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"Almost all such patients have had abusive childhoods and traumatic lives, and they recognize the link between BPD and trauma." This is the single most important sentence in the article. Why don't we call these people "People with multiple ACE's who thereby have serious difficulty regulating their emotions and managing relationships, because they were never regulated by emotionally healthy parents"? If we put their experience of neglect and trauma front and center, then they will be treated with epistemic justice. Far too often, their ACE's are ignored, and their present day behavior is the focus of attention. Never forget the line from The Body Keeps the Score, where Bessel talked to "Chris Perry, the director of research at Cambridge Hospital, who was funded by the National Institute of Mental Health to study BPD and other near neighbor diagnoses, so-called personality disorders, in patients recruited from the Cambridge Hospital. He had collected volumes of valuable data on these subjects but had never inquired about childhood abuse and neglect." (p.212)

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"People with multiple ACE's who thereby have serious difficulty regulating their emotions and managing relationships, because they were never regulated by emotionally healthy parents"

That's kind of the idea about the notion of complex PTSD, yeah. I think what BPD adds to this is additional consideration of the psychodynamics of personality, since the issues go beyond mere emotional regulation.

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Thank you for writing this article up Dr Aftab. As a person advocating for patients with severe PTSD, I myself have previously been diagnosed and treated for BPD and faced exactly these struggles just to get medications, and faced a ramp up of persecution in my family as well as a result. Very freeing to read. It was truly the “rudest” I have been treated in a medical setting and set me back in asking for help with physical illnesses fearing my doctors reactions. I was diagnosed in 15 minutes for intimating to a Muslim psychiatrist my preoccupation with suicide and depression at a time when I was very vulnerable, to have him respond aggressively with religious and culturally biased rhetoric and diagnose me right away. It took many years to find a psychiatrist who even asked me a past trauma history, something I didn’t remember/was aware of myself when I went in for treatment. Do you believe BPD belongs anywhere as an over arching diagnoses secondary to other disorders, as opposed to a category of its own?

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Thanks for sharing your own experience, Aun. I am sorry you had to go through this. I think BPD makes the most sense from a psychodynamic perspective. It's useful as a clinical prototype, but psychometrically it breaks down into component dimensions such as negative affectivity, antagonism, and disinhibition (similar to other personality disorders).

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Jun 21Liked by Awais Aftab

Hi Awais, when you refer to “the psychodynamics of personality” are we long past psychoanalysis? I’m curious, are the kinds of Freudian ideas about the dynamics of conscious and unconscious motivations etc., still in play these days? Or, is the term used to refer to ideas that have much more empirical support now? I.e. a modern understanding of personality etc? Thank you!

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Oh, psychodynamic thinking is still very much alive, especially in clinical psychology and quite indispensable in the psychotherapy world. It doesn't quite have the same scientific standing as psychometric approaches to personality because of the difficulties with measurement and quantification, but it would be foolish to dismiss it. I recently wrote about current status of psychodynamic thinking in this post: https://www.psychiatrymargins.com/p/an-intro-to-freud-is-not-an-intro

And Shedler's chapter on personality disorder is a good illustration of how to think about personality disorders in psychodynamic terms: https://jonathanshedler.com/wp-content/uploads/2021/10/Shedler-2021-The-personality-syndromes-R.pdf

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Thanks Awais. Would you say a psychodynamic approach is much more alive in Psychiatry than in Psychology?

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Psychodynamic approach is more alive in psychiatry compared to most academic psychologists (that conduct research, train PhDs, etc.) but the comparison doesn't quite hold for clinical psychotherapy, where psychodynamic approach has a heavy presence. The clinical psychology world is quite divided into ideological camps, and it is often difficult to generalize about "psychology" as such.

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Jun 17Liked by Awais Aftab

Some thoughts:

Have you read Shay Welch's "am I safe enough for you now?" in the Philosophical Forum? She embraces the diagnosis, and says she is, among other things, very INTENSE in everything, but that's not necessarily bad. It depends on what you do with it. Also, it's def her personality. She talks about being medicated to the point that other people find her much more easy and pleasant to be around, but for her it was hell, because her entire personality had been medicated away.

I remember being in an online support group (international, btw, so don't know specifically which country the people involved came from) where one woman had just received a BPD diagnosis and felt bad about it. Others advised her to seek out a second and perhaps third opinion. "If you go to one or two more docs, one of them will probably diagnose you bipolar instead. You should seek treatment under that diagnosis, they'll treat you much better and with more respect than if they think you've got BPD."

I also remember Luhrmann's "Of two minds" and the horrible, horrible things interviewed psychiatrists (USA 2000) say to her about BPD. BPD patients sometimes pick out certain staff members as trustworthy, and then tell them they've been abused by other staff. It's important to NEVER BELIEVE BPD patients who say they've been abused or otherwise treated badly by staff, because that's just manipulative splitting behaviour! Also, the most reliable sign that the patient in front of you should be diagnosed with BPD is the "meat grinder test" - when you feel UGH, it's like your intestines go through a meat grinder as soon as you're talking to the patient, that's BPD. This horrible feeling you get with some patients is way more reliable than some box-ticking exercise with the diagnostic criteria.

Also that 2006 paper by MacKinnon and Pie, "Affective instability as rapid cycling", where they mostly discuss overlap between BPD and bipolar, but also speculate wildly that maybe BPD patients are just born horrible and that's why their parents neglect or abuse them.

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Thank you Sofia! Good pointers!

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Jun 17Liked by Awais Aftab

I enjoyed your balanced perspective on this diagnosis. It was interesting to learn about differences in US and UK healthcare systems. I am in NZ, where the healthcare system is similar to Britain. Although I have no diagnosis of BPD, I have met some lovely people for whom this diagnosis was very difficult, both in terms of symptom management and trying to access care. I have been diagnosed with another personality disorder myself and found it a potentially helpful but ultimately frustrating label. I am looking forward to further evolution in psychiatric care. Where once we were burnt at the stake, now we have rather sticky labels. Perhaps one day, a label will always be a key to open the door to good mental health. And if not, the label is easily removed, and apologies made.

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Thank you, holden. It is my hope as well that our labels can be less sticky! I'll say more about US vs UK if I get the opportunity

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