Interview of Mr Daniel C Claiborn Ph D granted on november 23th 2002

Q: Could you first of all talk a little about you and your experience in mental health research and / or in the BPD treatment?
I am a licensed psychologist with a Ph.D. degree from the University of Missouri--Columbia, 1975.  Over the years I have specialized in the study and treatment of personality disorders, including Borderline, Narcissistic, and Antisocial.  I have presented lectures frequently on BPD, and I treat BPD in my practice

In a few words very simple to everyone (not DSM)
Q: "What is the Borderline personality disorder ?"
BPD is a chronic psychological disorder beginning in childhood or adolescence and characterized by instability (of moods, of relationships, of identity, of perceptions of self and others), by an unrelenting stream of consciousness (of thoughts of guilt, blame, criticism, anticipation, traumas, and losses), and by waves of emotional intensity often unrelated to immediate stimulus events--though mistakenly connected to them.
The inner emotional life of a BPD person consists of  an unusual combination of rage, emptiness, anxiety, depression, and desperation --interspersed with periods of calmness and productivity.  BPD people can be intelligent, gifted, and good at their professions.  BPD disorders occur on a continuum from almost psychotic, paralyzed conditions at one end to high functioning neurotic-like conditions at the other.  Some scholars think BPD personality adjustment is situated on a dimension between psychotic disorders and neurotic, anxiety-related disorders.  Psychologists debate whether BPD is primarily a mood disorder, an anxiety disorder, a dissociative disorder, or a disorder of self-identity, since BPD individuals can manifest all of these in differing degrees.  It can be said that BPD individuals have all the normal psychological dynamics, only much more so, and it can be noted that many BPD characteristics are similar to those of adolescents (whereas Narcissistic and Antisocial characteristics are more similar to those of children).
Origin: BPD results from a combination of several ingredients, and it is more severe the more ingredients are present and the earlier they entered the person's life.  The ingredients include (1) an inherited, biological, temperament predisposition toward a highly associative and reactive nervous system, (2) trauma experiences, and (3) parental inadequacy (neglect or uneven parental availability, lack of appropriate role modeling and guidance, lack of warmth and security.  Thus, for example, a person might inherit a highly excitable nervous system, but if he or she experienced no significant childhood traumas and if he or she had warm, adequate, secure parenting, that person would likely not develop BPD.  The ultimate degree and severity of BPD manifestation is related to the confluence and intensity of these causal factors

Q: Is it a "woman illness" ?
I have not found that BPD is exclusively a woman's illness, though keep in mind that many more women than men seek therapy services in general, so with any disorder it might look as if that disorder occurs primarily in women.  I have worked with a number of men BPDs

Q: What differentiates it from other diseases and personality disorders?
Differentiating BPD.  The chief characteristic of BPD can be considered  "inexplicable" instability and impulsivity, and the primary emotional feature is fear.  The personality disorders in general can be considered as resulting from (1) "hardening" or "intensifying" of certain personality defenses through overutilization in the face of persistent, chronic stress and trauma plus (2) a certain biological, temperamental predisposition.  Which specific predisposition is inherited and which defenses are overused determine the specific type of personality disorder the person might have.  Whereas Narcissistic Personality Disorder individuals are more focused on self-gratification, domination, attention-gathering, and access to support and adoration, Antisocial PD individuals express more hostility, deception, and violation of societal rules, Dependent PDs abdicate personal responsibility and shrink from choices, Obsessive-Compulsive PDs engage in anxiety-reducing rituals and structures, and BPDs vacillate among all of these strategies, being most conflicted about intimacy and closeness with others.

Q: A lot of specialist suggest that the "childish" side of the adult borderline totally essential in the illness? (including Black and White thinking - All good - All bad - No middle)
Q: Same comment about the sudden rage ?
Childishness and sudden rage.  Yes, these seem to be present typically and episodically, though the BPD person often functions maturely and calmly for long periods of time and in certain (particularly non-intimate) roles

Q: How to be sure that it is borderline disorder and not another mental illness ?

