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Summary

Evan Iliakis, MD PhD student at the University of Pennsylvania, took time to talk to us about his research and a personal experience helping his friend navigate hospital systems with borderline personality disorder. We had a discussion on stigma and the natural course of untreated borderline personality disorder, which is in fact one that naturally improves for most people. This fact is not often conveyed well to patients, and can instill hope that many of the symptoms will improve with time. Evan worked at McLean hospital with researchers, such as Dr. John Gunderson, who developed and disseminated Good Psychiatric Management to clinicians in the US and abroad.

Chapters / Key Moments

00:00 Preview

05:06 Stigma in working with a borderline diagnosis

09:00 How to break the news of a diagnosis

14:47 Experiences with Good Psychiatric Management Model

23:29 Course of BPD

26:46 How was borderline personality disorder taught in medical school?

33:42 Opinion on apps for borderline personality disorder

39:36 FDA non enforcement of apps

41:59 Borderline personality to avoid a negative outcome

Transcript

[00:00:00] Evan Iliakis: And so for borderline personality disorder, the description was this is the quote unquote difficult patient. And, these, these are the patients who are the overly attached anxious girlfriend, there was a, a gif at the bottom of the slide and then that was it, that that was all the coverage. There was no mention of DBT. and I,

[00:00:20] Bruce Bassi: Hey everyone. I’m Dr. Bassi. Welcome back to the Future Psychiatry Podcast. Today we have an awesome guest, Evan Iliakis. He’s a medical student at Penn. He’s an MD PhD student. He had finished two years of his clinical training and he’s now in the thick of his neuroscience research for the PhD. And a lot of his background and interest was in borderline personality disorder. So I thought it’d be great to have him on the show to talk about good psychiatric management and borderline personality stigma and what his experience was in that, because he was a advocate for helping revamp borderline personality lecture material as a medical student and as a keen interest on that, given his time at McLean Hospital.

If you have borderline personality disorder, I would suggest talking to a, a doctor or a therapist or a psychiatrist about those symptomatology and not getting your diagnostic information from a podcast. This is meant only to be only educational material and is not medical advice. We are simply enjoying unpacking the aspects of borderline personality, from a diagnostic perspective, from a treatment perspective, and from a stigma perspective. So I hope you enjoyed the conversation. I definitely did.

So welcome to the Future Psychiatry podcast. Today we have Evan Iliakis, a third year medical student at Penn, and we are going to talk a little bit about his experiences in psychiatry at Penn, and also a bit about his research, and borderline personality disorder as well. So this is gonna be a good conversation. Welcome Evan.

[00:01:47] Evan Iliakis: Yeah. Thanks so much for having me. I’m very happy to be here and excited to talk about all these things with you.

[00:01:51] Bruce Bassi: Awesome. So tell me a little bit about your background and how you’re, how you’re liking psychiatry at Penn.

[00:01:58] Evan Iliakis: So yeah, my background, I, I come from a bit of a kind of winding path background. So I actually started out studying linguistics in my undergraduate. But during my time in my undergraduate, one of my close friends actually attempted suicide, had developed some pretty serious mental health concerns that, as we went through the system and through, a couple runs of psychiatric hospitalizations turned out to be borderline personality disorder and kind of seeing the gap in services and seeing, how difficult it was to access not only a diagnosis, but also evidence-based treatment for the diagnosis.

I, I got very interested in mental health services and how to provide accessible and effective treatments to people. And regardless of their diagnosis, regardless of their geographic location.

[00:02:37] Bruce Bassi: Were you already interested in medicine at the time already and this kind of geared you more towards psychiatry or were you already kind of realizing you wanted to do Psychiatiatry?

[00:02:45] Evan Iliakis: I did have medicine in the back of my mind. And I, I was starting in my second year, I did start to take some biology and chemistry classes just in case I wanted to pursue the pre-med path. But this really reinforced my desire to, to stay the course and really keep going with what was at times a difficult workload balancing the linguistics major with this.

Yeah. This was a really influential event in my life and I, I mean, I still, I would say that it’s very, very possible that I would not have gone into medicine or had the research interests I have if that had not happened.

[00:03:12] Bruce Bassi: What was that experience like getting plugged into healthcare for the first time, knowing that borderline personality is part of the diagnosis.

[00:03:19] Evan Iliakis: Yeah. So I mean, I mean, for me, at first, I, I don’t think I really appreciated the ramifications of what it meant that my friend had received this diagnosis. I, I think people have a lot of stereotypes about borderline personality disorder, that people are, I don’t know, quote unquote wild or out of control or, or quote unquote bad people.

And I had none of those stereotypes. I was basically hearing this word for the first time. And so I think for me, it was more of something that I started realizing over time what exactly the ramifications were. And so because of that, it was a lot of rude awakenings. I mean, first of all, seeing, the psychiatric hospital that my friend was brought to, it was, it was a decent hospital, but hearing, that she had to, be stripped down and searched for, for, sharp objects and hearing then what providers were saying about the diagnosis that this is, this is stigmatized, but you could work through it.

And kind of, I think the act of saying it stigmatized made it, made it feel like there was a stigma on her where maybe there wouldn’t have been otherwise. And then the other battle of, oh, okay, you have this diagnosis, I Googled it and it looks like the treatment is X, Y, Z, or, or DBT, I guess dialectical behavior therapy in this case.

And then seeing that there were very limited offerings in the community, if any in fact we, we couldn’t find anything for her in the community. So we went to just general practitioners and with kind of not much success for a couple years. So yeah, I think it was a disillusioning experience and I mean– psychiatric care in the US is, is great.

And compared to other countries, there, this is a very resource rich environment. And seeing that even in such a great environment, there were shortcomings in terms of addressing kind of more new diagnoses or diagnoses where not many treatments was available. That was really influential in giving me motivation to wanting to pursue something where I thought that maybe I could affect change based on some of the more difficult experiences I, I saw other people having in the system.

