Mental Illness and the College
July 12, 2023
Peer Training Support Project 2022-23
July 27, 2023
Show all

Physicians and Personality Disorders (Borderline and Narcissistic)

Trigger Warning: Mentions of abuse, self-harm, and suicidal ideation

It’s 2018. I am a wide-eyed second year medical student sitting in a room full of other budding physicians, mildly self-conscious about my nerdy excitement. This is a psychiatry lecture, and the human mind just fascinates me. My fingers fly over the keyboard, determined to capture every morsel of knowledge. I really want to be a good doctor one day. 

And then I hear them, words spoken with conviction and authority, a punch to the gut. 

“Because, actually, patients with personality disorders ALWAYS lack empathy.” 

My fingers freeze for a moment before hitting the keys furiously, recording verbatim statements, bearing witness to this moment. The “lacking empathy” statement is reiterated not once, not twice, but four times throughout the lecture. A memory aid summarizes the three personality disorder clusters as “Mad, Bad and Sad.” Descriptive acronyms like “AM SUICIDE” for Borderline PD and “CRINGES” for Avoidant PD are meant to help us remember the symptoms. We are taught that “personality disorders are incurable” and “every encounter with a personality disorder patient is always unpleasant.” 

There is no mention of disease etiology. OCPD is illustrated via a movie clip in which the “patient” is referred to as “a truly appalling individual,” a “freak show,” and “the worst person I’ve ever met.” It’s a comedy starring Jack Nicholson. Everyone laughs. 

The lecturer, a psychiatrist who runs the crisis program for ER patients with self-harm and suicidal ideation, moves on to tell a story about a restaurant and its patrons. It’s from the perspective of the wait staff, at their wits’ end to manage the ridiculous antics of their patrons. With names like “Mr. Excon” (Antisocial PD) and “The Other Woman” (Borderline PD), these caricatures are nothing short of grotesque. The class laughs again as “Mrs. Diva Divine” breaks out into an impromptu belly dance, dramatically exclaiming that she needs to be the center of attention. 

There is no mention of transference or countertransference. There are plenty of blanket statements. In stark contrast to our anxiety and depression lecture, there is no discussion of the patient experience. The word “trauma” is not mentioned in this lecture. 

It is shocking to hear a specialist physician educate your colleagues about a patient group that you belong to with such damaging inaccuracy. 

I was diagnosed with Borderline Personality Disorder when I was in my early 20s.

How does reading these words change your view of me? How will they colour the way you read the rest of this article? Is it now harder to trust me, my perspectives and my judgement? Is it harder to see me as “one of us”? 

If you dug deep to answer these questions, thank you for your radical honesty. Some readers may be surprised or uncomfortable with one or more of their answers. If that includes you, just know that it’s okay to let go of any shame that may accompany this discomfort, and replace it with curiosity. You’re doing your best with the tools you have; everyone is. We cannot address the biases that run rampant in our profession if we are too ashamed to even acknowledge their existence. 

We’ve come a long way as a society in dealing with mental health. These days corporations sponsor mental health campaigns and celebrities speak out about their struggles with depression and addiction. The medical profession is more accepting, educated, and compassionate towards our patients’ mental health than ever, yet not so much our own. Personality disorders remain among the most stigmatized, misdiagnosed and misunderstood psychiatric conditions, both by physicians and society at large. 

Like all mental health disorders, the etiology of BPD is a mixture of nature and nurture. There is both a genetic vulnerability and a combination of life circumstances that lead to the development of its personality traits. In BPD this often begins in early childhood with a mismatch between a child’s environment and their emotional sensitivity, resulting in chronic invalidation of the child’s emotional experience. The majority of BPD patients have suffered some kind of childhood abuse, often chronic and harrowing, though it may not always be conventional. Most parents and caregivers are doing their best, but they all have different limitations and carry some degree of trauma. Parents can be loving, dedicated, and well-intentioned – even raising other relatively well-adjusted children – and still not have the ability to understand, validate, or soothe a particular child in a way that meets their needs. The child who never learns to self-soothe or form a secure attachment in this untethered state goes on to have experiences that are deeply distressing to them but not validated by their environment. This overwhelms all of their adaptive coping mechanisms, and they have no option but to develop a survival strategy that  will bring them much suffering later in life. 

