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CPTSD vs BPD: How to Think About the Difference and What to Do About It — Transcript

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0:02Welcome to the Psychopharm podcast. This
0:03podcast is for education and
0:04entertainment. It [music] certainly is
0:05not medical or psychiatric advice,
0:06diagnosis, or treatment. Listening does
0:08not create a doctor-patient relationship
0:09with me or Dr. Boo. If you're a patient,
0:10certainly don't change your treatment
0:11plan because of something you hear in
0:12this show. If you're a clinician, do not
0:13use this podcast [music] as a clinical
0:14reference or substitute for your own
0:16training, judgment, thinking, and
0:17up-to-date sources. Opinions are our own
0:18and don't necessarily reflect any
0:19employer or affiliated organization and
0:21may even be detached from reality.
0:23Good morning, Dr. Boo.
0:25Good morning. How's it going?
0:27Oh, not too bad. A little afraid.
0:30A little afraid? What are you afraid of?
0:32Well, I think we're discussing a bit of
0:34a complex [music]
0:35topic today, aren't we?
0:38Yeah.
0:39Um, we'll be talking about
0:41complex PTSD and borderline personality
0:43disorder.
0:45You actually
0:46on our PTSD episode, you opened up
0:48saying, "Are you afraid?"
0:50And then this episode, you're saying,
0:52"I'm afraid."
0:53Well, that was supposed to be a little
0:54Easter egg for anyone who's halfway
0:56paying attention, which is nobody.
0:58Um, before you listen to this episode,
1:00if you have not already, you may want to
1:02listen to the original trauma episode
1:05from back in the day because that's
1:06going to cover a lot of more
1:07foundational stuff, I think, that you'll
1:10need to understand before this one makes
1:12too much sense. But, you can always skip
1:13it.
1:15I think Yeah. You did a spectacular job.
1:18After that
1:19after that conversation, I had a much
1:21better understanding of PTSD.
1:23And that episode actually
1:23[clears throat] didn't perform
1:24particularly well. Mhm. So, if you
1:26didn't listen to that one, I
1:28I think it's one of our best episodes.
1:31It's a good one. I like it. Uh, you
1:33know, you can never predict what seems
1:35to be popular.
1:36Uh, maybe this one will be because it's
1:38going to garner controversy.
1:40And a heads-up, when we say popular, we
1:42mean
1:43yeah, maybe like a thousand listeners.
1:45>> [laughter]
1:45>> Yeah, exactly.
1:47So, when can we start?
1:49I want this I'm hoping that this is a
1:51very practical podcast. So, I see this,
1:54you you CPTSD versus BPD debate and
1:58sometimes it can devolve into like
2:01symptom clusters, research, analysis,
2:04all that good stuff. I I
2:06I think I'm fine if we start with that,
2:07but I want to be end maybe I
2:10you know,
2:11setting people up to listen the whole
2:12thing. I want this to be super duper
2:13practical in terms of what does that
2:15mean for what you say to patients and
2:17what does it mean for like day-to-day
2:18care, not some theoretical conversation.
2:21That's how I hope it it evolves. Yeah,
2:22that's important part. I think it's very
2:24easier for clinician facing materials,
2:27articles, podcasts to really get in the
2:29weeds and I I know I have a tendency to
2:31do that. I'm going to try to avoid it to
2:33the best of my ability.
2:35>> [laughter]
2:35>> Uh no guarantees.
2:37That being said, I think we should kind
2:39of get in front of some common things I
2:42see when this discussion comes up online
2:44and this discussion does come up uh
2:46relatively frequently.
2:48At least on common threads that happen.
2:51And uh few things that we need to know
2:54before we can start to have a productive
2:56conversation about this.
2:58I would say that the first one is that
3:01PTSD as defined by the DSM-5
3:04is different than PTSD that is defined
3:07by the ICD-11.
3:09Baseline PTSD in the DSM-5
3:13essentially more or less covers what is
3:16actually called complex PTSD
3:20in the ICD-11. So, if you look at
3:23studies that are using the ICD-11
3:26criteria for complex PTSD, they'll talk
3:28about how valid it is as a construct.
3:30Americans who are paying attention don't
3:33disagree with that. We call it regular
3:35PTSD. Now, you may disagree with the
3:38decision [clears throat]
3:39from DSM-4 to DSM-5 to add additional
3:42criteria to make you qualify for full-on
3:45PTSD. Personally, I think it's a good
3:47change and I like it, but also that's
3:50probably my bias from where I trained.
3:54See, this is the pedantic stuff.
3:57>> [laughter]
3:58>> It is, but it's necessary because again,
4:00every time
4:01we talk about this, someone goes like,
4:02"Oh, but these studies. All these
4:04studies. Look at this research. Look at
4:05this psychological research. We're going
4:06to
4:06>> [laughter]
4:07>> do this." Well, let's define what we're
4:08talking about first. Okay. I don't want
4:10to bring in any other pre-knowledge. I
4:12think that's super important. Um as you
4:13your point is like we The reason why we
4:14need to define these things, it's not
4:16like we're as we say like cutting nature
4:18at its joints. It's not like we're
4:19finding out exactly what's going on.
4:21Essentially, we have definitions of
4:23things and if people use different
4:24definitions, then they're not going to
4:25be able to communicate effectively or
4:27just going to be they're going to be
4:28talking past each other.
4:30Um yeah.
4:31Yeah. But yeah, before There is a
4:32There's old couples therapist
4:34who I'm
4:36you know, we we got some training under
4:38the person who trained under this
4:40couples therapist. So, pretty ancient
4:41grandfather style training, but uh
4:44there's old clip of him taking He's
4:46doing couples therapy with these two
4:47couples and he picks up like an ornament
4:50from his office and he's like, "Oh, we
4:53have to both We all have to agree that
4:55this statue is a statue before we can
4:57continue on and talk about anything
4:59else. We can't just talk about, you
5:01know, two different things. We have to
5:02say all of Sit down and agree this
5:03statue is a statue and it's there." And
5:06that's the same thing when it comes to
5:07these kinds of debates.
5:09Yeah, we have to We can't just talk past
5:11each other by saying different things by
5:12using definite different definitions.
5:15Before before we jump into the debate, I
5:18want to talk about what is my
5:20underlying fantasy of what this debate
5:23is.
5:23And I think what it is is essentially
5:26straw manning both sides. But this is
5:28This is how I think most people think
5:32what the debate is.
5:33We have these very stoic learned men in
5:37bow ties
5:38who think BPD is everything. BPD is the
5:40problem.
5:42And these are these are stoic, rigorous
5:44scientific men and they deny they So,
5:47they they say borderline personality
5:48disorder is real, and CPTSD
5:51is just nonsense. And they deny the
5:53reality of of women in trauma.
5:55Then we have this
5:56>> line that was used once online by
5:58something like a Hungarian genius in a
6:01wood-lined office in Manhattan or
6:03something. [laughter] Yeah, something
6:05like that. Uh you could replace BPD with
6:07borderline organization, depending on
6:08who's the thinker. Anyway, go on.
6:10>> But yeah, Eastern European is what I'm
6:11picturing. Men, the flip side, are these
6:15perfectly emotionally attuned, very
6:18caring typically women.