[00:05:06] Stigma in working with a borderline diagnosis

[00:05:06] Bruce Bassi: One thing that I feel like is kind of rarer these days is for somebody to go into the medical establishment or medical care, medical treatment without having researched quite a bit on borderline personality or have heard about it on TikTok, and to be coming in with a blank slate. Of like no stigma against it. And I think that’s, it’s rare and cool when I can detect that, as a clinician. And I know that I have like the ability to kind of prepare them for what they’re about to experience on forums and whatnot. And I can never really understand what a patient’s experience is. I can only kind of superimpose what I think their experience is based on my own experience is, and I know that from a clinician’s perspective, there’s definitely quite a lot of negative attitude surrounding what it’s like to treat borderline personality disorder patients, where they require more time, they’re time intensive, maybe a little bit more sensitive to certain wording, so it puts you on high alert.

There might be a little bit of back and forth there where they’re kinda exiling you or devaluing you and no, no clinician wants to experience that. So there’s this kind of feeling that those are difficult, quote unquote, difficult patients. And so, I, I’ve recognized that as a clinician and I think that comes out too in terms of how patients research the, the topic of borderline personality.

It’s definitely not one that a lot of people are proud of, and it’s a, it’s not a kind of seen in, in a positive light.

[00:06:28] Evan Iliakis: So that’s difficult because I think, I think one of the challenges of receiving the diagnosis was receiving it with, what kind of, what you’re saying, the warning that there is stigma in the system and I think all the things you mentioned with the, the care of borderline personality disorder requiring more time, more resources, and more care, I think that’s all true.

And I think, that, that those, that on some level the clinicians alerting her to that was maybe kind of a way to tell her, brace yourself for what you’re about to get into. And I think maybe on some level, the clinicians aren’t creating, maybe the clinicians are contributing on in some small level to the stigma, but I think the stigma is societal and I think it’s out of their hands.

And I guess that’s a really tough question as to how to, how to frame the diagnosis in a way that’s not stigmatizing while telling patients to brace themselves for stigma. And I mean even, even as a medical student, like when I was, when I was pre charting on patients that I was about to see, and I saw that they had borderline personality disorder on their chart, on other services too, on family medicine and on internal medicine and otherwise, I, I would go into the room making sure I was smiling more, making sure my, my, sentences were less ambiguous.

So I, I did find myself altering my behavior and then, know, I don’t know, like should, should the patients know that, that the clinicians are possibly modifying the way they act in, in an effort to, make the patient feel more comfortable or avoid potential pitfalls when maybe that’s possibly a little discriminatory behavior if you’re being treated a little differently than other patients.

So I think, I think that is a good question. I, I don’t know the answer to that question. I mean, how to, how to go about, the stigma in the field. I think I, I’ve seen very useful, papers that talk about the role of language in stigma and making sure using words like “people with BPD” or borderline personality disorder instead of borderlines and how those, how those small things can reduce negative perceptions.

And also how patients are talked about in clinical rounds or I think being mindful of that can help reduce clinician stigma. But I think on some level, it, it’s difficult to conduct destigmatization campaigns. And I think, and I think that’s, that’s possibly the main way in which, in which this can be addressed is if, if we do evidence-based destigmatization campaigns that, that are geared more to the public as well.

Because I think even if clinicians destigmatize themselves completely, there’s still probably going to be a lot of societal stigma that you’d still have to possibly prepare the patients for. So it’s a difficult question, it’s a difficult question. I don’t know what the right answer is to that.

[00:09:00] How to break the news of a diagnosis

[00:09:00] Bruce Bassi: One theme that I think we’re kind of scratching the surface on is how to break the news. To a patient of the diagnosis. And I think every clinician kind of finds their own way of communicating that eloquently to a patient in a way that’s compassionate and gentle and also respects the patient as a person to, and I can think of it a few times in my career where the diagnosis itself really caused quite a bit of, and maybe, and maybe it wasn’t always borderline, but just the act of diagnosing somebody can cause a lot of high emotion, high stress on the end of the patient.

And I think as clinicians there are instances where we kind of put less weight into the diagnosis for whatever reason. Maybe it’s kind of ambiguous or there’s a lot already. So we don’t, we’re kind of in our mind thinking that there’s a lot of diagnoses, so we gotta put something down for insurance, for the claim, for, the note, that type of thing, for the most urgent thing to treat.

And sometimes the, the patient sees the note before the clinician can kind of explain to them what it means. And there was a, there was a time when I remember I was an intern and I knew I was going to psychiatry, but I was on a neurology rotation. And so I, I think I diagnosed a patient with a mental illness because that was kind of my interest.

And the patient exploded. Seeing that I think it was going to sort of disability prognosis or something like that, or have an impact on, on something down the road. He didn’t let on fully as to what it would affect, but basically they, they, he strong armed us into taking that off the re medical record.

And then also just a few other times where, you have to put mild, moderate, severe, and somebody disagrees with it being diagnosed as too mild or too severe and having an impact on that. And it’s, it’s definitely like a very touchy, kind of sensitive topic. And I think because the clinician has, like, they have their own viewpoint, vantage point of a diagnosis and what it means from medicalization type of framework.

And then the, the person is like, “oh, this is me now?” Like, “what does it mean to, why is somebody calling me that?” And “why didn’t they tell me about what that is and what that means?” And “does this affect me for the rest of my life?” This has like so many more downstream questions that I now need to, to ask.

And I dunno if you want to talk about how that news was broken to your friend and yourself and how that kind of came about, because I think everybody kind of has their own story for that.

[00:11:23] Evan Iliakis: The two years I spent working in Boston at a psychiatric hospital there, McLean Hospital, where I was at the borderline personality disorders treatment institute. I think one of the cornerstones of the model that we use there good psychiatric management for borderline personality disorder was diagnostic disclosure. And, we were sitting on some preliminary data with I think a handful of patients, I think somewhere between 30 and 50 patients was a sample size where they filled out self-reported questionnaires after receiving the diagnosis, and on a whole, it seemed like they were they felt empowered by the diagnosis and they were, happy to receive the diagnosis, especially insofar as it a, explained what they were dealing with which, they possibly didn’t even have an understanding of, why what was happening was happening.