The DSM breaks BPD down into a list of symptoms, including an unstable view of self and others, intense emotions with sudden mood shifts, impulsivity in areas that are potentially damaging, extreme sensitivity to real or perceived rejection or abandonment, intense and unstable relationships, chronic feelings of emptiness, self-injurious behaviour, chronic suicidality, periods of derealization and depersonalization, and transient paranoid ideation when under stress. The name Borderline comes from an outdated belief that these patients are on the “border” between neurosis and psychosis. More descriptive names like “Affective Instability Personality Disorder” have been proposed, and there is also a push to scrap the “personality disorder” label altogether, understanding this cluster of symptoms as a type of complex PTSD. I agree with this latter approach; it seems far more useful and empowering to teach patients that they have adapted a survival strategy that they can now change, rather than telling them that their entire personality is a disease or that they are fundamentally flawed humans. 

Labels and lists don’t really capture what it’s like to have BPD. It colours your entire experience of existence. It is the lens through which you interact with yourself and other people. As a twenty-something-year-old undergrad, my predominant experience of the world was pain. Intense and intolerable pain. After I told a lab partner that I routinely self-harmed and spent several hours crying in the library bathrooms daily, he became alarmed and insisted that I seek help. I was perplexed by his concern. I thought this was just how life was – at least my life.

Marsha Linehan, the creator of DBT, equates BPD to the psychological equivalent of having third-degree burns. If your whole body was covered in non-healing third-degree burns, the slightest touch or movement would cause agony; seemingly innocuous interactions like a simple handshake would leave you reeling with pain. The DSM’s list fails to capture the fact that the frantic efforts to avoid rejection, the dissociative symptoms, the self-harm and impulsivity, the suicidality – it’s all just a futile attempt to escape constant torment. It misses the cruel irony that these coping mechanisms only perpetuate the pain.

After years of suffering and crises that threatened my academic future, personal relationships, and survival, I was finally able to see one of the university psychiatrists. She was one of the rare ones who practiced psychotherapy. Fairly quickly she suggested that I might have BPD. I had never heard of this, so I googled it. The Wikipedia article was a revelation. It didn’t just give me a list of symptoms; it talked about etiology and trauma and treatment. At the next appointment, I pulled out a printed copy with large portions of highlighted text that finally made me feel like I made sense, like I wasn’t crazy or hopeless.  But there were other websites that also explained BPD to me and told me I was hateful, cruel and dangerous, and incapable of love.

Allow me to reassure you that I am not best described as “Bad” or “SUICIDE,” and in fact empathy and compassion are among my chief assets as a physician. This strength is partly facilitated by memories of my own suffering, and partly by a heightened ability to easily pick up on the needs and emotional states of others, a trait that is shared by many survivors of childhood trauma. We all have blind spots and no one has perfect empathy. People with BPD may sometimes appear to lack empathy because they tend to have different blind spots than others. Pain clouds judgement and it sometimes makes people act out in desperation. Aggressive or destructive behaviour would be met with more understanding in a patient whose arm had just been torn off, but the pain of BPD is invisible. Once the crisis is over, the aftermath is yet another reason to sink into shame, despair and self-hatred.