6:20And they think everything is trauma, and
6:22it's CPTSD everywhere.
6:24Now, these these providers are they're a
6:25little emotional,
6:27and they think that all these people
6:28need is is understanding and
6:30accommodation.
6:32Now,
6:33it's a totally false dichotomy.
6:36So, there's so many
6:37>> Linehan, are you talking about Kernberg
6:39et al. and Herman et al. right now? No,
6:42that's that's libelous, I think. Those
6:44are the archetypes. Those are the
6:45archetypes, but So, there's so many
6:47false things within what BPD versus
6:50CPTSD is in that in my little fantasy of
6:53what people's fantasy is. People think
6:55that the BPD means it's the person's
6:57fault, that the person just needs to be
6:58more be less emotional, and then and
7:00that they're manipulative, and that
7:02CPTSD means this person needs
7:04understanding, accommodation, their
7:07reactions are justified, and they're not
7:09responsible for the outbursts. The the
7:11per- the persecutor is responsible for
7:13the outbursts. And both of these
7:15Both of these are just totally wrong
7:16ideas of what these two disorders are.
7:18BPD isn't the person's fault, and they
7:20deserve understanding, and CPTSD people
7:23can be manipulative, and they're
7:25responsible for what they do.
7:27And we'll get into more nuance, so it's
7:29not like there's just two groups of BPD
7:31people versus CPTSD people, but all I'm
7:34saying is the whole the whole thing is
7:35built on a house of lies.
7:37I guess the problem is this. I doubt
7:39that either of the academic camps, the
7:42expert camps, who put forward either
7:45borderline conditions as a major
7:47explainer, or who put forward complex
7:49trauma as a major explainer, are ever so
7:53simplistic and silly in terms of how
7:55they conceptualize these things, yeah?
7:57It seems to be, my impression is that
7:59it's lay people and clinicians who have
8:03a superficial reading of these thinkers,
8:06who lack knowledge about the history,
8:08and as a result,
8:11almost operate on a caricature
8:14of these ideas, when they're pretty
8:15complicated ideas. But, I think we got
8:18to talk a little about
8:21history, I suppose.
8:22Yeah. Because
8:25people don't know where complex trauma
8:27comes from. Yeah.
8:28>> If you actually read Judith Herman,
8:31her book, she came up with this term.
8:34She more or less says there are three
8:37major categories in diagnosis,
8:40borderline personalities,
8:42dissociative disorders, and somatoform
8:45disorders, uh that you see a lot in the
8:48women,
8:49are identified a lot in women,
8:51and I think that it's better if we
8:54conceptualize these as the result of or
8:58related to traumas.
9:00That's a very simple uh way of putting
9:02it. Let me read from her book, Trauma
9:05and Recovery.
9:07Survivors of childhood abuse often
9:09accumulate many different diagnoses
9:10before the underlying problem of a
9:12complex post-traumatic syndrome is
9:14recognized. They are likely to receive a
9:16diagnosis that carries strong negative
9:17connotations. Three particularly
9:20troublesome diagnoses have often been
9:22applied to survivors of child abuse
9:24somat- uh child abuse, somatization
9:27disorder, borderline personality
9:28disorder, and multiple personality
9:30disorder.
9:31All three of these diagnoses were once
9:33subsumed under the now obsolete name
9:35hysteria.
9:36Patients, usually women, who receive
9:38these diagnoses, evoke unusually intense
9:40reactions in characters. Their
9:42credibility is often suspect.
9:45Uh they are frequently accused of
9:46manipulation or malingering.
9:49They're often the subject of furious and
9:51partisan controversy.
9:52Sometimes they are frankly hated.
9:56These three diagnoses are charged with
9:58pejorative meaning. Etc. etc. I'm not
9:59going to keep going, but you get the
10:01idea.
10:02There are values.
10:04Uh there are feelings that are driving,
10:08in my opinion,
10:09uh the decision to categorize in one
10:11direction or another. And we have to
10:14understand that it's not just such a
10:17simple situation where we're just having
10:19an intellectual disagreement.
10:23Yeah, that book's great. It's very
10:25readable. And I feel like my takeaway
10:27from that paragraph when I had read it
10:29was
10:33you know, when I hear complex PTSD, it's
10:36often in the context of like, is it Is
10:38complex PTSD just a renaming of
10:40borderline personality disorder? And
10:42this really helped me to understand that
10:44complex PTSD, the way I think about it
10:46now, is it it's a very large category
10:50of patients. And there's a lot of
10:52different phenotypes that kind of
10:54present. And borderline personality
10:56disorder is one potential phenotype of
10:59someone who's got a complex PTSD
11:01history.
11:02Um and whereas somatization and What's
11:05the third one? Dissociative identity.
11:08Disso- Yeah, uh multiple personalities.
11:09So th- those I think now of CPTSD as a
11:13big bucket that contains a bunch of
11:15small buckets. And one of those small
11:17buckets is BPD. But I'm not saying that
11:20these th- they perfectly overlap at all.
11:22BPD is subsumed under CPTSD. But um
11:26if you've ever seen, when I did my child
11:28psychiatry rotation, they have these
11:30circles of the different childhood
11:32diagnoses and it's oppositional defiant
11:34disorder, DMDD, and ADHD. And you see
11:37this giant It's not even a Venn diagram.
11:39It's just like these majorly overlapping
11:41things. And the gist is that like, you
11:43know, these diagnoses don't as you know,
11:45quote unquote carve nature at its
11:46joints. Like it's not like we're talking
11:48about different things. It's we they had
11:50this output and we're catching a certain
11:53a certain section of the population with
11:54these problems and sometimes our labels
11:57catch the same sections and there's a
12:00little overlap and then there's areas
12:01where, you know, a patient can have only
12:03one or only the other. That was probably
12:05a little confusing in my wording, but if
12:07you had the picture it would be it would
12:08make more sense.
12:10>> you put it nicely, but I I also think
12:13that now it's time for us to uh state
12:15our positions and I'm frankly more of a
12:18hardliner than you are. I don't think
12:21that complex trauma should exist as a
12:22concept. I think that it um while is
12:26clinically useful and can be used to
12:29actually describe many clinical types,
12:31that it's flawed in its origin.
12:33And that the origin doesn't exist
12:35because the original concepts were poor,
12:39inaccurate in any way other than certain
12:43areas that probably should have been
12:44updated. I can't argue against that. But
12:47we should have refined the diagnostic
12:49criteria and description of the original
12:52conditions including DSM defined
12:55borderline personality disorder instead
12:57of
12:58just trying to lump them essentially
13:01into one category and worst yet
13:03attribute it to external forces trauma.
13:05Because I don't think that it is a
13:07settled science and I also personally
13:09doubt that external forces are the sole
13:13cause of these conditions. I think that
13:15it's a mixture
13:16of external forces and internal
13:19tendencies.
13:20Just a small plug to leave a review if
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13:44single one.
13:45Let's get back to the show.
