible for people who don't have my job. So in general, the approach that I take for for patients the first time that they're coming or one of the first times that they're coming and presenting to the emergency room is I tend to take approach that gives people more time. So the assessments of the work often does end up taking a little bit longer. And I actually have a rather particular approach that I will use with these patients, oftentimes beginning with the interview similar to what Dr. Fraser described before, more emphasis on people's or in the previous podcast, more emphasis on people's personal history, understanding their context or situation. I'll give people a lot more time to talk and share a lot about their story. And during those times, I'll be looking for clues as to what's the stressor, what are the triggers for why they're presenting to the emergency room that particular day? Because sometimes it's very obvious there was a particular stressor problems at work, relationships, school, etc.. But sometimes people will come in and say that they've just been feeling unwell for a very long time and being able to identify what it is that was making today that much more difficult than the day before is is very useful and it's a source that are the ones that I identify that particular topic. I spend a fair bit of time validating and validating that the person is having a lot of difficulty, that they're doing their best to cope with the situation. They might not necessarily have the best coping skills at work over the long term, but again, to come back to that idea that they're trying their best. So a fair bit of time validating and oftentimes patients who are coming in to the emergency room have not had the opportunity to have these sorts of specialised types of therapies that Dr. Fraser and I are both able to provide. So I'll also talk to them about the the hope for change and see how motivated they are for something like a specialised type of psychotherapy that might be different than other treatments they've received before. I don't try to do psychotherapy in the emergency room. I'm not going to be trying to teach them skills because it's not the best time to do that. But emphasising that there is hope and there are things that can be done. I take a model that's similar to a school that you never had the chance to learn this before in the past, so you kind of need to sit down with the books and have a chance to learn it in a structured way to kind of catch up for the things that you've missed. It often, again, destigmatize a bit about the illness and. Helps people feel more comfortable with the idea of going for a therapy if they're not so comfortable with it before. So, yes, that's kind of the approach that I take. Again, it does take a little bit longer, but most of the time patients again, it often ends with disclosing and discussing the diagnosis. Most of the time patients are quite satisfied with that. They feel like they've been heard, they've been understood, and they're interested in treatment when they're eventually able to get it.
Dr. Sarah Hanafi (PGY3): [00:16:16] Thank you for that. So it sounds like in the emergency department, the stance is very supportive. I'm wondering, outside of the emergency department, can you touch more on these different specialised psychotherapies? It sounds like psychotherapy really is the mainstay of of treatment.
Dr. Robert Biskin : [00:16:43] it's worth mentioning at the very beginning that there's not really any evidence of superiority from one to another. So they're all probably equivalent in many ways. And it's possible that certain elements from one or slightly better than another, but it's minimal. As we talked about before, the frame is kind of a central component of these these specialised psychotherapies. But one of the ones that probably are the one that does have the most research behind it is specialised treatment called dialectical behaviour therapy, which is a variant or it developed out of cognitive behavioural therapy, specifically designed for people who have intense or chronic recurrent suicidality and a lot of self harm. So like many of the cognitive behavioural therapies, it emphasises a toolbox approach. So in DBT it's again a combination of individual and group therapy. In DBT, there's many, many different skills that are taught to patients depending on how you might read the book. There's about 30 or so core skills with a few hundred variants of all of those different skills. So it can often be overwhelming for people at the beginning, but emphasising that there's just a few core skills that people need to work on and develop is part of the treatment and the four main areas that the skills come in is mindfulness, which overlaps a lot with mentalization or sorry, mindfulness based CBT. I mean the ability to just be aware of what's going on inside you and ideally do so non-judgmentally. The second main area is emotion regulation, which kind of steals a lot of the ideas from cognitive behavioural therapy, such as thought records. In DBT, we would call it checking the facts. Opposite action often incorporates a lot of elements of exposure therapy from cognitive behavioural therapy, and there's a lot of activity or a lot of emphasis on kind of having pleasurable activities and developing skills and mastery and things in different parts of life. The third component in DBT is interpersonal effectiveness, which is a lot of skills about managing relationships. So both being assertive but also trying to learn how to validate other people when it's appropriate to or to set boundaries and establish or self respect, as well as managing conflicts and building new relationships as well. And the final component of DBT is what we call distress tolerance, which is a lot of crisis management skills. So distraction techniques, breathing exercises. And a huge component of this section is also radical acceptance, which is accepting things that cannot be changed, accepting things the way they are. And that's often a very challenging part for people in therapy. But the very core idea of DBT. So DBT is typically a therapy that's given over about a year and has been shown to be very effective, particularly for suicidality, self harm. And depending on how you read the literature, certain other elements of BPD as well. So that's the most common type of psychotherapy. But there's a number of others. So mentalization based treatment focuses on the capacity that somebody has to recognise the internal states of other people as well as themselves. So be it. Emotions, thoughts, impulses and the work in that sort of therapy is focused on practicing and developing that is built. It's kind of emphasise as a muscle that you continue to develop, to develop with treatment and it also includes individual and group therapy, other types of therapies such as transference, focus therapy, take a more psychoanalytic approach and focus on the relationship between the therapist and the patient and the expectations that the patient might have of the therapist. But this is just a few of the psychotherapies, and there's a good dozen more that I probably can't talk about in much detail because I don't know them enough.