And kind of getting that context was helpful and b, insofar as it then made it seem actionable so they could get treatment. And so that was kind of what that model said was that this is a helpful first step to guide next treatment steps. And then I think, in practice, and I’ve seen this not only in my clinical rotations, but also with my friend, I think, I think it can be, it can be a big deal and it can be a little destabilizing to receive a diagnosis that, essentially the criteria, I think are phrased in a, in a pretty non-stigmatizing way, but still hearing all these things about yourself, like impulsive spending or frantic efforts to avoid abandonment, I mean, I think these things are not necessarily, in and of themselves if you read word for word what it says on the paper, I don’t think that someone would necessarily, want to identify with that or choose to identify with that. And so while on one level it was validating for my friend to hear that what you’re experiencing, it’s not, it’s not something that’s, unknown or that clinicians can’t really grasp, it’s this entity possibly alongside other comorbid mood disorders, et cetera that is actionable.

So, on one level it was a shock. I have the diagnosis, it’s stigmatizing, and on the other level, it helped, it helped explain a lot of what was going on and it kind of took it out of the realm of this mystery symptomatic presentation that it seemed like clinicians weren’t fully able to address, or maybe they were targeting without telling her that they were targeting it to then something that she had more ownership of and more control of but something that did lead to a few months of, reckoning with, with a new label, honestly, I mean, it’s hard for people to feel that they’re being reduced to a, a label. And so I think it, it was, it was difficult to deal with. I mean, it, it wasn’t, it wasn’t a cancer diagnosis, it wasn’t something, which is even more difficult to process. And I think p patients feel awful receiving cancer diagnosis. But it was, it was a bit of a shock. And then, maybe if we had resources available in the vicinity, it would’ve been easier to deal with. But there, there weren’t, those resources were not available. So–

[00:14:12] Bruce Bassi: Yeah. By nature, these individuals are people who essentially struggle with self-worth. They have low feelings of self-worth, and their self-worth is defined by their relationships and their interactions with those around them. And it, and they’re like directly linked. It’s like, the over reactionary type of feeling of self-worth based.

How people have treated them that day. And even sometimes subtle reactions that they’ve gotten from other people. And so when they, when they see these words on paper, like you said, it’s, it’s almost pretty, pretty shocking.

[00:14:46] Evan Iliakis: Yeah.

[00:14:47] Experiences with Good Psychiatric Management Model

[00:14:47] Bruce Bassi: You mentioned good psychiatric management, and I like that, that segue there for the listener.

Basically good psychiatric management is one modality of treating borderline personality disorder, and it was found in 2009 in a randomized control trial to be quite as effective as the gold standard DBT was in on a number of outcome measures at a quarter of the resources. So some of the main principles there are that there’s once weekly treatment, once weekly therapy sessions.

It’s grounded in diagnostic transparency. Like you said, there’s incorporated case management. It uncovers unrecognized motives and defenses. It’s multimodal where they incorporate also family interventions. And I’d like to hear you have like kind of an insider view with the, the mothership of good psychiatric management. What was it like working there? What was your experience like, and tell the listener about that.

[00:15:43] Evan Iliakis: Yeah, I’m happy to share about that. I mean, honestly, I, I feel, I feel honored that I was able to, work there for two years. I think the, I think the principles of the treatment model are. And I mean, I don’t wanna, I don’t wanna sound promotional and I, I don’t, it’s not like I have any financial benefit from saying these things, but I think the, the principle that we want to come up with a treatment method that’s effective for people, and that is not rooted in kind of specialist treatment guidelines with, intensive group requirements and, requirement for phone coaching, et cetera, like a structured program.

I think that is a strength, and I really appreciated that the, one of the goals of the program was to– was thinking about borderline personality disorder more as a public health problem. With in need of, in need of a solution. Basically, the solution, the, the public health problem being that the disorder is, is prevalent.

It’s disabling, it’s stigmatized. There are high costs to society and at the same time there are, there are treatments available, but the treatments are specialized, they’re resource intensive, they’re difficult to access. And I think what’s happening right now is that for the most part, there’s a very small amount number of clinicians who are trained in these treatments and a larger proportion who maybe have the manual in their bookshelf and might be pulling skills from it, but you know, might be implementing it in isolation, the absence of possibly skills coaching or in the absence of, guidance or, or training in that intervention? I mean, I don’t wanna be, I don’t wanna generalize cause I know that there are a lot of DBT training programs out there that train more informally and I think it’s great that there’s, increased access to these interventions.

at the same time I do think that there is a hurdle to entry to specialized treatments and I really appreciated that the good psychiatric management, the GPM approach really tried to– we would organize trainings locally nationally and, and across various countries where we aim to in a couple days equip clinicians with the skills to treat borderline personality disorder effectively and feel comfortable and confident as, as much as you can feel that way after two days of a training. But of course they had experience beforehand as well. I think inevitably a provider will run into someone with borderline personality disorder.

So it was, it was honestly, it was honestly great to, be at these trainings, interface with clinicians, and then work, work to, to also, help out with outreach initiatives. I think one of the highlights of my time there was organizing a GPM training in, in Athens in. , which is Greece is my country of origin. So it was great to, to bring the treatment there and to translate the family guidelines. As you mentioned, the family interventions are a big part of the good psychiatric management approach and adapting that to Greek.

So to be available to Greek families was a, was a, was a, an honor. And also working with the international collaborators and seeing that this was an, an international. Gap in services that we could help fill was, was, was awesome. And it really, it really impacted the way I think about mental health to this day and looking at treatments not as, not, not in term, not only in terms of their efficacy, but also in terms of their, implementation and dissemination, which is a whole additional hurdle that think in the world of treatment research. It is, it is appreciated, but I think me, as kind of a novice going into this, I did not appreciate kind of the how difficult it is to, to implement a new treatment.