13:48So, here's my response to what you're
13:50saying. I am a pragmatist. So, in in my
13:54head, I agree entirely with what you're
13:56saying theoretically. But,
13:59when it comes to the patient in front of
14:00me, when they have certain ideas of
14:02these things, the debate that debate I'm
14:05just saying like it doesn't doesn't
14:06matter to them. And so, it's it's weird
14:09in that in terms of like my my my
14:11philosophical,
14:12nosological, Dr. Malzburg agrees
14:14entirely with that. But, then the
14:17clinician Dr. Malzburg has so many
14:18patients that go,
14:20"But, I don't I don't care I don't care
14:21how you guys categorize it. What do I
14:23have?" And that this that debate isn't I
14:26just see so many patients with CPTSD.
14:29And I don't
14:31the debate over whether or not it's the
14:34category itself is not helpful because I
14:36have to I have to live in the world with
14:38that patient.
14:39Sorry, I know I'm moving away from your
14:40point.
14:40>> thought you might have had more genuine
14:42opposition and we could have a debate.
14:44Uh but, the fact is my patients never
14:46hear about that kind of position. I
14:48don't get into nosological arguments
14:50with my patients. I do the same thing.
14:52What I say to trainees is I don't care
14:54what you call it.
14:56Give the right treatment.
14:57And that's my approach. And so, whatever
14:59a patient prefers to call something,
15:01we're going to go ahead and call it
15:02that. Now, does my population really
15:04talk about complex trauma all that
15:06often? Not necessarily. Uh the college
15:08students do.
15:09Sometimes. On top of that, are my
15:12patients unwilling to accept the
15:14borderline condition once I've actually
15:17done my diagnosis and given the
15:20psychoeducation in a empathic and fair
15:23manner. Very, very, very, very rare. I
15:26don't know if I've encountered that.
15:27Because in the end, I think that what a
15:29patient really wants is for you to
15:32understand who they are, what their
15:33problems are, and to give them some kind
15:35of working solution that works for them.
15:36And so, that's another reason why
15:38intellectually, academically, I'm so
15:41opposed to the concept of complex
15:43trauma. It is a solution for a problem
15:46that was, in my opinion, misidentified
15:49in the first place. The problem at the
15:51outset was not the diagnostic
15:53categorization. The problem was the lack
15:55of general practice in building
15:57therapeutic alliance and having
15:59collaborative care where both the
16:01patient and the physician are equal
16:04parties.
16:05Or there. Absolutely. Absolutely.
16:07Absolutely.
16:09I I I apologize. I don't want to move us
16:11too much. Why don't we define the what
16:13we mean when we're we're using the terms
16:15right now.
16:16Okay. I'm Do you have any other things
16:18you want to before we move on to that?
16:21I guess it depends on the terms. Well,
16:22let's go on. Then
16:24So, I guess we'll start
16:26with
16:28Well, first off, when we you know, we
16:30need to use definitions when we talk
16:32about diagnoses. So, PTSD, we're
16:34referring
16:35right now I'm referring to the the DSM-5
16:37PTSD. I really like how you taught it in
16:40the last podcast. And just to you almost
16:43use it so like it jumps the criteria
16:45build off of each other. Criterion A
16:47being that the person had a trauma, then
16:50the trauma comes back to that person, so
16:52they have re-experiencing, then the
16:54person avoids that trauma, so they have
16:55avoidance, then that person has a broken
16:59mood and spirit is how you kind of put
17:00it, but negative mood and cognitions,
17:03and then the the last criteria is
17:04hyperarousal. Um Yeah, physiological
17:07changes. Yeah.
17:09Um now
17:11I think you kind of mentioned this
17:12earlier. This is a This was the criteria
17:15the fourth criteria, the one negative
17:17mood and cognition, was added. So,
17:19before it focused less on the negative
17:22mood and cognition and it was more about
17:25the specific trauma occurring, the
17:28avoidance, and the the reoccurrence in a
17:30person's life. And the
17:33the fourth criteria, the one negative
17:34mood and spirit as we call it, was added
17:38when
17:39trying to add more of that complex
17:42acknowledging the complex PTSD stuff of
17:45how it impacts the person's, you know,
17:48personality in some sense. The the
17:50DSM-III had a or one of the DSMs had a
17:53diagnosis of personality, I'm messing it
17:55up cuz I I actually lost my notes on
17:57these. It was like personality
17:58alterations due to a trauma. And this,
18:01to me that was a predecessor diagnosis
18:04to CPTSD.
18:07Yeah, you know, I haven't had the
18:08opportunity to
18:09interview the people who actually made
18:12these decisions, even though that's
18:13theoretically possible for me to do. I
18:15don't think I should do it. It'd be
18:17bothering them. But,
18:19but I'll give you my
18:20sense
18:22what happened. I think that starting
18:24from the 1980s and onwards, the
18:26important work of Judith Herman and
18:27people aligned with that camp began to
18:30show the psychiatric community that PTSD
18:33was not just an issue from war veterans.
18:36And I suspect, not a VA psychiatrist
18:39myself, I suspect that in war veterans,
18:42that population tends to show PTSD with
18:45more numbness and repression
18:47as their major areas of alterations in
18:51mood and cognition
18:52or spirit.
18:54And so, prior to DSM-5, that was the
18:58emphasis. It's not that there was never
19:01any reference to mood and cognition
19:03changes, it's that it was emphasizing
19:06basically numbing
19:09withdrawal type symptoms.
19:11But, if you have
19:13This is from my clinical experience now.
19:15Sufficient experience with people who
19:17are not war veterans with PTSD, then
19:20you're going to see that in the really
19:23clear cases, almost
19:26without exception, you are going to see
19:28criterion D of the DSM-5 PTSD construct.
19:31It's going to be there. There's going to
19:32be changes in mood, changes in
19:35cognition, how you experience yourself
19:37in the world. And this is why I don't
19:40like complex PTSD. You see this happen
19:42in people without anything that I
19:44personally would consider a personality
19:46syndrome
19:48prior to the onset of the PTSD.
19:52PTSD properly should be something that
19:55interrupts and impairs the normal flow
19:58of somebody's personality functioning.
20:01Now, if you already have low personality
20:03functioning or personality problems of
20:06any kind to begin with, then certainly
20:08it's going to make it worse. But, I I
20:11think that I'm not happy with
20:13psychiatric categorization where we only
20:15look at symptoms. I think that we should
20:18operate on some hypotheses about what
20:21happens, why, and when, and that's why I
20:24don't like complex PTSD. I think that
20:26the way complex PTSD has been
20:27conceptualized is really pointing to um
20:30majority things that are problematic in
20:33terms of personality. And while a lot of
20:36that adult personality problem stems
20:39from uh impairments and stressors and
20:43traumas, true traumas, uh occurring in
20:45the developmental period, the injury is
20:47not to some
20:49fear response and understanding of the
20:52world issue that's circumscribed to the
20:53trauma. It's a wholesale inhibition or
20:57change of this person's personality due
21:00to developmental issues.
21:02Absolutely.
21:03Yeah. Now, let me
21:04Maybe we should keep our categorization
21:06going. So, complex PTSD. Now,
21:10CPTSD is not in
21:13the DSM.
21:14It is defined in the ICD.
21:17But I I again, my contention is that
21:19that's the same as DSM 5. But go on.