Dr. Ronald Fraser: [00:21:07] I actually wanted to share a clinical point that has absolutely nothing to do with your question, but popped into my head as I was listening to Dr. Biskin, and it's related to actually to diagnosis. So oftentimes one of the reasons I see people who have never been diagnosed with BPD that have BPD is because they lack one of the nine criteria. And if they happen to be an individual that has never had a past suicide attempt, does not engage in self harm. For some people, for some reason, clinicians feel that this is an essential component of BPD, and if you don't have that, then it's like exclusion criteria. But there's up to 20% of patients with BPD actually don't don't have that criteria. So often these patients will not get picked up and not get identified as having borderline personality or even if maybe they have eight, all eight of the other criteria. So I think that's actually an important point for learners and for trainees to realise that just just because of the absence of suicidality and self harm, that doesn't necessarily mean that this individual may not have borderline personality disorder.
Dr. Sarah Hanafi (PGY3): [00:22:35] Thanks for that clinical pearl, Dr. Fraser. So I wanted to go back to the topic of therapy after that. So bouncing off of the discussion that we've just had about psychotherapy. Could you maybe discuss the role of pharmacotherapy in treatment for these patients, for example, in in terms of how different medications can be used to target the different symptoms that we may commonly see them present with?
Dr. Ronald Fraser: [00:23:00] So this is actually. Probably one of the areas of greater controversy. If you look at the treatment guidelines that come out of, say, the U.K. and compare and contrast treatment guidelines that come out of North America with the APA, there's tremendous differences of opinion on the role of medications. There certainly can be a role. I think everybody agrees that there could be a role for medications. There's no medication that has an indication or treatment of any personality disorder. So they're all used off label. Often the approach is symptom focused. So for example, there are certain medications that one might use for impulsivity. Other medications that people or the exact same medications that people might use for mood stabilization or for anxiety or for insomnia. There's another whole set of medications, obviously, that might be indicated for comorbid conditions, and those have much more robust evidence. One of the things that's always sort of of concern and, you know, I've seen hundreds of patients and so I've seen patients on zero medications and I've seen patients on 12 different medications. And there isn't necessarily much in the way of clinical differences in terms of their outcome. And there's other patients know, you give them one medication and they really find that it makes an a profound impact on one domain. So perhaps there's a diminishing of their anxiety, and that really makes a significant difference in their quality of life. But the main concern that we often have as clinicians is that we see polypharmacy where there's one medication added and maybe there's a little bit of benefit, but it's not certain. And so then another one is added maybe targeting a different symptom or trying to augment the first medication. Very seldom medications are taken away and then gradually over time, you get you find a situation where you're on a 10 to 12 different medications, including medications to treat the side effects of the original medications. You're not entirely sure how the heck we got here, and you're certainly not sure how are we going to get out of here? So you don't like today? I had a follow up appointment with patients, which of course was done virtually because we're in the middle of a pandemic. She joined our program in January, and since she arrived in January, we've been gradually trying to clean up her pharmacotherapy. She's been since let's we're September, so that's nine months. So in nine months we've taken away one at a time. And so she's been taken off lithium. Let's see. So when she started, she was on three mood stabilisers. One of which was lithium, two antipsychotics, two antidepressants, two sleep aids. And so we've removed lithium. Epival, Emmavain, regular Seroquel, Seroquel, XR and Zoloft and Wellbutrin. And her clinical condition is no different, except she has a lot less side effects. So it's complicated and every patient is different. Some patients have a significant response. Very rarely is there like symptom remission. So if you're treating anxiety, it's very rare that they're going to describe, you know what, I'm no longer anxious. I don't have any anxiety. But their anxiety might go from 10 to 8 or 8 to 6, and that may be clinically significant. Even though you don't have remission of the particular symptom, you may have taken enough of the edge off that it makes a difference in their quality of life and perhaps allows greater functioning.