Depression does not involve the instability and impulsiveness of behavior,
Bipolar Disorder's features are not triggered by perceived rejection or abandonment,
Attention Deficit Disorder can involve frustration but not personal and intense rage or profound emptiness, and
Asperger's Disorder typically manifests through a deficiency or restriction in social skills and sensitivity (inability to relate or connect adequately, and inability to experience and express emotions fully) -- these are not characteristic of BPD.  These are some examples of differentiating characteristics.

Do you think that brain imaging can help to an accurate diagnosis for BPD ?
"Brain imaging"   I do think there is a biological aspect to BPD, in the form of an inherited, excitable, overly responsive nervous system, but I am not familiar with brain imaging studies.  I do not think all BPD individuals are alike on a biological or neurochemical level -- there is a lot of variety among BPD individuals, both in symptom patterns and in severity and scope of the disorder.

When we are in the circle of one person potentially borderline.
Q: What are the behaviors, the alert signs to tell "this time it is not normal, it would be necessary to him/her to consult a therapist"
Alert signs.  One signal that might indicate BPD (or another personality disorder) in a person is that person's attributing to you (or accusing you of) an angry, critical, or rejecting emotion or attitude toward him that you do not have (but that he has about you!)--in other words, projection onto you of his frame of mind.  Another signal might be someone's conflicting manouvers in an intimate relationship -- for example, "I hate you--don't leave me!"

Q: At which age can we start to see the first signs and worry about ?
Age of onset.  Signs of BPD can be seen in childhood and certainly are noted by adolescence.  Sometimes in childhood, BPD-like patterns are diagnosed as Identity Disorder.

The people having this disorder "used to be" like this from all their life and it is "the way they are"
Q: why in that case don't leave them and let them continuing to live their life ?
"Why don't we leave them alone...?"    If BPD people are not given proper treatment, most of them will improve anyway, particularly in their 30s or 40s.  20--30% will improve almost completely, and another 30--40% will improve significantly.  However, until age 30 or 35, BPD individuals are at higher risk for suicide.  Also, without treatment of the BPD person and his/her family, much distress will be suffered by everyone, often alienating the BPD person from friends, lovers, and family.

Medication.  There is no medication to treat the overall condition of BPD, but certain anti-anxiety, anti-depression, anti-psychotic, and anti-obsessional medications can be used for certain periods of time to treat these particular symptoms specifically when they are occurring.  We teach the BPD person to anticipate the phases and changes in his/her condition, and to work with a physician to target medications appropriately.  Unless it is an emergency involving suicide or potential violence, we try not to hospitalize BPD patients, since they may respond to hospitalization counterproductively.  We want the BPD person to feel in control of his/her treatment, so that the treatment feels elective, not forced.

Q: Are borderlines patients more "fragile" and subject to "somatization" ?
lot of small illnesses, some somatics illnesses (dermatological, ORL, ...)
"somatization"   I do not know for sure whether BPDs are especially prone to somatization.  My guess is that the ones who act out impulsively and destructively will not be as prone to somatization as those who are more anxious and depressed.  Keep in mind that persons with psychological disorders often have more than one diagnosable problem.

Precisely about this illness
Q: "is there a cure ?"
Yes, BPD can be effectively treated using psychotherapy, behavior modification, and medication as needed.  Often the treatment takes 3 to 5 or 7 years


Q: Is using medication (almost during a time) necessary or a "simple" therapy can be enough ?

Q: Same question but only medication without therapy
Medication without psychotherapy is not indicated.

Q: Is that mean that only a psychiatrist therapist doctor is able to cure a borderline patient ?
"Only a psychiatrist able to cure?"   Treatment of BPD requires specialized training, supervised and extensive experience, and, most importantly, the therapist having access to peer support or ongoing supervision, since BPD patients can present the therapist with emotionally complicated and personally stressful dilemmas (just as they often present their families and loved ones with emotionally complicated and personally stressful dilemmas).  Some psychiatrists have the required training and experience and some psychologists do also--supervised experience with BPD people is necessary.