21:22Now, how it's defined in the ICD is it
21:25uses the exact the ICD PTSD
21:28with an additional three categories. So,
21:32it includes PTSD plus what's
21:36the major category of the three
21:38categories is disturbances of
21:39self-organization.
21:41And that includes three things that they
21:42name. So, difficulties in regulating
21:44emotions, change Number two is changes
21:47in beliefs about oneself, such as
21:48feeling worthless with significant
21:50shame, and number three is difficulty in
21:52maintaining close relationships with
21:53important people.
21:55So,
21:56the IC According to the ICD, how it
21:59categorizes CPTSD is I'm just
22:02reiterating what I just said. PTSD plus
22:05disturbances in self-organization, which
22:07are defined by those three things, which
22:09are essentially emotional dysregulation,
22:11negative self-beliefs, and interpersonal
22:13difficulties.
22:15Yeah.
22:16We again run into a problem, right?
22:19Chicken and egg. Chicken and egg.
22:22Where do personality syndromes come
22:24from?
22:26Why do some people develop PTSD from
22:28traumas, but some do not? These are
22:30difficult questions to answer,
22:33uh but I still think that we should be
22:35maintaining a separation. The DSM 5 for
22:39these kinds of issues that are called
22:41complex in the ICD maintains that these
22:44have to be worse and
22:46worsening, basically, as a result result
22:48of the traumatic event.
22:50And
22:51>> [clears throat]
22:52>> I
22:53if I see that and that's clearly the
22:54case for someone with childhood traumas,
22:57I just call it PTSD.
22:59Now, could they have maladaptive
23:01personality traits on top of that? Sure.
23:03But I'm going to have to see additional
23:04evidence for that, right? Uh what I'm
23:06not going to do is I'm not going to say
23:10that someone has complex PTSD
23:14when they simply have a bunch of little
23:16T traumas in their history. I've seen
23:19that done.
23:20I've seen that done clinically. I've
23:21seen that done clinically even in the
23:23objection of the patient. The patient
23:25may even be saying to the clinician, I
23:27think I might have borderline
23:28personality disorder.
23:29And then you know, some clinicians will
23:31not make that diagnosis.
23:33And then I've I've seen the same thing
23:35in that people are like don't even
23:37think of CPTSD as P like they don't even
23:41include PTSD as part of the CPTSD. It's
23:43like, oh no, they had a lot of difficult
23:45things in childhood and now they're
23:47experiencing, you know, the all their
23:48symptoms are the result of trauma, which
23:50is not even how it's, you know, defined
23:52in the DSM. One little acronym that is
23:55actually in Judith Herman's book that's
23:57that I like and for PTSD and CPTSD is
24:01fear for the symptoms of PTSD. So it's
24:03fright, exposure, avoidance, and
24:05re-experiencing. And then CPTSD is bad
24:09fear. So that include that adds
24:11betrayal, affect regulation, and
24:13developmental impact. You know, I I
24:16rarely actually like think through
24:17acronyms, but sometimes it's helpful for
24:19me to kind of just to think about it if
24:21I'm struggling to think of one or
24:23uh it it also is helpful for me to
24:25think of PTSD as or CPTSD as PTSD plus
24:29uh the disturbances in
24:30self-organization.
24:32Should we talk about the
24:35concept of CPTSD in Herman's book? At
24:39least go over kind of major categories
24:41because another challenge here is that
24:44there's no single body that defines it
24:47necessarily like the DSM. So again, when
24:51people say complex PTSD, they mean a
24:53bunch of different things include the
24:54ICD.
24:55Sure.
24:57Okay. But let's read the highlights
24:59anyway. Complex post-traumatic stress
25:01disorder, a history of subjection to
25:03totalitarian control.
25:06I mean, that's a very loaded way of
25:07writing a criteria already, if you ask
25:09me. Um over a prolonged period, months
25:11to years. Examples include hostages,
25:13prisoners of war, concentration camp
25:15survivors, and survivors of some
25:16religious cults. Examples also include
25:19those subjected to totalitarian systems
25:21in sexual and domestic life, including
25:24survivors of domestic battering,
25:25childhood physical or sexual abuse, and
25:27organized sexual exploitation.
25:29>> [clears throat]
25:29>> On top of that, you got alterations in
25:31affect regulation, and they list
25:32different types.
25:34Alterations in consciousness.
25:36Alterations in self-perception.
25:38Alterations in perception of the
25:40perpetrator.
25:41Alterations in relations with others.
25:44And then alterations in systems of
25:46meaning.
25:47That comes on top of something that you
25:51have already developed. Uh you were
25:52humming along in a certain way, and then
25:54something really threw you off kilter.
25:57Then maybe that's a trauma disorder or a
25:58stressor disorder. That that's how I'd
26:00like to just cleanly do things. I want
26:02to try to keep judgment values out of
26:04this as much as possible, because the
26:05purpose is simply what happened to you,
26:09why, what is happening to you, how much
26:11of this is something that you can
26:13control, and what should we do about it.
26:19I want to change move the conversation a
26:21little bit.
26:23Do you have anything else you want to
26:23say that's connected to this before I
26:26make a small movement that's partially
26:27connected?
26:28>> Uh I suppose the problem is this. We we
26:30try to make the title of this episode,
26:34which one's more valid, I suppose, or
26:36I'm not even sure. But
26:37I'm afraid that it has become we vent
26:40about what why we don't like complex
26:42PTSD. But maybe we need to give as hard
26:46of a argument as we can. We need to
26:48steel man or steel woman the
26:52diagnosis of complex PTSD, why should it
26:54exist as a diagnostic entity? What are
26:56the strongest arguments for it?
26:59Oh, I actually and I want to move away
27:01from arguments for or against the
27:02validity and talk about how I what I see
27:05in practice and how I operate in
27:06practice. But Okay. But then do we have
27:09an answer for the audience? I guess the
27:11answer is pretty obvious on my end. I
27:13think complex PTSD is invalid category
27:16that was created for ideological reasons
27:18and it simply reorganizes existing
27:20categories and we should be open about
27:22that and we should have open debate
27:23about that and we need to come to a
27:24decision about whether we're going to
27:25keep the old categories. If so, why not?
27:27And maybe we should just rename the old
27:29categories.
27:30That's the big initial debate is that
27:32like it doesn't add anything and it's
27:34the CPTSD, Mark Ruffalo talks about this
27:37a lot, is essentially just PTSD plus
27:42some borderline personality disorder
27:45sub-syndromal symptoms. Yeah. Um and
27:47that like we're not adding anything.
27:49We've just taken something that can be
27:51viewed as can already be kind of
27:54described in our diagnostic system and
27:58just haven't added it like doesn't have
27:59discriminatory power. Now,
28:02I disagree. Or it's not that I disagree.
28:05It's just that I don't like like when
28:07you add like plus BPD uh sub-syndromal
28:09symptoms.
28:12I you can't pick and to me it's like you
28:14you've buffeted the BPD part and if you
28:17loosen up BPD in in terms of
28:19sub-syndromal
28:21I don't know. I don't love that. And I
28:23think CPTSD does capture something
28:26that's a little bit different than
28:28um cuz there's a lot of patients who
28:29don't have typical BPD symptoms and I I
28:33I do see a lot of the CPTSD stuff. So, I
28:35do think it's actually I don't know. I
28:37think it's a a useful term.