I left my medical school Personality Disorders lecture in disbelief at the devastating ignorance and lack of empathy. I was aware of the stigma but had naively not expected it from a psychiatrist who worked primarily with chronic self-harm and suicidal ideation patients. This first taste of systemic bias was poor preparation, however, for what would come next. Half-way through my first day of clerkship, a mood disorders psychiatrist explained matter-of-factly that the next patient had a personality disorder, but such patients don’t take their diagnosis well – “they tend to sue” – so we don’t disclose it. Psychiatrists have a code word for personality disorders, he said: “Persistent Depressive Disorder.” There is no cure for personality disorders, he said, so we do our best to treat them with mood disorder medications and accept that their prognosis is poor. Over the next few weeks of this rotation, I lost count of the personality disorder patients I met who did not know their diagnosis, had never been offered access to an evidence-based treatment for their condition, and therefore did not even have the opportunity to research treatment options. From nurses, residents, attendings, I heard statements daily like, “Oh no, another borderline, why me?” and “They’re a nightmare. You have to keep them separated because two of them together – they’ll just disrupt the whole ward.” One psychiatry fellow notably remarked, “You know, I couldn’t feel any empathy for her while she was crying, so that’s how I know she has a personality disorder.” 

One very dysregulated patient in the ER became more and more agitated, until he was forcibly sedated while smashing his head repeatedly. Once he had calmed down he asked the psych nurse “Didn’t you see how much pain I was in? Didn’t you feel like helping me?” The nurse did not say, “I see your pain. I wish I could take it away.” He said, “Why would I feel bad for you?  You just wanted some attention.” I was shocked at the vitriolic disgust in the face and voice of a healthcare professional who I considered to be empathetic, fair, and level-headed. This patient was clearly begging for validation and some human connection. He needed it so badly that smashing his head over and over was more tolerable than his internal agony. Standing behind the protection of two windows, as he raged against the walls of his empty room, it was all I could do to keep the tears inside my eyes. I felt his pain catch my breathing, then gush down my arms and into my belly. I recognized it. It was my own pain. Meanwhile, an off-service resident wondered out loud beside me, “Do you ever think that we should just have this place up north where we send people like this, so they can spend all their energy surviving the winter and stop this nonsense?” 

I have regretted being alive since I was at least eight years old. When I was first diagnosed with BPD, my level of function was quite low. The emotional pain overwhelmed me so much that at times, I would spend hours in bed physically writhing, wishing I could die, or thinking I’d go crazy because no human could possibly tolerate that much pain. Mundane daily interactions like going to the bank or a driving lesson inevitably left me feeling rejected, plunging me into self-loathing and agony. Trying to form friendships or relationships was infinitely riskier. I was constantly on the lookout for facial expressions, tones of voice, mere looks that confirmed I had overstayed my welcome, I was unwanted, I had no value. Of course I had anxiety and depression – as would anyone who went through life this way. I failed every single class in my first two semesters of undergrad and spent 80% of my time in bed, sometimes too depressed to eat or even get water for myself. I’d spend hours thinking about how thirsty I was without moving a muscle. I eventually felt hurt and betrayed by everyone, so I could trust no one. No one could fill my needs in the way I wanted, the way I thought they should; this proved to me that I was unlovable and worthless. I had learned that my suffering was willful weakness, and expressing it was manipulation. So I watched drops of blood bead the blade of my knife and the skin of my thighs with the conviction that one day, I’d give up and finally end my life. Someone would find my body, and they’d see all the scars. The scars would be incontrovertible proof that I wasn’t making it up; my pain was real. 

It was therapy that saved my life. At first, I learned to contain the most destructive behaviours and to protect others from my worst moments. I worked incredibly hard to do this. For years I shook hands with third-degree burns day in and day out, and I breathed through the pain and picked myself back up over and over. My internal world continued to be coloured by intense pain, but most people would never know. Slowly, I acknowledged and healed from my trauma. I learned to set boundaries and take ownership of myself. I learned how to communicate effectively so that my needs could be met, and to soothe myself when they could not. I came to see myself as an individual, separate from anyone else’s actions, thoughts or opinions. I didn’t have a sense of self before, so I could not grasp that your judgement of me was irrelevant to the essence of who I am. I learned to value and validate myself when others could not. I learned to have grace and forgiveness and to form genuine connections. I confronted my deepest pain, and learned that it’s okay to feel it; I don’t have to escape because it can’t kill me. I learned to love me, even the parts that make me feel ashamed. I learned to stop getting overwhelmed by all the suffering around me, because the boundaries between myself and others were no longer blurred. 