[00:19:02] Bruce Bassi: Awesome. For the listener, if they’re interested in getting GPM training, it is available on Harvard CME website for just $40. For eight hour training course. And I also don’t get any sort of royalties or referral bonus, but I’ll put that in the referral links and on the website for people who might be interested because I do think it’s, it’s obviously very effective and could be useful to a lot of people also where they don’t have to do manualized DBT type of approach. I went back and looked– I went to I went through residency from 2014 to 2018, and I looked through my PRITE resources and also my board certification, study manuals and whatnot to look for the GPM good psychiatric management, and in quotes, I put it in quotes to try to search and see if it, how much it was referenced, I couldn’t find it anywhere. Granted, it was, in its infancy at that time but the, the randomized control trial came out in 2009. I think his first book was in 2013 or 14, Dr. Gunderson’s book.

[00:20:00] Evan Iliakis: I think it was 2014.

[00:20:02] Bruce Bassi: So it was, would’ve been just around the time it started, but I don’t think it

really kind of took off as a brand name type of treatment yet until, obviously it kind of still is growing. More people are learning about it. I typed it into PubMed and I compared the number of results that popped up for DBT from 2010 to 2023 and there were 5 5400, 5,439 results. And then I typed in good psychiatric management into PubMed and there were 17 results from that same time period. So obviously it’s got a ways to go to kind of catch up to the stature of DBT but– But I think, keeping with the theme of the podcast, I think it is going to definitely catch on more in the future for a lot of clinicians, therapists, psychiatrists, moving forward because a lot of people call and, and expect people to specialize in DBT.

And like you said, and I think this parallels your experience too, there’s just not that many people who only do DBT like solely do DBT, and they can’t really find a clinic dedicated to DBT it’s like they might have a clinician who has a certification in that, but it’s not their only area of expertise.

[00:21:09] Evan Iliakis: For sure. Yeah, and I think it’s also difficult to maintain a DBT program. , I think there, there’s some studies out of Wales, and the UK showing that the 10 year survival rate of the programs is somewhere around 50%. I think it’s just, they’re, they’re very resource intensive and I think in the long term it is, it is difficult for clinicians to work with this population in a setting where there is possibly, clinician dropout from these clinics.

And kind of what we’re seeing in the healthcare system in the era of Covid where people have a, a high workload and they’re not a lot of people certified and so I feel like they’re carrying a lot of the weight of the problem on their own. And so I think there is a lot of burnout tied into that. And so having some treatment models kind of be more disseminated and possibly saving the specialized treatments for the more severe cases that can’t be handled in the community with a more generalist approach, like GPM that does not require as extensive, specialized training would be kind of what we were thinking might be an optimal solution to the, to the, public health problem of borderline personality disorder. But we will see, I think, I think as you mentioned, GPM in many ways is still in its infancy and there there are really promising data from that randomized control trial.

And at the same time, GPM there was designed as a control condition. The study is the largest study to, to date at least as of a year or two ago, and it might still be of treatments of borderline personality disorder. And, but still, I don’t know if it was sufficiently powered or designed to be an equivalence or like a non-inferiority trial.

And so I think there’s still probably a bit of a ways to go in terms of establishing the scientific foundation or the, the, the clinical efficacy of, of GPM. And not only in the US but also internationally, because I think that’s another strength of DBT, that there are trials from across the world from different treatment settings, US, Canada, but also European countries. And so I’m curious to see how that will develop. I think even, you know, in the presence of the evidence that we have now, I think gpm it, it, it is a, is a good thing to have in the toolbox or in the bookshelf, or at least in mind, to keep an eye on Cause I think the, the principle that we should have easier to administer treatments for GPD that might still be effective without kind of sacrificing that effectiveness is, is a, is a promising future direction.

[00:23:29] Course of BPD

[00:23:29] Bruce Bassi: There were three good points that I came across in a lecture on the GPM model. And so one was tell them the symptoms and we, we kind of mentioned this earlier in the podcast for diagnostic transparency. Tell them the prevalence that there are other– a lot of other people out there with this and they’re not alone. And then also the course tell them the course of borderline personality. And I thought this was a very interesting statistic, that 40% of individuals, even without treatment, remit by two years and at 10 years, it’s 80%. So even if they didn’t get any treatment at all, they don’t meet the criteria for borderline personality later on in life. Do feel that we do a good job at communicating that to patients when they get started to get plugged into treatment?

[00:24:15] Evan Iliakis: So I think, I think the answer to that question is probably. I mean, I think it really depends on the situation, but I think as a whole, I think probably, no, I think a lot of clinicians are surprised to hear that the longitudinal course of borderline personality disorder is one of remission. And a lot of the times also recovery, although there is also long-term, impairment associated with the diagnosis, unfortunately. I think one of the big surprises for me, coming from the, the, my, my background where, we learned about these personality disorders as former access to kind of stable problems against, the backdrop against which the mood disorders and anxiety disorders and schizophrenia come and go really colored my perception of the diagnosis.

I think also the description of it as a personality disorder makes it sound like something that’s stable and that is not changing. And I think theoretically for a very long time, up until I think the two thousands when tho that that evidence first started coming out from longitudinal trials of borderline personality disorder in its course.

I think up until that point people just assumed that it would be kind of a stable and unremitting problem. . And so I think, I think that is a more recent paradigm shift, and I think it hasn’t really arrived yet. And I, I think, at least for my friend, no one really brought up the course of borderline personality disorder.

But I think, I think it is a helpful discussion because I think on, on some level, we, we did compare some of these statistics to some other, psychiatric disorders and, unfortunately other, other diagnoses like schizophrenia, bipolar disorder and of the, on the serious, serious mental illness spectrum might be more lifelong concerns and might actually be more former access to, like, in terms of being more kind of stable long-term problems than borderline personality disorder, which I think it, it really, the longitudinal courses tends to remit as people get older and I think prognosis is especially good if people are in their teens or twenties, where some of the behaviors associated with the, I guess the diagnostic criteria might be more normative, like still, you know, having some emotional Instability and some interpersonal sensitivity.