Again about médication: Selective Serotonin Reuptake Inhibitors (5 hydroxytryptamine) seems to be very important. A lot lot of patients (and studies) are talking about Fluoxetine as a "miracle drug".
Q: What is your opinion ?
SSRI medication is most helpful for obsessive-compulsive symptoms, sometimes helpful for self-mutilation and depression, and occasionally helpful for anxiety.  Some people get quite a bit of benefit from SSRIs, and there is little risk, so they are worth trying, since that is the only way to assess potential helpfulness.  Sometimes SSRIs increase the vividness of dreaming, interfere with sleep, increase weight or reduce appetite, or cause sexual arousal difficulties, so these potential side effects must be monitored, since they may be of special alarm to BPD individuals.  It is best to present medication and even specific psychological treatments as only partial remedies, so as to reinforce the patient's need for active, willful responsibility in his/her management of the disorder.  I have not found SSRIs or any other medications to be miracle drugs for BPD, except in occasional cases where the individual is suffering from obsessive-compulsive disorder and/or major depression which responds dramatically to SSRIs.  Often tranquilizers such as Xanax or Ativan are more helpful as they are used specifically to reduce intense anxiety and prevent panic attacks.  Sometimes these are used initially in psychological treatment to help the patient learn behavioral anxiety management techniques more rapidly.

Q: We talk about "low functionning" borderlines (cut, suicidal) and "high functionning" patients (seems "normals").
Do you believe in this ? (two illnesses)
"Low and high functioning"  Yes, I do observe the range from low to high functioning in BPD patients, both in cognitive functioning and in interpersonal, goal-directed behavior.  Treatment for lower functioning BPD individuals needs to be much longer and more basic and intensive, including skill building and practice in a safe context.  Therapies with lower functioning patients tend to be more structured and programmed, whereas in therapy with higher functioning patients, the therapist can be more flexible, personal, and revealing.  Medication is more strongly indicated as a part of treatment in lower functioning patients, often including use of the major, anti-psychotic tranquilizers.

There seems to be a debate. First of all a "truth" seems to be that "classical standard therapy don't work with borderline peoples" right ?
"About therapy"    Yes, classical standard therapy, if by this we mean insight-oriented interpretation therapy only, is inadequate in treating not only BPD patients but most others.  If by "classical standard therapy" we mean the current state of the art standard therapy, which is eclectic, active, problem-oriented, behavior-change-oriented, and includes experiential techniques, practice, and homework in addition to insight, then this classical therapy is appropriate for BPD persons.

We have read that DBT therapy "Dialectical Behavioral Therapy" is accurate (working)
Q: Your opinion ?
"DBT"     Dialectical Behavior Therapy is known to be helpful to BPD persons.  DBT is a collection of practical behavioral, emotional, and cognitive strategies designed to address the several problem dimensions of BPD.  Any approach which does this is more applicable to a complex personality disorder such as BPD.  Especially important is the therapy including supervision or consultation available to the therapist as he/she works with the BPD person.

We have read that all of this doesn't work with "high functioning" borderline. To be clear they are hopeless, condemned to suffer all their life
Q: not really optimistic no ?
In my experience the good therapeutic approaches work with both low functioning and high functioning patients.  However, higher functioning BPD persons may tend not to think they need therapy (even though they find themselves moving from one failed relationship to another, for example), and lower functioning persons may not be informed of their disorder or the treatment available, or their depression, anxiety, and skeptical, mistrustful perceptions may prevent them from being hopeful.

Really a disease

Q: Is the word "Borderline" suitable, borderline means "not really"
The term "borderline."  Borderline originally referred to a pattern of pathological behavior that appeared to be partly psychotic and partly neurotic--in other words, on a borderline between categories.  These patients had some characteristics of psychotic (out of touch with reality) patients, but they were not psychotic, and yet they did not respond readily and quickly and permanently to traditional talk therapy.  "Borderline" thus partly means "not really" psychotic and partly "not really" neurotic or easily treatable.

In France, some peoples, and even psychiatrist are saying, "we are all borderline", to be clear that this illness doesn't exist
Q: what is your opinion about this point of view ?
We all have mild aspects of some of the symptoms of BPD, but certainly not to the intensity or in such an unrelentless, pervasively destructive way as do BPD individuals.  However, people can be labeled BPD or "borderline" just because of one resemblance or symptom, and this is not appropriate.  BPD consists of a stable pattern of instability which severely disables the individual in interpersonal relationships especially.  To say "We are all borderline" is to misunderstand or distort the concept, out of ignorance or for an economic or political purpose.