Perhaps most importantly, I learned that my trauma never broke me. I used to feel like I was smashed to pieces, and a core component of me was stolen, so I would never be whole. Now I know that it was not the scars that determined my form. My shape was not the result of violence done to me, but of a personal strategy to survive. During my childhood, it was not safe to have authenticity, boundaries or a sense of self; the price was too high. I attuned myself exclusively to the wants of others and learned to avoid rejection at all costs, because I did not have better ways to secure my safety. The intense suffering I felt, and the list of symptoms in the DSM, were the natural result of a violent clash between my deeply-ingrained survival skills, and basic human needs like authenticity and connection. I am not broken;, I am a shape-shifter. I’m not a victim;, I am a survivor who chooses to let go of coping skills I don’t need anymore. There were parts of me I had to send away in order to survive my childhood, but they still existed all along. Now that I found them, I am complete. 

Within two months of starting therapy, I could barely recognize myself. About three years in, I was surprised to find that I kind of wanted to be alive. Five years in, I was starting to have 50/50 good and bad days. Almost a decade later, I think I’m getting ready to graduate from therapy. It has been years since I fit criteria for BPD, and even “Cluster B traits” no longer apply these days. My inner experience is no longer one of pain. I am at peace. I remain a deeply sensitive person, and I embrace that. I am grateful to be alive. I am so very grateful for each of my therapists, and all the wonderful human beings who, with incredible patience and forgiveness, witnessed me and carried me in moments when I could not do it for myself. I am grateful for the knowledge and empathy that all my life experiences have given me. 

It has been a long journey, but my timing is not surprising. 50 per cent of patients no longer fit criteria for BPD within five years of starting evidence-based treatment, and 80 per cent within 10 years. There’s no easy fix, but the outcomes are far better than those for many psychiatric conditions. I personally never took medication for my BPD. There are several evidence-based treatments for BPD, including DBT, all of which are psychotherapy based. There is low-quality evidence for use of mood stabilizers and antipsychotics in BPD, but only as adjunct treatment. There is no evidence for medication as monotherapy. 

Treatment programs are resource and time intensive, and government-funded treatment options are scarce. DBT as designed by Marsha Linehan has both a group and individual therapy component, as well as access to a limited number of 15-minute emergency phone calls to be used in moments of crisis. Evidence shows these phone calls are usually used judiciously and appropriately by patients, and greatly beneficial in the early stages of treatment. Nevertheless, how many patients do you know who have access to government-funded individual psychotherapy for years? 

Access to short-term group therapy is limited, but more readily available. Nevertheless, it is often difficult for dysregulated individuals to participate effectively in groups when they don’t have the opportunity to first establish a sense of trust and safety with a therapist. Even if they do manage to stick it out, short-term crisis-based groups teach important skills to minimize more outwardly destructive behaviours, like suicidal gestures and self-harm, but do little to address the underlying emotional agony. Patients rarely have access to continue their progress in a therapeutic environment long enough to address the root causes of their distress. Due to the paucity of appropriate treatment options, BPD patients face stigma, misdiagnosis, overmedication, and a lifetime of pain. 

As a university student, I did not have access to a full treatment program like DBT, but I was fortunate to have access to psychiatrists and other psychotherapists during my undergraduate and medical education. Through residency and beyond, I have spent thousands of dollars on private therapy. I have been to therapy once a week for nine years. My recovery was not only a matter of resilience and determination on my part, but also largely a matter of access and privilege. 