So, yeah, I think I do think that that is a point that that should be brought up because I think it, it does instill optimism and it does instill motivation to engage in treatment and I think even in the absence of treatment, knowing that it, it, it, likely will get better and it has for a lot of other people is a message of hope. I think that can counteract the effect of delivering a, a pretty hefty diagnosis.

[00:26:46] How was borderline personality disorder taught in medical school?

[00:26:46] Bruce Bassi: Oh, definitely. Yeah, I like the way you put that. Looking back at how it was framed to you as a medical student and how it was medicalized, and I wanted to maybe use that as an opportunity to kinda shift into your experiences as a medical student going through psychiatry and talk about what, that was. And one aspect that I thought was interesting that we had talked about earlier was how as a medical student, by nature, you kind of need to be exposed to everything in medicine. And so you might have a slide on SSRIs and slide on tricyclic antidepressants and. Since there’s one slide on each, you’re kind of thinking, oh, this is of equal, of importance to me throughout my career.

But really they needed to put that slide in there because they needed to mention them that. they exist and whatnot, when in fact we hardly ever use them unless it’s for like pain and sleep or something like that. And and I think, I think that kind of skews a little bit what, what a medical student should expect for the remainder of their career.

And it’s always hard. I mean, that’s like one of the biggest challenges I think of being a medical student is that you’re learning about these facets of medicine where you don’t have that clinical experience to kind of fall back on, say, Hey, like the, I see how this is going to apply to me cuz it’s like all in the future. So, how, how was borderline personality kind of presented to the medical students, medical school by the medical school and your experiences?

[00:28:14] Evan Iliakis: Yeah, so before I get into that, I, I do want to point out that, my, my initial experience with borderline personality disorder at Penn was not positive, but I shared that with the course director of our psychiatry block. And she was taking over from an old course director and it was her first year running the course and she wanted in her first year to try to maintain the structure that that other course director had.

But in response to my feedback, but also feedback from other people about various different aspects of the psychiatry block, she completely reformed the block. And my friend, the year under me sent me the slides from this past time that they had the psychiatry block and already it was much improved.

And I think, there was a much better job, job done of framing personality disorders against the backdrop of research and kind of discussing some of the things that we’ve discussed here. But my initial exposure to borderline personality disorder in medical school was we were, it was through the lens of personality.

So we had a 50 minute lecture on personality. Initially we covered the big five personality traits, but also I think spent five minutes discussing the Myers-Briggs personality types, which I guess are, are very, commonly discussed in pop culture. But I don’t know that they’re necessarily clinically relevant or , that there’s a, there’s a robust evidence base for conceptualizing personality through that lens, even though it is a fun approach. But yeah. Then we went into a segue on the, the three clusters, cluster A, cluster B, cluster C, which I think are important to know for boards possibly. But again, also have limited utility and validity according to, to some studies that I’ve seen in terms of, people not falling neatly into one cluster and that there’s comorbidity across clusters, so it’s questionable to what extent those are even useful. And then kind of with, with 25 minutes left, we then did a survey of all the, the personality disorders. And there was one slide for each of them. There was no comment on treatment, on prognosis, on course. And I think in fact in that slide, we didn’t even get the raw criteria.

We got kind of the lecturers interpretation of the criteria. And so for borderline personality disorder, the description was this is the quote unquote difficult patient. And, these, these are the patients who are the overly attached anxious girlfriend, or, and there was a, there was a, a gif at the bottom of the slide and then that was it, that that was all the coverage. There was no mention of DBT and I, I dunno. I did bring this up to some of my friends and they said, we’ll probably learn it more in clerkships. And we did get a bit more coverage of the diagnosis in clerkships.

But still most of what I, in, in our, in our question banks, the, the UWorld question banks there the questions were so impressive. The answers to the questions and the explanations were very impressive. They commented on basically all of the things that we’ve been discussing, and none of them made me think, wow, these people don’t know what they’re talking about. In the contrary, I was very impressed that this this information was available to medical students preparing for boards.

So I think there was a heavy emphasis on DBT there, but I think that, I think in the current day and age that’s possibly justified just given the, the evidence base. But yeah, my initial coverage of borderline personality disorder was a little disappointing to the point where I organized an lecture series on what is BPD, what treatments are available for BPD what are some of the problems facing, BPD research and next steps that we can do to to take, to improve the treatment landscape.

So, it, it gave me space to then, try to give medical students some additional resources. And we did have very really robust attendance at those events too. I think at one of them there were 50 plus people, which is equivalent to almost half of my medical school class. So I was, I was glad to provide that, but I also wished, we had had more, but now there are, there have been improvements to the system, so, the coverage is improving.

And I think it’s similar at other medical schools too, where, even within the past couple of years, they’ve implemented much improved lectures that provide a representative sense of the diagnosis rather than simply listing the criteria. Which, if they had done that for, mood disorders, anxiety disorders, or schizophrenia, I would’ve been a shock, but I was, a little surprised that for borderline personality disorder, they could get away with not doing that. And I guess I guess part of the problem is that we have to learn all of the 10 personality disorder diagnoses for boards, and so there is a time pressure and you can’t go into depth.

But that’s the other thing that was surprising to me was that there, there is a pretty robust literature maybe for, for antisocial personality disorder and kind of a nascent literature on narcissistic personality disorder and obsessive compulsive personality, but really the bulk of of research and personality disorders has happened in borderline personality disorder. And so you I think can, list the criteria for the other personality disorders, but maybe also provide a representative sense of, this is borderline personality disorders, the one that’s the best studied, it’s the one have resources for. And these are the resources and maybe this is my bias having worked in that field, I’m providing a little more so that it’s more on par with what we got for other diagnoses in the former axis one.