Q: About DSM IV. A lot of therapist in France when we say "DSM" have some "disdain", like it was "useless"
Could you answer this ?
(question not asked)

The answer is certainly not but I ask
Q: Is each / every psychiatrist has the training and experience to treat borderline patient ?
"Each and every psychiatrist have the training?"  No, treatment of BPD requires special training and supervised experience.

Q: Do you think that there is actually some deficiency in this domain ? (training and education of mental health providers)
"Deficiency in this domain?"  Yes, there is a deficiency here in the US and I imagine in France.  Also, here many therapists do not choose to treat BPD individuals because of the difficulty involved.

In France, mental illness is a taboo like cancer was some years ago
In everybody mind, someone going to consult a psychiatrist is "mad" or "retarded"
Q: what could you say about this ?
"Mental illness taboo"   Unfortunately I do not know much about the view of mental illness or BPD in France, but I think the internet has the potential to help tremendously.  In fact, many of my patients look up information about their personality disorders on the internet.  I think this is very helpful.

About this subject, we often associate the "cure" with the "willing" to
"Please stop to do, acting like this and do what it is necessary !"
A kind of "if you want, you can" and "if you are not doing, that's mean that you don't want"
Q: what is your opinion ?
"Associating 'cure' with exercising the will"   I believe indeed that exercising the will is very important in achieving a cure or a better adjustment.  I also believe, however, that individuals need information, coaching and direction, emotional support and guidance, and encouragement to exercise their will effectively and persistently, just as they require when learning anything complex that necessitates behavior change and proper practice, such as learning a foreign language, learning a sport, and so on.

Q: What do you think about the idea to create an association to promote knowledge of this illness and help peoples ?
"Creating an association"    I think your creation of an association to promote knowledge of BPD and effective treatment is wonderful and much needed.  I am so happy to help you in whatever way I can.  I would strongly encourage you to develop and maintain a web site such as BPDCentral , and I recommend their book:  Stop Walking On Eggshells.  It is especially good for family members of BPD individuals.

It is ethically very difficult to force something to be treated (I suppose that it is also useless if he don't want)
But we know that all over the world there are thousands of sick peoples, which don't know that they are sick, and thinking that it is the "way they are" to suffer
Q: What do you think about the principle of "diagnosis obligation" when we are in contact with someone potentially Bpd (or other mental illness), to "force" him / her (i don't know how) to see a therapist, not to treat him (her), but only to give him (her) an accurate diagnosis ?
In that way it would be more difficult to him (her) to say "i'm not sick" (and also to the family circle to believe the lyings)
The second point is that perhaps it could help him (her) to become aware that he (she) is sick
So ?
"Diagnosis obligation"   I do not believe in diagnosis obligation.  In fact, BPD may not occur with much prevalence at all in other cultures.  It typically requires a certain genetic predisposition, significant childhood traumas, and deficient parenting or identity support -- any or all of which might not be present in some cultures
Perhaps I do not understand what you mean by this concept.  If a therapist is working wtih a person who exhibits the BPD patterns, then I do think that therapist should inform the patient of his/her condition and its effects and recommended treatments.
But yes, if the BPD person realized he/she had that diagnosis, it would be more difficult to deny the problem.  Usually I recommend the family member show the BPD person a list of symptoms or other information from the web and let the BPD person draw his or her own conclusions.  It might be very clear that the diagnosis fits.

(Only if you think that it is not a good idea)
Q: In that case, don't you think that there is an high risk for the borderline patient to think
"I suffer, I know, but I'm unique, it's my nature" and not thinking "I'm not alone like this, I'm just sick" and then never be treated ?
(question not asked)

Question without answer I suppose
Q: "how to convince the patient to consult a specialist ?"
I would recommend supplying accurate information through your association, literature, and the web site.  Most BPD people and their families respond immediately and positively when they see a list of the typical BPD symptom patterns explained in a sensitive, logical, and compassionate way.