28:41Okay. I suppose then our we should have
28:44gotten someone who's an advocate
28:46because
28:47uh neither of us are advocates enough I
28:50think to argue well in the other
28:52direction. But my summary then for the
28:55other camp is that we can make this a
28:58valid diagnosis. We can create a
29:00construct in a way to describe complex
29:02PTSD that separates it from the rest of
29:04the disorders. We can do that well, we
29:06can get there.
29:08Uh and it's clinically useful.
29:11I suppose you have to be No, I should
29:13not qualify that anymore because that's
29:15further crisis. I would then add for
29:18their camp the way the older diagnoses
29:22were constructed was based on biases
29:26that were unique to the cultural
29:29backdrop of the framers, the people who
29:32wrote the diagnostic constructs and
29:35therefore are not they don't capture
29:37enough of what is really going on. And
29:40what is really going on is that if you
29:43are victimized in a fashion in a
29:47long-term way, if you are under
29:49totalitarian control, then you are
29:52naturally going to respond to that, no
29:54matter who you are, in a particular
29:56fashion and that's complex PTSD. Maybe
29:58that's the steel man argument.
30:00Yeah,
30:01when we say totalitarian regimes like
30:03she a lot of her book is about Holocaust
30:06survivors. So
30:07um
30:08and so all the lot of characteristic
30:09ways that people were responding.
30:11Now,
30:13sorry, I'm jumping around a lot. What
30:15What one of the biggest arguments
30:16against the CPTSD is that like changing
30:19the names of things doesn't it's not
30:21helpful. Like you can't just change the
30:22name of things and that gets rid of the
30:24stigma because the stigma exists like
30:26independent and you're not it's not
30:27helpful to just kind of keep moving
30:29things and and changing terms. Now, the
30:33again, the theoretical me agrees. Like
30:35we can't just keep renaming terms
30:37and renaming BPD something different,
30:40which I'm not even saying is what CPTSD
30:42is doing. But the the pragmatic in me
30:45says
30:46there is major stigma against BPD that
30:49exists
30:50as a result of the fact that many
30:52patients view the most sickest patients
30:54of BPD as BPD only. And
30:58there's so many people who
30:59when they think of BPD think of these
31:01awful manipulative people and they're
31:03going like, I don't that's not me. And
31:05they want a label that isn't stigmatized
31:07that they can say to their doctor and
31:08not have their care completely change as
31:10a result of of this label. Yeah, so the
31:13the pragmatic in me
31:15understands
31:17that it's
31:18that there is a helpful thing of
31:19changing
31:21or people not wanting a label that is
31:23very harmful.
31:25Yeah. I guess what I would like if I
31:27could control the APA
31:29and the ICD is that I could in a
31:33totalitarian fashion
31:34if I could control them in a
31:35totalitarian fashion, I would
31:38rename everything. Okay. Yeah. That's
31:40what I would do. I would just rename
31:41everything
31:43and I would tweak some of the diagnostic
31:44criteria. I do think there's too much
31:47stigma
31:48but that's not where I would end things.
31:49I think that's only at least half of the
31:51problem and there is much more problems
31:53and the major problem is that clinicians
31:56do not understand and empathize with
31:59personality problems. Yeah.
32:01And as a result in my opinion borderline
32:04personality disorder is basically
32:06reserved now for patients that the
32:08clinicians dislike. And complex PTSD is
32:11being given to the patients who they
32:13like because if you look at the life
32:16history of patients with borderline
32:18personality disorder, they have a lot of
32:19trauma. Okay, they have a lot of trauma.
32:23So
32:25now I want to move to the pragmat like
32:26the Okay. clinical part.
32:28>> that stuff. Yeah, let's go let's go
32:29clinical practical.
32:31So
32:33one thing I do want to point out It
32:37there are a lot of patients that
32:40fit
32:41complex PTSD
32:44that
32:45have
32:46personality dysfunction.
32:49But BPD isn't the personality that
32:52best categorizes them.
32:54And I think that's one of the problems
32:57that clinicians have is that they don't
32:58have a good way of communicating to
33:00patients or to like way of thinking
33:02through the fact that
33:05um it's like this person has complex
33:07PTSD and they don't have real fears of
33:10abandonment and they don't have all
33:12these other things. So yeah, they don't
33:14like why would I call them BPD?
33:16And
33:17a lot of providers don't have an
33:19effective way to communicate or even I
33:21guess it's even think through the fact
33:23that you can have personality
33:24dysfunction. It can be the result of
33:26your personality and you can either not
33:29meet full criteria for one of the
33:31personality disorders or not be one of
33:36fit neatly into the box. Like you can
33:37have severe personality dysfunction but
33:39not fit neatly into BPD or NPD. So a lot
33:42of providers get caught up on that and
33:44that because they don't have a way of
33:46thinking or talking about personality
33:48dysfunction that's not the most absurd
33:51the most archetypal BPD. They they don't
33:54know how to talk to the patient about
33:55it. Yeah. No, that's a very good point.
33:57And I think it's because of that that
33:59many clinicians will then reach for the
34:01complex trauma bucket. They won't even
34:03call it complex PTSD, right? They'll
34:04just say, "Oh, this is a complex trauma
34:06patient." It's a much cleaner, easier
34:09way to capture and describe a patient's
34:12issues when they frankly and obviously
34:15do not meet borderline personality
34:17disorder DSM criteria. But we have a
34:20solution today. It's 2026 and I think
34:22the field's moving in this direction, at
34:23least I hope it is. It's the alternative
34:25model for personality disorders in the
34:27DSM-5. And if we simply look at
34:29criterion A and we look at level of
34:31personality functioning.
34:33I don't know if I've made a borderline
34:35personality disorder diagnosis in the
34:38last 2 years. Okay? Most of the time, I
34:41just point to
34:43maladaptive personality traits or
34:46problems of personality functioning, and
34:49those are the things I'm going to be
34:50discussing with patients and other
34:52clinicians. That it's about the
34:54self-functioning and interpersonal
34:56functioning.
35:00Now,
35:02I guess I want to talk about maybe my
35:03approach, but I guess before I jump into
35:04that, so how how do you communicate to
35:06patients when
35:08like you don't say like, "Oh, you have
35:10other specified." Or you don't say to
35:12the patient obviously like, "Well, we
35:13need to use the alternative model in the
35:14DSM." So, let's say you do have a
35:16patient um
35:17that doesn't fit neatly in either bucket
35:19or is doesn't meet full criteria. What
35:22is like your typical spiel for that
35:24patient for
35:25how do you package that like it's the
35:27personality that's causing the
35:29dysfunction?
35:30>> Well, it's rare
35:31uh that personality is the only thing
35:33going on. So, the first thing I'll do is
35:36discuss the things that are going on. I
35:38do think that you have XYZ conditions.
35:40You meet criteria for those or it seems
35:42pretty reasonable that these are
35:43problems for you. It could be PTSD,
35:45could be depression, it could be alcohol
35:47use disorder, could be anything, right?
35:49Um and and let's pretend in the rare
35:52case where those are not present, all I
35:54think it is is personality dysfunction,
35:57then I'll say, "This is what I usually
35:59do." We've talked I covered this in the
36:00previous episode.