[00:33:42] Opinion on apps for borderline personality disorder

[00:33:42] Bruce Bassi: I totally recognize that it’s, it’s easy to kind of criticize medical school curriculum because you really only have like finite, time in your day to, so if you either focus more on the kind of the new, novel and effective treatments of borderline personality, it kind of takes away from you have to cut something else out and that we the most you can be like, well, you didn’t talk about this and this, and this related to personality disorders.

So I can kinda understand that. I, I’m glad that they have moved away from kind of the meme and gif based presentation of, of certain personality disorders and, and thanks to your efforts have made it a little bit more, balanced and, and evidence-based. There’s this thing I’m thinking of in the back of my mind– you mentioned how Myers-Briggs is like a, a very much a popular kind of social media and internet based personality test. And there, there is kind of often in medicine this, sense that our, our two Venn diagrams are not like, completely aligned in terms of our areas of interest.

So for example, like physicians and psychiatrists were polled on what are the most, common side effects that you feel like patients would, be most, upset by? And historically, they ranked sexual side effects like the lowest. And patients will rank sexual side effects like the top couple. so the, we often have like this sense that we think we know what patients want and what the general population wants, and then there’s like this separate driver of like really vocal advocates that are like, Hey, doctors are like missing this thing.

And I think where I’m going with this is, like this, app-based types of treatments for BPD I want to talk a little bit about how a patient could potentially go online, download an app, and think that they’re getting DBT because it’s like mindfulness. What, what do you see as potential pitfalls with that sort of approach where they’re receiving like this kind of unidirectional treatment from the app itself, but it’s not grounded in any sort of principles of DBT or, I mean, it’s not actual DBT nor is it GPM either so. But yeah, people are very interested in that. They’re interested in something that’s accessible and easy to use and something that’s around on their, at their fingertips.

[00:36:08] Evan Iliakis: That’s a very good question. And I think, I think a lot of aspects of DBT do lend themselves to an app-based format and actually when I was working at McClain was interfacing a little bit with Chelsea Wilkes, who is a researcher who worked with a group at Harvard to develop an a DBT app that was rooted in, DBT principles. She did her PhD with Marsha Lenahan, who is the developer of DBT, and that app itself looked great.

I have, and I think the, the principle of apps themselves is also an excellent one. I think they, they do lend themselves to, to, to not only teaching skills, but also, they’re, they’re accessible and so they help, deal this problem with this problem of like a treatment landscape where, it might be hard to access care for BPD and, possibly even provide. A bridge to services if there, there’s a year wait period that, that someone can start to work on things on an app even if they’re not supervised. So I am all for the principle of apps. I do have a couple reservations at the moment. I think one is that you alluded to is and possibly I’m rephrasing this in a less eloquent way, but I think there’s not really a lot of control, like centralized controls to what apps are uploaded. People can kind of generate whatever they want. There’s no requirement that it be evidence-based. There are even situations where people might claim it’s evidence-based and maybe it it isn’t necessarily, or they might say this mindfulness app is evidence-based and maybe mindfulness itself is evidence-based, but the app hasn’t been rigorously studied. And even in apps that are rigorously studied, we actually, the group I worked in conducted a meta-analysis of smartphone based interventions for borderline personality disorder. And where we basically looked we were, our search terms included, borderline personality disorder, treatment, and then smartphone apps.

So we looked at papers that were investigating the clinical efficacy and effectiveness of smartphone apps, and designed specifically to combat BPD or BPD symptoms like emotion dysregulation or otherwise. And what we found was that compared to control conditions and compared to, in-person treatment conditions, there was no advantage of those apps.

And I think shockingly to me, over wait list control conditions. And sure, like I think, I think there is, there is, with meta-analysis one of the issues is heterogeneity. And I think there is a possible pitfall in grouping together different apps. I think it’s that that might almost be like grouping together apples and oranges. It might, one app might be great and the other one might not be great. And then if you aggregate them, you can draw the conclusion that apps are not great when maybe that one app is great.

So I think we should be cautious as to the conclusions that are being drawn from those studies or from that meta-analysis. But I think as a holder, promising direction and there are some promising studies on some of the apps like, that DBT app I mentioned, but last that was not publicly available yet. And I think, yeah, there still is a ways to go, but I think it’s a promising direction and something that clinicians could also use as an like to augment the in-person sessions or as an add-on if, if they feel comfortable. And I think that would be a great place to get to if, as part of manualized treatments or as part of treatment guidelines that the apps, like some apps that have efficacy in clinical studies could be then recommended to clinicians for patients to implement as an add-on to their in-person psychotherapy or medication management.

[00:39:36] FDA non enforcement of apps

[00:39:36] Bruce Bassi: Right. Yeah. You make a really good point to not generalize apps in their entirety because it’s like saying therapy and then it’s entirety, and I often point that out to. The patient’s like, okay, what kind of therapy didn’t work for you? You know, what was it about their approach that didn’t work for you? Do you want to go see a different therapist? And it’s like, yeah. So, I often catch myself kind of making the same, same mistake. And I think in the world of apps, it’s like they sometimes want the, the, the developers of the apps want the best of both worlds where they want to say that it’s providing like this sort of treatment but they also don’t want to go too far where they were considered a medical device in providing treatment because then it would require FDA approval as a medical device. And there’s, oh, since, since the start of Covid, there’s been a FDA non-enforcement of apps because they are kind of seen as low risk type of modality of interfacing with patients. So they’re not going to enforce, whether or not they’re, they should or shouldn’t be FDA approved, during the period of covid, and I think. It kind of opens up a little bit of a can of worms there where marketing teams are kind of quick to, to jump on that, to sway certain patients in the general public that they’re pro, quote unquote, like providing treatment for DBT providing treatment for borderline personality, whereas it’s, maybe not what a clinician would think of as treatment

[00:41:05] Evan Iliakis: Yeah, that’s a really good point. I also didnt’ know that about the fda the stance on apps as of the pandemic. That’s really interesting.