Dr. Robert Biskin : [00:27:21] My opinions about pharmacotherapy are probably a little stronger than Dr. Fraser's. I'm not particularly fond of pharmacotherapy for patients with BPD, and there's evidence that the medications themselves are of generally limited value. And when you look at the literature, the research, the better quality of the study is, the less likely it is to show any benefit over placebo. And this has been shown now with a number of different agents, Zyprexa, Lamotrigine or two that come to mind with recent examples. So I'm skeptical of most of the medications because again, these are most of the medications we use in psychiatry do have a substantial side effect burden. And as well, one of the things that I'm always concerned about is toxicity. So I'm highly concerned about people who are, for example, on mood stabilizers and things like that where the risk, if they overdose on it is quite profound. So I'm very reluctant to prescribe these medications and will often do prescribe medications as well. I tend to if in situations where, for example, anxiety or things like that Are Significant, depressive symptoms are really getting in the way. I occasionally do prescribe medications more than occasionally. Sometimes we'll prescribe medications, but often it is ones that are lower risk, less side effect burden as well. And interestingly, there's been one study that showed that when you prescribe medications for depressive symptoms with people who are actually in the program, the people who receive medications actually did worse. Which is fascinating. And it interestingly fits with my clinical opinion perspective as well in that sometimes people wish or hope for the medications to be the solution because it seems easier to take a pill than it does to do therapy because therapy involves a lot of hard work, whereas the pill, the side effects are not immediate. You're not going to feel anything immediately after taking it. So they might prioritise taking medications as solutions as opposed to therapy. So sometimes emphasising medications too much or people focusing on medications too much lessens their focus on actually making the necessary therapeutic changes and committing themselves to the to the process of psychotherapy. So again, I do use medications on occasion, again, lower typically lower risk medications and again, always monotherapy stopping the medications if they're not effective, sometimes medications for sleep as well, but more or less, less frequently.
Dr. Ronald Fraser: [00:30:05] Yeah, I wanted to actually emphasise this point because I think it's really key in Western society. We have a real love affair with medications and we have this sort of belief that we should never feel any physical or psychological discomfort and if we do, there should be a pill for that. And. As Dr. Biskin points out, it can actually prevent people from engaging fully in the therapy because of their never ending quest for just the right medication or just the right combination of medications. People's belief that there's got to be some medication or combination of medications, and we just haven't hit it yet. And that's going to resolve. All my distress can can really be quite remarkable and it can be very difficult, despite providing tremendous psychoeducation, that that's unlikely to happen. We know from the literature that medication is not likely to be that beneficial. And we know from the literature what is likely to be beneficial is psychotherapy, which sadly is a heck of a lot of hard work. And I think that it can't be emphasised enough but dynamic.
Dr. Robert Biskin : [00:31:35] In my opinion, it often comes back to this idea about trying to the self and validation that people have learned that they're not supposed to feel things, so they will seek out whatever it might be, including prescribed medications, if they're feeling sadness, if they're feeling anxiety, to do whatever they can to make those feelings go away. Many of the patients that I've worked with have said that they wish that they could turn off their feelings if possible, but that's not actually possible in psychotherapy. It's a very clear point that you have to live with your feelings. You have to learn how to cope with them and how to be with them instead of trying to make them go away.
Dr. Ronald Fraser: [00:32:14] Which, of course, is what leads so many patients with borderline personality disorder to develop substance use disorders because there's no more effective short term solution to negative affective straights than intoxication. Unfortunately, it's a spectacularly poor long term solution, but it's the same principles.
Dr. Sarah Hanafi (PGY3): [00:32:37] I actually wanted to address something that you had briefly mentioned earlier, Dr. Fraser, in regards to comorbid disorders. How do you approach treating comorbid disorders in this patient population?