36:02Have you heard of a personality
36:03disorder?
36:04What does that mean to you?
36:06What is a personality?
36:08Get that information from the patient
36:09first. Okay. This is what I mean when I
36:12talk about the personality. Your
36:14personality is the way that you are used
36:16to dealing with yourself and other
36:18people and how you think and feel about
36:20yourself and other people. And where
36:22does that come from? It comes from the
36:24things that you went through growing up
36:26and who you are as a person. It's a
36:28combination.
36:29And let's look at all the things that
36:31you've been through growing up. That was
36:33not easy, right? And I think you can
36:35agree that you maybe didn't have the
36:36right guidance, parenting, or the
36:38opportunities that may many other people
36:40did have when you're growing up. So,
36:43that has caused some problems for you in
36:45my opinion about how you deal with
36:47yourself and others and how you think
36:49and feel about those things. And that's
36:51the personality and that's really not
36:53something that responds to medication.
36:56That's something that you will have to
36:57work a little bit more slowly towards in
36:59a talk therapy one-on-one and in group
37:02and in making lifestyle changes. So,
37:05it's a long spiel. But that that's
37:06that's how I do it.
37:08And then what therapy would you refer
37:09them to typically? Let's say you're a
37:11provider who doesn't you're you just
37:13moved there and you don't know any
37:14individual therapists, so you're really
37:15just basing it off of different
37:17modalities people offer that you can
37:18find on the internet.
37:21Honestly, it it kind of depends on the
37:24patient's individual problems. But let's
37:25pretend that it's somebody who's
37:27essentially fairly well within the
37:30borderline cluster B range or camp and
37:34they're essentially substance drawn for
37:36it.
37:37For me, if they are getting sufficiently
37:41severe
37:43and if the resources are there, I will
37:47want them to get a named therapy
37:49for borderline conditions like
37:50transference-focused psychotherapy,
37:52mentalization-based therapy, DBT there's
37:55a program for that. Uh if you see more
37:57of that classical picture.
37:59But otherwise, what I'm more focused on
38:01is that they're in some longitudinal
38:04talk therapy that is affect-focused.
38:07That hopefully provides some skills,
38:09too. Um but this is my setting. My
38:11setting is too under-resourced. I don't
38:12get to pick and choose. Um it's more
38:14important to me that you're they're
38:15actually in a talk therapy that they
38:17commit to and they're engaged in uh than
38:20specific recommendations.
38:21Got you.
38:22Now, I kind of want to talk about a
38:25little bit of my approach to
38:27with patients in terms of and again,
38:30when a patient I'm more comfortable I
38:32kind of think of it as
38:34you know, there's patients who
38:36I think fit really well into C-PTSD and
38:39patients who fit really well into BPD.
38:41Patients who are both and I'm
38:43in some it's I
38:45me and my wife kind of make a joke of
38:46like, I'm fine if they want both. If
38:48they want both, that's fine. But there's
38:49patients that I need to like they I need
38:52to give them BPD. And there's some
38:54patients where it's like if they just
38:55want C-PTSD, all right, they don't we
38:57don't need to give them BPD. But I want
38:59to kind of talk about my approach that
39:01I've kind of developed. Um
39:04and I'm I'm sure you'll have some um
39:05there'll be aspects of you don't love,
39:07but typically what I do is so a lot of
39:10my patients come like the initial thing
39:12is like, do I have what do I have
39:14C-PTSD? Do I BPD? Or they'll say I have
39:16C-PTSD and then I do the intake.
39:19But how do I differentiate it? So
39:23the I'm going to try to make this super
39:24simplistic assuming you don't have a
39:26deep theoretical knowledge of of
39:28personality. I use I really like the
39:30McLean McLean
39:32screening instrument for BPD. So if I
39:34have a patient that I'm starting to pick
39:36up or or I do this with a lot of
39:38patients when I'm seeing signs of like
39:39especially if they ask, do I have
39:40C-PTSD?
39:42And I search McLean m a c l e a n b p d
39:46p d f because I need to pull it up very
39:47fast usually. And then
39:50I'll mix these questions in with We
39:52we've talked about how we do intakes. I
39:53usually have a very free form narrative
39:55based in the beginning and then at the
39:56end I'm kind of just like
39:58giving them a
39:59more specific questions to hone down on
40:01it. And I'll go through these questions
40:03and usually sprinkle in other questions
40:05so that it's not like they feel like
40:07it's leading towards one particular
40:09thing.
40:10And I go through these list of questions
40:12and it really helps me to formulate
40:13whether
40:14I feel like
40:16one, if they have insight into the
40:17whether or not they have BPD, and two,
40:19if I think they have primarily BPD.
40:22If they screen really, really high on
40:24the McLean Screening Instrument, then
40:26I'll feel like more of a necessity to
40:28talk about BPD and say that that's a
40:29part of their diagnosis. And there's
40:31particular things that pop up on there
40:33that lead me to saying like uh BPD to
40:36prioritizing BPD. Uh the big one is if
40:39they have a lot of close relationships
40:41that are marked by arguments and
40:43repeated breakups. If there's a lot of
40:45anger, if they feel chronically empty,
40:48things that I
40:49think of as core and part and parcel of
40:51borderline personality disorder.
40:53Now, there is some research
40:55when they're trying to differentiate
40:57CPTSD or or borderline that
41:00externalizing behaviors are more part of
41:02BPD. So, things like impulsivity,
41:05attempts to avoid abandonment, temper
41:07outbursts, theoretically those are more
41:10BPD type traits. CPTSD, typically you're
41:13going to get more of the avoidant
41:15attachment style. In that, these are
41:17people who think the world is unsafe and
41:20they don't want to engage in it and they
41:21desire closeness but move away from
41:23people. Whereas BPD, you have more of
41:25that fluctuating
41:26idealization-devaluation.
41:28These aren't just theoretical terms.
41:29It's like what you see in patients with
41:30BPD is they have relationships that are
41:33super close, super intimate, and then
41:35just explode in some dramatic fashion.
41:37And CPTSD,
41:39there's more of an avoidance of
41:40relationships. So, again, I do the
41:43and those are overgeneralizations. I So,
41:46I do the McLean screen and that usually
41:47is a great jumping off point for at the
41:50end when I'm kind of giving my
41:51formulation. And typically what I'll say
41:54is I'll talk about CPTSD and I'll talk
41:57about BPD. And let's say that I think
41:59that there's they're not full criteria
42:01for BPD, I have the conversation of BPD
42:03traits. So, what I'll say is, you know,
42:06BPD, it's not a binary thing. It's not
42:08like patients are there's a category of
42:10people that have it and a category of
42:12people who absolutely don't have it.
42:13There's a spectrum of of different
42:15clusters of symptoms and some patients
42:16have some of those symptoms. Some
42:18patients have some of those symptoms to
42:19varying degrees. And a lot of the things
42:21that you've been describing to me really
42:23fit into those BPD traits. Now, do you
42:26meet the full criteria?
42:28I don't really think so. I don't think
42:29you fully meet the criteria and the
42:30extent of the dysfunction of someone
42:33with borderline personality disorder.