[00:41:14] Bruce Bassi: Yeah, I came across an, an app that was providing treatment for kiddos and they said that they’re the first FDA approved app.

And I looked into it because there’s an asterisk on their website and basically it referenced the release, the press release from the FDA saying that there’s non reinforcement. So I’m like, that doesn’t mean that you can say that you’re actually FDA approved. There’s just not an approval process going on for for the apps at the moment.

[00:41:40] Evan Iliakis: Wow, that that’s misleading.

[00:41:42] Bruce Bassi: Yeah. I, I thought so too. So I understand from what you have told us, it sounds like you had a, a really kind of nascent interest in, in borderline personality and that, grew one you during your time at McLean. And did that have any impact on, on the direction of your PhD research? And can you tell us a little bit more about that?

[00:41:59] Borderline personality to avoid a negative outcome

[00:41:59] Evan Iliakis: Yeah, sure. So I think, I think the, the answer to that question is twofold. I think the first, the first aspect of my work at McLean that made me become interested in the neuroscience research that I’m doing now is that McLean is a, is a really interdisciplinary environment. You have everything from social workers to, to, neuroscience, PhDs that work with neurons and culture.

So there’s such a broad range of research going on there and I was very impressed at the systems neuroscience research that was happen. where people were, looking at, mouse models of depression or schizophrenia or looking at specific brain circuits and going in and, stimulating or inhibiting certain populations of neurons or certain brain regions and then generating a fundamental understanding of how the brain works.

And I think that’s something I was interested in from afar and something that I noticed was missing, from specifically borderline personality disorder research. I felt like there was a lot of that basic research going on in the, in anxiety disorders, in depression and psychosis. And it felt like it was, it was, it was missing from the personality disorder realm.

And I think that that’s another, aspect that, having a, a better neuroscientific or under better understanding of the neuroscientific underpinnings could possibly help reinforce not only the validity of the diagnosis, but also inform next steps in treatment. So when I was at Penn, I felt a little intimidated by reaching out to neuroscience researchers, but I did, and I got involved in research there.

And what drove me to pick the lab that I was interested in was not only that they were, interested in looking at OCD and autism from a neuroscience perspective, and had a proven track record of doing so. But also that a project that the postdoc that I ended up working with at that lab was working on, was on negative reinforcement, which I mean, I think is, is covered in medical training, but, and I don’t mean to overexplain, but, the process whereby, you perform an action to avoid a a negative outcome. So an example would be possibly taking a pill to alleviate a headache or in the case of the mice that we were training, pressing a lever to avoid a shock. And in the case of patients with borderline personality disorder, I mean, I had this discussion with some of my colleagues and they said that, Evan, this is a great way to possibly generate a neuroscientific understanding of that that could be relevant to borderline personality disorder as well.

Cause I think a key problem in borderline personality disorder is that there are these emotions that are overwhelming, that are unbearable, and that people, in order to avoid those emotions or to escape those emotions, perform actions such as, impulsive spending, reckless driving substance use self-injury, but also, relational things like, like sending texts to kind of avoid these, these overwhelming feelings of, be it loneliness, be it anger, be it sadness. And so I think generating a better understanding of how those processes work could help, improve treatments not only of entities like Obsessive compulsive disorder, but also things like, PTSD and all the way up until possibly borderline personality disorder.

So that really, that, that was another way in which the borderline personality disorder background drove my research interests.

So I think, in the more immediate future, I’m trying to learn as many techniques as I can in terms of, basic neuroscience research. So I’m trying to learn how to, go in myself and stimulate or inhibit specific populations of neurons and look at readouts of mouse behavior. My current research interest is, I, I, I did the negative reinforcement project and I thought that was very cool and contributed there.

And now I’m trying to more independently look at something called goal-directed behavior, which is basically described as how do we, in the face of changing environments, perform actions that are more likely to lead us to have a, a favorable outcome or to survival. And I guess in, in an everyday life example, would be, I don’t know, like I’m, I’m running late to a meeting, how can I, how can I best navigate this situation so that I can, save face, I can make it to the meeting and, and still be professional and still be able to contribute to the meeting.

And I think that it’s possibly a little bit of a confusing example, but I think in an example in, psychiatric disorders would be that possibly. Someone with borderline personality disorder in the face of emotional duress might make decisions in a way that’s different than how someone who’s not in that emotional duress or does not have that diagnosis would make decisions.

For example, in the face of high emotional stress may be binge drinking, maybe self-injury, maybe impulsive spending or sexual relations. And I think understanding, understanding how we make decisions and how we deem things in the environment, as, valuable or favorable versus things that we should avoid.

I think this is another thing that’s, that’s perturbed in borderline personality. and understanding the basis of that from a neuroscientific perspective and kinda how that works in terms of not only which regions are involved, but which cells in those regions are important in in, in mediating kind of value based decision making.

Like what is, what is most favorable or beneficial for me in this given moment? I think that’s important to understand. So I’m just working on a, a project right now. There’s this population of inter neurons in the, in the striatum, which is the input nucleus of the basal ganglia, which you know, implicated in in Parkinson’s, et cetera, but also in decision making and picking actions and kind of comparing the values of different actions and selecting one as most favorable, and also guiding movement, hence the relevance to Parkinson’s movement disorders.

We’re looking at a population of entering neurons there that we found that when we inhibited. This was before I arrived in the lab, but when the lab inhibited them, they found that mice learned a novel behavioral task more quickly.

And we have a, a number of hypotheses as to why that might be. Maybe they’re performing the task more, quickly. They’re more, there, there’s more motor output, but we have reason to believe based on preliminary data that that’s not the case. And that possibly what’s going on is that when you inhibit those neurons, they perceive novel stimuli as more valuable, which sounds innocuous, but I think, if you, if you go downstream, which is what I’m doing, and then put mice in positions where different actions are associated with different outcome values you might end up in a position where if you knock out those, those entering neurons, you might lead to perturbed value-based decision making.