Due to the stigma I have witnessed, I fear the impact that my experiences with this diagnosis can have on my professional career. BPD is still largely thought of as an incurable disease. I worry about licensing bodies, potential employers and patients questioning my professional ability. I am afraid that if my history with this diagnosis were to be known to colleagues and superiors, all of my actions and reactions would be put under a microscope and interpreted under the lens of mental illness. I worry that in any sort of interpersonal conflict, it would be easy to dismiss my actions and perspectives as symptoms of a disease, instead of being taken at face value. It’s a habit to hide this part of me. There have been times, however, when I felt I could not stay silent and I felt compelled to say, “Listen, where I am now is where this patient could be in 10 years, if they only have the same opportunities I had.” There is a lot I could say about my personal difficulties accessing treatment, the stigma I have faced as a patient and as a colleague, and the help for which I never asked due to fear of repercussions. Ultimately, all these experiences pale in comparison to those of most personality disorder patients I have met. I cannot imagine where I would be if I had never learned my diagnosis or had access to long-term therapy. 

Stigma surrounding BPD has undoubtedly improved in recent years. There is more recognition among the public and healthcare professionals of the etiology, and a more empathetic interpretation of the symptoms. When I rotated back through the same Psych department just a few years later as a resident, there was a palpable decrease in bias compared to when I was a medical student, even though access to treatment had not changed. At the same time, another personality disorder, Narcissistic Personality Disorder, has seemingly become the villain in vogue. Thousands of social media posts, articles, and “#NarcTok” videos warn about the dangers of narcissists. Celebrities are diagnosed with NPD by hoards of “haters” who have never met them. The phrases “incapable of love,” “abuser,” and “manipulator” were once plastered all over the internet to describe those who suffer the way I did. 

People with NPD often hurt those around them. I know. I was raised by one who hurt me terribly in many ways for as long as I allowed him to do so. Surviving him is one of my biggest accomplishments. But if my BPD was the result of me surviving him, what is his NPD helping him survive? In between “Five ways to drive your Narcissist crazy” and “15 types of terribly toxic narcissists (#5 is SO scary!!!),” there’s little room to wonder. Beyond the lists and labels, is there a complex human being with their own flaws and virtues like all of us? Could it be that the “toxic narcissist” is just a terrified and lonely human, trapped behind an impenetrable shell of projected power and perfection, blinded by a survival strategy that emerged before they even had use of reason? Or are they just a med school acronym, PRAISE ME? 

I don’t know to what extent those with NPD are aware of how their actions impact others. I do know that narcissistic traits are on a spectrum and not everyone is the same. I also know what it’s like to be trapped behind a survival mechanism that I don’t understand, what it’s like to interact with a world full of people that cannot relate to me. I know what it’s like to be reduced to a stereotype, for my actions to be interpreted without the benefit of empathy and context. I know how bewildering and painful it is when my desperate and unskilled attempts to connect are rejected without me understanding why. I know what it’s like to say and do things I regret, to believe that it is outside of my control to be different. I know the relief and hope that comes with learning that it’s not my fault but I’m the only one who can fix it, and there is a better way. Many of my former actions and reactions might be interpreted as nothing more than moral failings or malicious intent by an outside observer, but they always made sense within the context of my trauma and my capacity. I was always doing my best, and now that I know better, I do better. 

NPD is fear of shame, a shame so overwhelming and intolerable that it must be avoided at any cost. Shame that will engulf and annihilate them as soon as they come face to face with what they secretly know is true, that they really are worthless and without value. Every action and interaction must go towards reinforcing that shell that protects against the looming shame. Power and control must be exerted at every turn to ensure that nothing ever breaks through that defensive shell. Any hint that they might not be perfect or the greatest must immediately be defeated, because their psyche might break if they even entertained the possibility. In tragic irony, they can’t let their defenses down long enough to form genuine connections, heal from their trauma, and develop an authentic sense of worth that can finally bring them peace. 

Due to their hermetic defences, it is already so difficult for someone with NPD to seek help, obtain and accept an accurate diagnosis, and engage in therapy. Just like with BPD, there are psychotherapeutic models that can help those with NPD gain insight into their actions and motivations, develop new coping mechanisms, and confront their terrifying shame. I have loved ones on the long, painful and expensive journey of breaking down their NPD defenses and interrupting the cycle of intergenerational trauma. A few years into their treatment, I am shocked to find myself connecting genuinely with them, and discovering that behind the turbulence of grandiose aggression, there is an extraordinarily soft, sweet, scared, love-starved human being, for whom venturing out of their shell and showing any vulnerability requires a great deal of courage.   