42:34But you know, I think we can say you
42:36have complex PTSD, but there absolutely
42:39is borderline personality disorder
42:41traits in there. And I use that as a
42:43jumping off point to talk about
42:45treatment. That's sort of how I
42:49think about, I don't know.
42:51There's some patients that I don't think
42:52it's appropriate for them just to have
42:54the CPTSD label.
42:56And some patients use it as a defense to
42:57not look at their personality
42:59dysfunction. And I feel like the McLean
43:01screen and the conversation about traits
43:03allows me to open up that conversation
43:05earlier than I would in terms of having
43:07like the official conversation of like
43:09you have BPD.
43:10>> I I actually like your approach quite a
43:12lot. And I suppose it's an approach that
43:15exists because you actually see a
43:17substan- a substantial amount of
43:19patients who are coming in asking uh to
43:21be differentiated uh between these
43:24conditions and are aware of these
43:25conditions and ongoing debate. I
43:28probably don't do that
43:30uh for two reasons because I don't get
43:31that situation for patients coming in.
43:34Uh they don't do that. It's more still
43:36more of a ADHD issue. And then on top of
43:39that
43:40as you might suspect, I will refuse to
43:43make an official diagnosis of complex
43:45trauma.
43:46I will agree with a patient if they
43:48think they have complex trauma and it
43:49fits the definition of complex trauma,
43:52but that's not my working diagnosis.
43:55My approach is simply
43:57is there PTSD or not? If there's PTSD,
44:01that's PTSD to me and we're going to
44:02subsume most of those problems under
44:04PTSD.
44:06And there may or may not be maladaptive
44:08maladaptive personality traits on top of
44:09it. Okay. If there is not PTSD, then I
44:13want to find out are there any other
44:16explanations for this or is the clear
44:19explanation personality dysfunction? And
44:23if it's personality dysfunction, I'm
44:24going to be working on telling the
44:26patient about that and coming to some
44:28kind of a
44:29mutual agreement about what this is and
44:31what we're going to do about it.
44:32So, I suppose that's why. It's simply
44:35It's a practical approach that you have
44:36and I don't need it. But, if I need it
44:39someday, maybe I'll use it. And the
44:41thing the reason why
44:43it's I think it's helpful for especially
44:45beginners and people who aren't I mean I
44:47think it's helpful I use it, but it's I
44:49think it's helpful for people who aren't
44:50as comfortable talking about personality
44:53because you know, there are patients I I
44:56I think there's like a you know, there's
44:57different patients that
44:59I do think it's I don't see borderline
45:01personality disorder and I do see a lot
45:03of trauma and they identify with complex
45:05trauma. So, I don't think it's
45:07necessary I don't think they're using
45:09that label to not look more deeply into
45:12themselves. Like I I don't think they're
45:13avoiding another diagnosis. But, there
45:16are a lot of patients that the complex
45:19PTSD label is used as a way not to look
45:21further into
45:23themselves and and what's going on in
45:24their life. And those are the patients
45:25that I think it's important to kind of
45:26have a structure and ability to say,
45:28"Listen,
45:29yes, there's certainly elements in your
45:31history that that were traumatic, but
45:33there's something that on top of it that
45:36is important that we look at."
45:38And I think we even said this earlier,
45:39when these
45:40some people think that like these
45:42conversations go awfully. Every single
45:44time I've had this conversation of
45:46whether I say you have borderline
45:48personality disorder or I say there
45:49actually are traits, the conversation
45:51has gone really well.
45:53Most patients really just want help.
45:55They want to feel better and they want
45:57to understand themselves. And a good
45:58diagnosis and a good formulation
46:01helps them do exactly that. Now, the the
46:03flip side is there's a lot of people who
46:05argue that you shouldn't be giving a
46:07personality disorder label on the first
46:09appointment, and I think that's
46:11appropriate. I think it's not good
46:13practice to just be throwing out that
46:15label a ton after speaking to someone
46:17for 45 minutes. But, for patients who
46:19have insight, who know the label, who
46:21have thought about it, it can be a a
46:23really productive conversation. And the
46:25important thing is that it guides
46:26treatment. So, it's not like I'm just
46:27saying like you have BPD, you you're a
46:29problem. But, it really helps me to
46:31to talk with a patient about what I
46:33think treatment is, the work that we're
46:34going to do, and then the referrals we
46:36can provide for them to kind of to
46:37continue working on this.
46:39Yeah. And it's probably not responsible
46:41to confirm a personality diagnosis on
46:43the first visit. But, that's also
46:45probably true of many diagnoses unless
46:48it's hitting you in the face.
46:49Patient comes in and saying, "I've been
46:51diagnosed with borderline personality
46:52disorder by two prior practitioners.
46:54I've been two rounds of DBT, and I've
46:55been
46:56hospitalized 30 times." And I think
46:59you're probably safe. But, you can rule
47:01out the other conditions. But, you know,
47:03to highlight the aspects of what you
47:04just said, be very careful about the
47:07possibility of any diagnosis, but
47:08particularly culturally laden or
47:11emotionally invested diagnoses in
47:14functioning as a form of resistance to
47:16appropriate treatment, consciously or
47:18unconsciously for patients. Really,
47:19really important. I don't care what you
47:21call it, give them the right treatment.
47:23I don't care what they call it as long
47:25as you're doing the right treatment,
47:26okay?
47:27And then the other aspect
47:29is basically
47:32how that conversation goes. I think that
47:34the conversation going well or good is
47:37not about so much the specific words you
47:39use. It's about what you feel inside. If
47:42you truly feel care
47:44and that you want to help patients, and
47:47you're really actively having that
47:49inside of yourself,
47:51I think as a human being, unless you're
47:53quite impaired as a clinician, sorry,
47:56Uh you're going to do just fine in
47:58telling the truth to a patient. It's
48:00when there are parts of ourselves who
48:02are biased against a patient or who hate
48:05the patient either for good or bad
48:06reasons, for wrong or right reasons. I
48:08think that's when things get in the way.
48:10You're you're going to automatically act
48:12in a way that is not going to make a
48:14conversation go well. So, if it's a lot
48:16of um internal self-regulation to me
48:18anyway.
48:20Yeah, and um
48:22it's funny you say like internal
48:22self-regulation cuz a lot of the times
48:25it I think of it as less
48:28Like I don't think I'm self-regulating
48:29in the moment. It's that my formulation
48:31of BPD doesn't contain a lot of elements
48:34of anger and hate towards these
48:36patients. And I think that comes across.
48:38Whereas I think a lot of especially like
48:40inpatient attendings, the the label's
48:41used very pejoratively. So, of course
48:44it's going to come across if you think,
48:45you know, BPD patients you
48:48eye roll and uh these patients are
48:50manipulative. If that's your
48:51formulation, then it's going to come
48:53across when you talk about it. Where
48:55Where's my formulation is it's a a
48:56really helpful label for a lot of people
48:58and I really like when we're able to
49:01capture that diagnosis and get that
49:02treatment. Um and I I don't think that
49:05manipulation and being a bad person is
49:07part of the diagnosis whatsoever.
49:10Yeah.