I suppose that it is hardly more difficult to convince an high functioning borderline to consult a therapist (if they are saying "i have nothing")
Q: Once again what is your experience, the solution ?
I find that it is not necessarily hard to convince high functioning persons to get treatment, since they are usually intelligent and well-informed, and they can see the destructive and repetitive patterns in their behavior and relationships

The BP Distortion Campaign
"When a BP deliberately tries to convince others that the Non (the one who know) is the one who is sick"
Q: is it a common data ?

Q: how to manage this ?

Q: More generally, how to "manage" relationships with a borderline ?
When possible, and within reasonable parameters, I believe we should always try to avoid provoking rage in another person.  On the other hand, I think we should mostly react normally to the BPD person, telling him or her when our feelings have been hurt or when we are upset about one of his/her actions.  Honesty is very important with BPD persons--we should be honest with our reactions to them, while not telling them what to do about our reactions.  I believe the second way is more respectful and ultimately the kindest.

The borderline seems to have a childish emotional IQ
Q: Is it "sensible" to ask a "children like" to take such a decision ?
(consult or not, treat or not)
"Childish emotional IQ"   I find that BPD individuals, while they have some emotional immaturities, are usually intelligent and fully capable of appreciating information that confirms their experience.  I believe it is a matter of respect for the person to provide information and to allow him/her to make an informed choice about seeking treatment.

Q: Is it not totally utopian and even cruel to ask them taking such a decision ?
I do not believe this choice is beyond the BPD person, and I do not believe this effort is utopian or cruel--though I understand your question and appreciate your sensitivity to this possibility.

Q: What is your experience about this ?
How borderline people "come to you" ?
Generally they come either because they have gotten my name from the internet or because they are involved in a troubled love or marital relationship

Origin of the disease

The origin of the illness seems to be really complicated when we talk about borderline disorder, but it seems that trauma during early age are the main reason
Q: What do you think about this?
"Origin"  I explained my view of the multi-source origin of BPD earlier.  Childhood trauma is only one major contributor, along with genetic predisposition toward an excitable nervous system, and deficient or destructive parenting.

Q: Could Childhood Epilepsy Cause the BPD ?
Q: Opposite question. Could Bpd cause epilepsy ?
Epilepsy"   I do not know of any connection between BPD and epilepsy.  Keep in mind that EEG measurements and other scans of brain activity are very gross indicators indeed and not specific and sensitive indicators of something so complex and variegated as BPD.

Q: This illness could have genetic and / or biologic origin, what is your opinion ?
(question not asked)

The family could be a great help to support the patient.
But when one of the parents has some part of "responsibility" (even not conscious) in the illness of her own children,
Q : How is it conceivable for this parent to open yes about the reality of the situation ?
"Family responsibility"   Yes, families can be defensive, but in many cases they have had little part in contributing to the BPD.  Many times parents are very open to information about BPD because it explains so much that they have experienced along with their child, and it implies a great deal is known about BPD and there is effective treatment available.

It seems that mental illness is passed down through generations like a child of an alcoholic would become alcoholic at the adult age
Q: Is it true ?
Q: Is it the same with borderline disorder ?
The borderline mother is going to make her daughter borderline ?
Q: How to break this infernal circle ?
Mental illness and BPD passed down?"    No, there is not significant evidence that BPD is passed down from parent to child, though certain components may be present in the extended family tree:  Obsessiveness, anxiety-proneness, depression-proneness.  It seems that fathers who are abusive were often abused themselves as children, whereas mothers who were abused as children run a greater risk of neglecting their children than of abusing them.   Borderline mothers do not typically make their children borderline, though growing up with a borderline parent is fraught with difficulty and usually causes some adjustment problems in the children.  Extended family members who are healthy (aunts, uncles, grandparents, etc.) often help children develop normally despite abnormal parents

Latest questions
Q: Is there one question you would like to answer and I didn't ask ?

Q: Is the last word "hope" ?
Hope!   Yes, the resurrection or instillation of hope is the primary ingredient in treatment of any mental disorder, and the primary ingredient in any effective psychotherapy or other form of psychological healing.  Accurate information and proper understanding can open the doors to such hope, and I wish you the very best with your Association's endeavor.  Let me know if I can help in any further way.

Questions answered with the kindness of Mr Daniel C. Claiborn Ph.D. - Overland Park, Kansas

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