Dr. Ronald Fraser: [00:32:50] So my perspective on this has actually changed over the. Decade and a half. And so this is more personal opinion than anything else. So I think we should have that caveat early on in my career. Saw tons and tons and tons of co-morbidities. Now more and more I conceptualise things as really it's part and parcel of the personality disorder and that really is what needs the focus of attention. There are some exceptions to that. So occasionally I have that conceptualization and then I see them, a year into treatment and they're fluidly manic. And I say, okay, we missed that. That's what's pretty clear that they have bipolar disorder, and that happens about once every 75 patients or something like that. I think the most prevalent comorbidity that I see is substance use disorders. And despite being an addiction psychiatrist, we don't do a great job of treating that. We're not even though we recognise it, we see it. I really wish we did a better job of that. I think the next most prevalent thing that I see is probably things in the eating disorder spectrum. A lot, a lot of very clear comorbidities there. Oftentimes patients we struggle with, we'll refer to the eating disorders program, patients that they struggle with, they'll send to us. And sometimes we have success with theirs and they have success with ours. Different interventions and perspectives resonate with different patients. Anxiety and mood disorders are described as very prevalent comorbidities, but I'm less and less convinced of that as as my career goes on, to be perfectly honest, that I don't think I see it. And I may be seeing a bias sample. And then, of course, trauma related disorders are quite common because unfortunately, many of these patients have had very difficult backgrounds, some of which are just literally horrific. And and often it would be shocking if they didn't have a trauma related disorder, given their experiences. So I think those are the sorts of things you see. The good news is, is that many of the treatments for borderline personality disorders, many of the psychotherapies, also have a certain amount of effectiveness for other things. So if you are suffering from a substance use disorder or trauma related disorder, distress tolerance is a super useful skill, right? If you're suffering from different disorders, usually they're impacting on your interpersonal functioning. So improving that is tremendously helpful. So you don't necessarily have to change the interventions regardless of the comorbidities. But I do think you need to be aware of them. You need to be cognisant of them, and that may sometimes inform your pharmacotherapy in particular.
Dr. Robert Biskin : [00:36:15] I would. I definitely agree with what everything that Dr. Fraser has said and I'm also of the mindset and perhaps slightly controversially so that a lot of the mood disorder symptoms, the depressive symptoms, the anxiety symptoms are often manifestations or components of the person of BPD as part of those difficult or dysphoric states. The comorbidities that are the ones that are most concerning and will lead to changes of treatment really are the substance use disorders, particularly if more severe. And it's that point that I'll refer people to Dr. Fraser, but as well the people with the severe eating disorders and I've seen quite a number of cases of people who once, for example, when they have an anorexia and once the anorexia becomes quite impairing and consuming of somebody's life, it's very hard to pull back from that without the structure and specialised support that eating disorder programs are able to provide. Other disorders. I've had patients in my clinics who often younger patients who at a certain point will have psychotic episodes that will persist for time. And at that point, clearly we have to revise the diagnosis to a psychotic disorder or something like schizophrenia, which dramatically changes the treatment approach. But for many of the more garden variety mood or anxiety disorders, I completely agree that treatment for BPD, whatever that treatment might be, is shown to be efficacious. People's symptoms of depression, anxiety with specialised psychotherapies will reduce will improve as well.
Dr. Ronald Fraser: [00:37:58] I just want to add one last point, because I think this is actually Dr. Biskin touched on an important point, that it's important to contextualize for learners about the controversial aspect of these things and that I think you figured out by now that what we say is not necessarily gospel. So you can have the same patients who Dr. Biskin and I might clearly conceptualise as having borderline personality disorder. And you could have one of our very respected and revered colleagues in a mood disorder clinic who would say, Look, Fraser doesn't know what he's talking about. This is clearly bipolar spectrum disorder. And you know, it's not clear that I'm right and they're wrong or vice versa. And I think that's where it's really important for learners to decide for themselves what makes sense for them, what they think is going on, and recognising that everything you hear from me and Dr. Baskin consciously or unconsciously, has a certain bias based on our training, our background, our experience, all of those factors. And if you had two other people here with different background training and experience, you might get very different answers that might be equally or even more valid than what we're sharing.
Dr. Sarah Hanafi (PGY3): [00:39:31] I'm really enjoying this this discussion. I think it's bringing up some really interesting points. I actually wanted to circle back to something you had mentioned, Dr. Biskin, about safety risk. Briefly, I was wondering, can you just talk about how you approach managing safety in this patient population?