49:11I guess if a layperson has listened this
49:14far and they listened with the intention
49:17of finding out what is real or not, what
49:20is more valid or not, I think that the
49:24disappointing answer is that's not very
49:27important. Uh
49:29the debate will rage on and the field
49:32will get to some kind of consensus and
49:34the field has had consensuses that are
49:38wrong
49:39ultimately and some that are right, and
49:41we're not going to be able to know in
49:42the moment. That's life.
49:44Worry less about what you call something
49:47in terms of a single label. Worry more
49:49about your overall understanding of
49:52yourself and how your clinician
49:55understands you and whether you guys
49:57agree on that and whether you agree on
49:59the treatment plan.
50:00And whether you do it. That's the
50:02important part. Doesn't matter what you
50:04call it. Make sure you're hitting those
50:06marks.
50:07Yeah, and that's why I like CPTSD is
50:09that there's all these patients that in
50:12the past here's my pragmatic reason for
50:14liking it. That in the past they go to
50:16psychiatry, they get labeled depression
50:19treatment resistant depression, they get
50:20labeled all these things, they get
50:21thrown all these different medications.
50:24And so a lot of times they don't fit
50:26typical personality disorders. And
50:28unlike you, a lot of providers don't
50:30have the ability to communicate about
50:32the alternative model in a way that that
50:34resonates with the patient. And now
50:36there's
50:37a diagnosis that patients can understand
50:39themselves a little bit more and can
50:41understand that maybe medications aren't
50:43the best treatment and can understand
50:45what are some treatments that help. So
50:46you do see a lot of the treatments that
50:48help with BPD also help with it's a very
50:50very similar. To me the only difference
50:52is maybe CPTSD should focus more on
50:55trauma focused therapy. So EMDR and
50:58trauma focused therapies.
51:00And BPD should focus a lot more on the
51:02interpersonal dysfunctioning and the
51:04emotional regulation.
51:06Yeah. Yeah.
51:07I I guess it's ultimately utilitarian
51:11versus truth seeking kind of
51:13perspective. My concern
51:15as you might have already caught on to
51:17is that it's just going to worsen
51:20stigmatization of the worst
51:22most severe borderline conditions that
51:24need the most help.
51:26That's my bias as a as a my primary
51:29psychiatrist these days.
51:31But you know, we just have to make do.
51:33It's an imperfect world, it's an
51:34imperfect system.
51:35We just have to try our best. I do think
51:38though it's like giving opioids to a
51:39broken bone instead of setting the bone,
51:42you know, and the equivalent of setting
51:44the bone in our world here is not what
51:46we tell the patients, but it's how we
51:48teach psychiatrists and therapists.
51:50People need to have a deeper
51:52understanding of the personality and how
51:54it's conceptualized and what the
51:57borderline conditions are, not just the
51:59stereotype versions that you see in the
52:01traditional DSM-4 model.
52:04Yeah.
52:05Now, there's one last thing I want to
52:07sign off on, or you know, a little thing
52:10in terms of something I commonly do in
52:12treatment with CPTSD or borderline
52:14patients.
52:15I think what's important when someone
52:17has CPTSD or borderline or you're giving
52:21those diagnoses,
52:22when I'm communicating it to the
52:23patient, I ask, "What's your
52:25understanding of what this means?"
52:27Because
52:27>> Mhm.
52:28it's very interesting that it's very
52:30possible you and the patient will be in
52:32agreement with a diagnosis, but then you
52:34hear what they think that actually means
52:35and it's like, "Oh, wait, I don't think
52:37that at all." Um and and it can be uh on
52:40the end of like you ask them what they
52:41think borderline personality disorder
52:42means and they go, "Well, uh I have one
52:45friend who constantly is threatening to
52:47kill himself and he's does it
52:49manipulatively and then he asks for
52:50money and he says he needs money, so
52:53then he like does all these awful things
52:55and he's a drug user." And then
52:58that's a great jumping off point for
52:59explaining that that's not what
53:00borderline personality disorder means.
53:02And then the flip side is you ask, "What
53:04does complex PTSD mean to you?" And
53:06you'll hear patients say, "Well, it
53:08means that because my parents weren't
53:10that nice to me um
53:12and all the problems I'm having now were
53:13the result of the way that my parents
53:15treated me." And you go, you have to go
53:17like, "Well, actually uh that's not what
53:19complex PTSD is." So, it regardless, I
53:23do think
53:24whenever a patient has a diagnosis, it's
53:26I think it's really important that they
53:28or for when I see a good prognosis, the
53:30patients do really well, that they
53:31better understand what that diagnosis
53:34is. And for complex PTSD, the book I
53:38very commonly recommend is Complex PTSD:
53:41From Surviving to Thriving by Pete
53:43Walker. I you know, it's written by a
53:45person who has complex PTSD. There's
53:48elements that I don't love in the book,
53:49but I had seen a lot of patients who
53:51have found it really really helpful.
53:53For borderline personality disorder, the
53:56opening resource I commonly give is the
53:59YouTube channel Borderliner Notes, and I
54:01really like the John Gunderson interview
54:04in
54:05he's got like five different videos. So,
54:08I'll find the one that I think fits the
54:09best for the patient whether it's there
54:11he's explaining globally what BPD is or
54:13one of them he's explaining like the
54:14common relationship patterns in BPD. And
54:17I say I'll send them that one video and
54:19I'll say, "But check out the other
54:20videos and see what resonates." Um so,
54:22those are my two um like openers for I I
54:26think it's really important if a patient
54:27has a diagnosis that they better
54:28understand themselves through that
54:30diagnosis and not let it be something
54:32that is simplistic. Yeah.
54:34Yeah.
54:35Got nothing to add. Great resources
54:37there. Um
54:38I suppose with nothing to add, I only
54:41have a question. I do wonder from the
54:43audience if there's anything that we
54:45didn't cover or anything that we didn't
54:47make clearer that they would like made
54:49more clearer to have more discussion on.
54:50That's something I'd like to hear about
54:52uh in the comments. And yeah, I think we
54:55are probably overdue for a reader
54:57comments or questions recap kind of
54:59episode though I don't know how popular
55:01those really are since they can be a
55:02little bit more individualized. Yeah,
55:04absolutely.
55:05Um anything else you want to add before
55:07on the the topic?
55:09Nope. I think I'm good to go. Uh want to
55:12hear from you guys and uh hopefully this
55:14was at least somewhat interesting even
55:16if it wasn't necessarily helpful for
55:18everybody. Uh it's kind of a niche topic
55:20even if it's a popular one.
55:23Awesome. Thank you so much, Dr. Fu. I'll
55:25uh I'll catch you next time.
55:27>> See you next [music] time. Bye.
55:31Thanks for listening. Um if you want to
55:33support the show, check out my very
55:35practical anti-depressant course. If you
55:37want to check that out, go to
55:39psycho.farm.f.a.r.m.
55:42If you prefer to read, you can go to
55:45amazon.com. You can search my name,
55:47Gregory, g.r.e.g.o.r.y.
55:50Malzburg, m.a.l.z.b.e.r.g.
55:53And the book is Psychopharm's Guide to
55:55Treating Depression. It's a nice, easy,
55:58readable, practical guide to medications
56:01for depression.
56:04>> [music]

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