Widespread awareness and education about NPD is necessary and very beneficial. It can allow those who suffer the collateral damage of NPD to understand and take control of their relationship dynamic, get away safely when necessary, and protect themselves from abuse. At the same time, is there no room for empathy in the wave of NarcTok? Not everyone with NPD is an abuser. Everyone with NPD is escaping shame. Societal vilification and derision will only make them burrow deeper into their defenses. Trying to end narcissism by shaming the narcissists makes about as much sense as curing hearing loss by yelling very loudly. Ultimately, it will only perpetuate the cycle of intergenerational trauma.

Ignorance, blame, and bootstraps have failed to eradicate addiction, metabolic syndrome, AIDS, depression and learning disabilities. We’ve also tried leper colonies, poor houses, prohibition, witch hunts and conversion therapy. With the benefit of hindsight, most of us can clearly see the foolishness in this approach. It didn’t work then and it won’t work now for NPD or BPD, nor any of the personality disorders. Our apparent yearning to understand each other as either good or bad, “us” or “other”, hero or villain or victim, suggests that our society could do with a lot more empathy, perhaps even some therapy. 

And as for us, the medical profession? It might be helpful to remember that anger often hides pain, arrogance hides shame, and we all have blind spots in our empathy. This goes both ways in any patient-physician encounter. In difficult encounters with BPD patients, I recommend staying with the subjective emotion, instead of focusing on things you disagree on. Only they know what they feel, so you can always agree on that. You often cannot give them what they are asking for. You may even have the impulse to save them or fix them, and you cannot do that either. But you can always validate their subjective experience and express empathy and a desire to help. “This has been so difficult for you, hasn’t it? I can see you’re in a lot of distress. What emotion are you feeling right now? I wish I could make it go away, I would do it right now. If only it worked that way.” And when your patients with Cluster B traits complain about mistreatment in the medical system, about a lack of services that actually work for them, or about their medications not helping, please believe them. Please don’t take it as personal criticism. You are both on the same side; the enemy is the broken system. You can validate their and your frustration by saying, “I absolutely agree with you. We just don’t have the resources available that you need, and I know that. It’s not fair. It is so frustrating for me as a physician that I don’t have the tools I need to help you. I cannot imagine how difficult it must be for you. I really wish it were different.” This can then be a helpful platform to refocus the conversation on practical solutions: “Given that the system is broken, I wonder what choice we have, other than to be creative and make the best of what we have? Or is giving up a better option? What do you think? Is it worth a try?” 

Personality disorder patients tend to elicit strong countertransference. Whatever emotions you feel about the person in front of you, whether it’s fear regarding their suicidal ideation, an overwhelming sense of helplessness, or another strong emotion because they remind you of a relative, those emotions are valid; it is okay to have them. They are also as much about you as they are about the patient. hey are not a reliable way to determine what kind of person the patient is, or how much care, respect, or empathy they deserve. The simple act of regulating your own emotions about the patient, not getting overwhelmed or exasperated or defensive, can be enough to show them that they are not too much, their emotion is not too much, and they, too, can learn to regulate it. 

To cure sometimes, to relieve often, to comfort always is one of the legacy adages of our profession. It reminds us that most of our therapeutic powers are constrained by the limits of science, but our humanity isn’t.  Amid the lists, labels, acronyms, statistics, waitlists, burnout, and helplessness, it gets hard to remember that the most unlikeable person we see today might be the one who needed our comfort the most. Writing these words has allowed me to reflect on some of my own patient encounters, and to learn more about my blind spots. How about you? Has reading this article impacted how you view your personality disorder patients? Will it colour the way you practice? Did it bring to mind any instances of bias that you have witnessed or participated in? You’re doing your best with the tools you have, everyone is. We cannot address the biases that run rampant in our profession if we are too ashamed to even acknowledge their existence.