Dr. Robert Biskin : [00:39:51] Boy, that's not an easy question. Much like Dr. Fraser is mentioning about different diagnostic approaches and different diagnostic thresholds. I would say the same applies for thresholds, for accepting risk, because you'll get many different answers for many different people. I would most clearly say that I accept a higher threshold of risk, fortunately or unfortunately, than many of my colleagues who don't work with this population. And it's something that is a particularly tricky question to answer. And I guess, as I pointed out before, for learners, it's something that you would be very careful to discuss with whoever it is that you're working with as time goes on, because you'll get very different perspectives. My particular approach or understanding is that people with BPD, they suffer a lot. And the idea of suicide, because I'm assuming that's mostly what we're talking about. The idea of suicide is something that's pretty much constantly present because it's the escape hatch. If there's a lot of pain in their life and they're doing everything they can to control it and it's just not working, it's sometimes reassuring. Your comforting to know that suicide is there as a backup option, which is very both comforting for patients sometimes when they're thinking about that and also terrifying for them as well, because many times that's not the path that they want to take unless it's absolutely necessary. So accepting the risk that there might be, which is a chronic risk, but people working with this population or in general mental health problems, that accepting that suicide might be a risk is part of the treatment. And it's one of the challenges with when you're deciding what to do with somebody who's presenting in the emergency room. It makes it very challenging because what we know that reduces that suicidality is specialised therapies that exist as on the outside. We don't really have evidence that hospitalization and the treatments provided in a general psychiatric inpatient unit are able to reduce suicide in the same way or suicidality in the same way that the outpatient psychotherapies are. So it's a very difficult question to answer.
Dr. Ronald Fraser: [00:42:18] So one of the things I would add is that, you know, if you don't want to have a patient die, you probably shouldn't go into health care because it's unfortunately an occupational hazard. Our job is, wherever possible to minimize the prevalence of that. But certain populations have higher risks than others. At certain populations are more unpredictable than others not. You have to have a certain tolerance of uncertainty and a certain tolerance of risk to work with this particular population. And not everybody has the temperament or disposition for that, which is fine. I don't have the temperament or disposition to work with other patient populations. I think it's super important to try to differentiate between chronic risk and acute risk. So, you know, I have patients that are, you know, are thinking about suicide every single day. And and as Dr. Biscuit points out. That can be perversely comforting because it actually gives them a sense of one thing in their life that they have control over. I can choose to kill myself or I can choose to not kill myself. I have control over that. I may not have to feel like I have control over anything else. And one of the rewarding things is that as people respond to therapy, you know, often with tears in their eyes, they'll say, you know, I haven't thought about end of my life in months. It used to be my daily companion. So that actually does respond to therapy, as he pointed out. But then there can be acute risk on top of the chronic. And that's where you sort of have to be cognisant of picking that up. And so particularly in acute crises, often if there's a loss of a significant relationship because relationships are so important to people in general and this population in particular. So the the loss of a therapist, whether it's through the end of therapy or if they've had the misfortune them, I've had patients with their therapists have died. So that's difficult or they've been kicked out of the therapy for whatever reason, or there's been a loss of a loved one or a relationship or a pet if there's been some other acute stressor. If you see in your patient that there's a profound clinical change, it helps if you know the patient really well. It's like, okay, this is like they're really disorganised or they're really struggling or they're really like severely dissociating or severely regressed. There's something acute going on here that's that is alarming. Then you're concerned that their chronic risk of suicide may have escalated acutely and you may need to make significant differences in your treatment plan in terms of brief containment and a brief intervention unit or a very short admission until that acute situation stabilises itself. And you may still discharge them with suicidality, but it will be back to their chronic state, not the acute state.
Dr. Nima Nahiddi: [00:46:09] And so to finish off and building on our discussion, which we started in the diagnostic episode. Can you both speak on stigma and Treatment of patients with borderline personality disorder?