A mouse might perform in a way that’s not in their best interest. And these inter neurons, they’re somatostatin inter neurons in the striatum. Aberrations in their activity have been linked to depression, have been linked to chronic stress. And so that’s a possible neural substrate for the behavioral manifestations, possibly a borderline personality disorder, that there’s possibly perturbed value-based decision making.

So that’s, that’s really what’s driving me to study these intern neurons in a task where the mouse pushes the lever, they have an 80% chance of reward, but if they pull, they have a 20% chance of reward. And then flipping those reward probabilities and seeing how well the mouse is able to update their representations of reward in the environment or tweaking them so that there’s a risky possibility where there’s a small probability of a big reward versus a big probability of a small reward. And seeing how modifications, how manipulations of those intern neurons, be it through optogenetics. So shining a light to activate or inhibit neurons, be it through well it through manipulations where we chronically silence those neurons, see how those can impact value-based decision making. And it sounds basic, it sounds far removed like a mouse pushing and pulling the lever sounds far removed from what we see in clinical practice. But I think that kind of gets at your other question of where I see this And I, I would like to help bridge the neuroscientific research that’s going on with kind of a more clinical and public health understanding of psychiatric disorders. And I think the fact that I have on one hand worked in a borderline personality disorder treatment institute and training institute, and then have gone to basic neuroscience lab and I’m also a medical student, helps me bridge those two worlds. And I hope in the future that I can, practice clinically, but also do both basic science research, but also contribute to clinical research and have, have the two inform each other and then kind of pick neuroscience research que questions based on, what I see as the, the biggest gaps in our understanding of of clinical phenomena that are very real And that, we, we’ve built treatment models around. But that we might not have a good fundamental neuroscientific understanding of. So that’s kind of my goal down the line.

[00:50:39] Bruce Bassi: well, I I be the importance of being able to bridge the two is that there’s almost this release when patients understand that there’s a underlying biological underpinning for some of their behaviors. They’re, They’re They’re kind of let loose of all of their guilt associated with certain maladaptive behaviors and traits that they have probably come to over-identify with and kind of feel is just part of them and who they are.

Maybe understanding the fact that borderline personality is 50 to 60% heritable and also it was protective during your toddler years in some way or another. And also there’s some sort of neurologic underpinning from your striatum that makes you think of all, all of your actions as equally valuable. I think you’re kind of setting yourself up for understanding that this is not your fault.

The structure of how everything came together in your upbringing, resulted in this diagnosis is not necessarily you or your choices, from a more conscious level.

So it’s interesting. I, I think that’s really cool and I’m, I’m happy for you to bring those two worlds together because of that reason.

[00:51:48] Evan Iliakis: Yeah. Thank. Thank you. Hopefully this MD PhD program will help me do just that.

[00:51:54] Bruce Bassi: When I have, learned about borderline personality, it is kind of conceptualized as affective instability, impulsivity, vulnerability. But I, I like the way you, framed it in terms of avoiding a negative outcome is the essential underlying core motivation for why there’s affective instability: they want to avoid the sense of abandonment. They want to avoid the insecurity. They want to avoid the worthlessness that they have come to experience. And so from that aspect, I feel like you’re going upstream, like one more additional. ,yeah, there’s affective instability, but that’s like the end outcome and not necessarily like where it’s coming from. I think helpful for patients to start to think about it that way like, okay, I did this, what am I trying to avoid here? And then like, going from there and, and kind of unpacking it with a therapist.

[00:52:47] Evan Iliakis: I think the, the diagnostic classification systems that we have now are very useful and helpful and are rooted in extensive research and at the same time, I do think like what you mentioned, that there are possibly trans diagnostic processes driving a range of psychiatric disorders and why a lot of them– think there’s some recent studies that have come out that have found that a lot of the symptomatic presentations of a range of different psychiatric disorders load onto this common P factor when complex principle components, analyses, mathematical analyses, possibly there’s clusters of internalizing and externalizing disorders, or possibly there’s also this just psychopathology factor that’s common across a range of disorders, and that clinically we see different patterns, but that maybe there’s a lot of common processes underlying them. and I think with all of these thi phenomena that I mentioned that we study in the lab, like I think negative reinforcement is probably part of what’s going on with borderline personality disorder, but definitely not everything. And similarly with, with I guess this value-based dysfunction that I think that that’s possibly also an aspect of what’s going on, but I guess the brain is big. It’s complicated. There’s so many different things going on, and so I don’t know. With all these phenomena, I think it’s interesting because I was coming from this clinical research background. we would think in terms of diag, DSM five diagnoses and criteria, and then moving into the neuroscience world where there’s not really much ground truth on the level of the brain to, I mean, sure, like maybe there neuro underpinnings of psychosis or maybe they’re in neuro underpinnings of depression. But I think mostly when we do these things in the lab, we just think in terms of quote unquote neuropsychiatric disease because it’s just hard to to translate, I guess, one-to-one or to back translate one to one these clinical entities to the the brain and the way that the brain works on kind of a circuit level or a cell type specific level. that’s a good point that you, that you made with the upstream question of what is upstream.

[00:54:43] Bruce Bassi: Evan, it was so nice to have you here today to hear a little bit more about your background and research and talk a little bit more about borderline personality and GPM good psychiatric management. So I appreciate you coming on the show and talking about all that stuff. Thank you so much.

[00:54:56] Evan Iliakis: Yeah. Thank you so much for having me. It was a pleasure speaking with you today.

[00:55:00] Bruce Bassi: As a reminder, if you’d like to support this show, one way you can help us is by subscribing to the channel on YouTube and leave a comment if you’d like.

It’d also mean the world to me. If you can share it with your social media network. Maybe there’s somebody out there who might be interested in the podcast. Hope to see you next week. Thanks a lot. Take care.

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Resources

General Psychiatric Management for BPD

https://pll.harvard.edu/course/general-psychiatric-management-bpd