Dr. Ronald Fraser: [00:46:19] So that's a big thing and it's less of a thing than when I started. So we're making headway. We've got a long way to go. But when I started the idea that there would be groups for loved ones and concerned others, for people suffering from a borderline personality disorder, like there's a whole network in Ontario of these things. We have Quebec here in Montreal, like the fact that there would that these would even exist was like unheard of. So we're still making headway. There's been a lot of education in the media that didn't use to exist. There's still a lot of bad information out there, as Dr. Biskin touched on in the last session. So the Internet transformed the world. But it's not all positive. And there's a lot of really. Misinformation. Know, I think that's sort of a buzz word for 2020 is misinformation. And so it's really important to try to direct our patients to reliable sources of information. For me, the National Education Alliance for Borderline Personality Disorder is a web resource that I often direct patients and families to. There's a lot of Biblio therapy that I direct people to. So you try to explain that there's just like everything else, the world is good and bad information. But the biggest challenge is, I think, still. Is stigmatization within the health care network. So the reception these patients get when they go to the emergency room. Is often far less than ideal. And many of my patients are smart people and they started to figure out I get a much better perception or reception story if I tell them I have schizophrenia or bipolar disorder, or I tell them I'm having auditory hallucinations. They sort of learn because it's aversive. To present with borderline personality disorder. And I've had patients that have engaged in self-injurious behaviour and they need sutures like that's the medically indicated treatment. And and the emergency room physician will say, you know, if you like pain so much, maybe I shouldn't give you any lidocaine or any anaesthetic or The emergency room physician who have a very difficult job, don't get me wrong, but it's very frustrated and says, you know, I should teach you to try sutures so that you can just suture yourself. How you can do one handed sutures, I'm not sure. But anyway, so they get abysmal Treatment Often when when they interact with the health care system, that really wouldn't be acceptable for any other human being, let alone any other diagnosis. So where we need to make the most progress is around reducing stigmatization within our own health care networks. And one of the ways we do that, which has also been quite fruitful, is through conferences and education and podcasts like this. You know, there's probably, I don't know, 86 people other than my father that are going to watch this podcast, but they will learn something from it. And these things make a difference over time. Maybe underestimated the numbers.
Dr. Sarah Hanafi (PGY3): [00:50:09] We we have more listeners than that, but.
Dr. Robert Biskin : [00:50:14] So to add to to what Dr. Fraser was saying. I do agree that the health care system is one of the sources of a lot of stigma. And I do think that one of the things that has changed and has helped improve the amount of stigma, particularly within mental health care, is greater accessibility to these specialised treatments. So the programs that Dr. Fraser have established and that Dr. Paris have established here in Montreal has helped people change their perspective and seeing that the beliefs that they have about these these disorders are not necessarily accurate. And unfortunately, not every region, not every city has access to programs like we do. Obviously, I think they should. And I think that both education information and advocating for increasing services and increasing recognition of the disorder is something that will help. And this is where I get concerned about people who might label BPD as another psychiatric disorder, such as the comment that Dr. Fraser made last time about the overlap between criteria with complex PTSD and borderline personality disorder, that one of the potential outcomes of that is that it might further stigmatise borderline personality disorder that might think of it as the unwanted illness, even though the symptoms are almost exactly the same. So further awareness and access to the disorder and to the treatments for it, I think is something that over time will help improve the perception within the health care system as well.
Dr. Nima Nahiddi: [00:51:58] A huge thank you to both of you, Dr. Biskin and Dr. Fraser. I certainly learned a lot myself. Do you have any closing remarks for our listeners?
Dr. Ronald Fraser: [00:52:07] Well, I think we both are really appreciative that you invited us. Obviously, hopefully it came through that this is a topic that we're both pretty passionate about. We've chosen to devote our careers to this and any opportunity we get to sort of share the gospel, we're really tremendously appreciative to have the opportunity. So thank you for expressing an interest in it and having it as a topic in your podcast series. And thank you for inviting us. We really appreciate it.
Dr. Robert Biskin : [00:52:40] Thank you very much for inviting us. Definitely something that is not just passionate for us, but something that we genuinely enjoy as well. So any chance that we get to talk about it and to kind of share some of that, that enjoyment that we have with working with these sorts of problems and people with these sorts of problems, we're thrilled to do it.
Dr. Nima Nahiddi: [00:53:01] Thank you both once again.
Dr. Sarah Hanafi (PGY3): [00:53:03] Psyched is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Dr. Sarah Hanafi, Dr. Nima Nahiddi and Audrey Le. Audio Editing by Audrey Le. Our theme song is Working Solutions by all live music. A special thanks to the incredible guest, Dr. Robert Biskin and Dr. Ronald Fraser for serving as our experts for this episode. You can contact us at psychedpodcast@gmail.com or visit us at psychedpodcast.org Thank you so much for listening.