Complex PTSD, Borderline Personality Disorder, and Diagnostic Validity with Dr. Mark L. Ruffalo

[00:00:00] Welcome back to Psychiatry Boot Camp. In today's episode, we are sticking with our seasoned theme on the future of psychiatry by discussing complex post-traumatic stress disorder, which is a diagnosis that is not currently in the DSM but is widely recognized on social media and discussed in academic journals and conferences.

We're gonna cover the validity of complex PTSD as a diagnosis and then discuss how to help patients that are experiencing this specific set of symptoms. My guest today is Dr. Mark Ruffalo, who is on faculty at the University of Central Florida College of Medicine and at Tufts University School of Medicine.

I have been eagerly following Dr. Ruffalo work for quite some time. It's an honor to have him on the podcast. Dr. Ruffalo is constantly publishing, I think, more than anyone I know. And if you're interested in learning more about this topic, we are going to drop a couple of useful links for you in the episode notes.[00:01:00] 

Um, on a personal note, uh, Dr. Mark Ruffalo is a primary reason he and my wife that I own a Greyhound. He posted a picture of his greyhounds on Twitter, uh, must have been five years ago now. And he said something about how they're beautiful, majestic, gentle animals and, uh, my wife has always had a pension for Afghan Hounds.

And so, uh, we compromised on a Greyhound because it seemed like a good dog for a psychiatrist if Mark Ruffalo had one. So thank you for that. Mark. Welcome to Psychiatry Bootcamp. And other than being a Greyhound owner, I will ask you to introduce yourself to our audience. Okay. Well, uh, that's awesome.

Thanks for having me. Uh, Dr. Mullen, uh, greyhounds really are great dogs for the listeners. Really, really gentle creatures and, and really cool animals. And so, um, you know, I, uh, I've done like eight podcasts this year and I promised myself I wasn't gonna do anymore. But then I got an email from Mark Mullen and I said, I gotta do this.

So, uh, so yeah, I, uh, went to, uh, grad school for social work. I trained at the University of Pittsburgh, did some psychoanalytic training, uh, after [00:02:00] that, uh, and I teach, uh, primarily psychiatry residents, uh, at the University of Central Florida. And also Tufts Medical Center. I tend to write a lot on psychodynamic psychotherapy, phenomenological psychopathology, history of psychiatry, and clinically I'm interested mostly in schizophrenia and borderline personality disorder.

You do tend to write a lot. You are difficult to keep up with, but your writing is always so engaging. So thank you for being so prolific and I'm honored about your kind words by the podcast. I'm happy to be your final podcast of 2025. Let's dive right in. So today we're talking about a complex topic, complex, PTSD, also known as complex trauma.

This is a term in psychiatry that is becoming more and more popular within the field and also among members of the general public. Do you remember when you first encountered the term complex? PTSD. And could you tell us about the genesis of this term? How did it come about? You know, I, uh, I trained in the late two [00:03:00] thousands and early 2010s is when I was in grad school right around the time the DSM five was being revised.

Uh, actually the, the chairman of psychiatry at Pitt was the chair of the DSM five task force when I was in grad school there. So I had like an opportunity to go to some of the grand round meeting grand rounds, uh, lectures and the like, while the DSM was, uh, being developed and, uh, revised. And so I don't think I had really heard the term complex trauma until.

Maybe five or six years ago. And then I think it came into the cultural lexicon. However, the, the term to my knowledge, dates to really the early 1990s, uh, with the work of the psychiatrist, Judith Herman, who proposed the construct of complex post-traumatic stress disorder as, uh, really an alternative to borderline personality disorder.

And so the idea really is, uh, quite old, at least 30 or so years old. Um, so it's not a novel idea. And people have been writing and talking about this for quite a while. [00:04:00] When I think of the diagnoses, the DSM diagnoses that relate to this topic, I'm thinking of borderline personality disorder, post-traumatic stress disorder, and then there's this sort of non DSM diagnosis that actually may ultimately be in the DSM at some point, which we're gonna talk about.

I'm gonna ask you just ever, so briefly for our listeners, could you paint a thumbnail sketch for me of borderline personality disorder classically and. Just PTSD classically, and then we'll dive into complex ptsd, TS D. Yeah, yeah. So, so borderline personality disorder. Um, uh, it really depends on the theorist that you ask, but, um, it's a disorder that is marked, uh, fundamentally by disturbance in interpersonal functioning and, uh, identity diffusion.

So, um, a very unstable sense of self, uh, trouble in interpersonal relationships, uh, marked by vacillating. Between idealizing [00:05:00] others and devaluing others. What, uh, Gerald Adler referred to as the need fear dilemma, which is basically a, a, a, both a need for and a fear of closeness with others. Uh, very turbulent and stormy romantic relationships, like I said.

Self-injurious behavior, other self-destructive behaviors. So, you know, the borderline, uh, diagnosis, this, you know, has a long history going back really to, you know, I think it was Adolf Stern who coined the term borderline in 1938 to describe, you know, patients who were not quite psychotic, um, but they were not patients who were well treated in psychoanalysis.

Otto Berg talks about. Borderline personality organization and a seminal paper in 1968, and it was John Gunderson with Margaret Singer in 1975 who publishes a seminal paper on borderline personality disorder. And that's sort of the, you know, we, we use the term borderline really in two different ways. Uh, we, we refer to, uh, borderline personality disorder.

That's what most of us know when we refer to the [00:06:00] DSM diagnosis. But, um, psychoanalyst in, in particular, object relations theorists talk about borderline personality organization, a, a broader construct, um, which is marked by identity diffusion, uh, a lack of coherence in one sense of self. I don't really know who I am.

I, um, have, um, just a, a, a really, uh, difficult time, uh, with, with a sense of identity. And so only 10% of patients with a borderline personality organization have borderline personality disorder. And so, uh, there's a lot of confusion around those things. So that's, that's a, a basic, uh, general overview on BP.

It's a tough question. You handled it really well, and I'm realizing this is gonna be a really tough interview and almost impossible interview because you're just leaving so many little threads that I could spend an hour, um, peppering you about. But that was wonderful. Thanks for being game for that question.

I'll ask you to gimme a thumbnail sketch now of classical PTSD. Okay. Yeah. PTSD is not really my area of expertise, but, you know, the, the, his historically went [00:07:00] by different terms, uh, war neurosis, battle fatigue, post-Vietnam syndrome. And then I think it was, uh, a, uh, social worker actually at the Veteran's Hospital in Boston who, who describes, uh, a syndrome called Post-Traumatic Stress Disorder.

It makes its way into DSM five nightmares, flashbacks, hypervigilance, avoidance, behavior, uh, avoidance of things that remind one of, of the traumatic event. And so a very, very, you know. Classic presentation thought, you know, at one point in time really to only occur in combat veterans and, you know, classically defined the disorder was required for diagnosis, the threat of, of loss of life or limb.

Um, so it had to be a major serious traumatic event. So, you know, the disorder is, is is very old. It's been described in the literature for, for a long, long time, but it wasn't until 1980 that it makes its way into dsm. Beautiful. Um, so borderline personality [00:08:00] disorder, a highly interpersonal problem that you might have.

I love the way that you discussed personality organizations versus personality disorders, right? We all have a personality. We all organize ourselves differently, have different ways to make reality less painful or make ourselves more effective at dealing with reality. Uh, and borderline personality disorder is.

Just 10% of people who have borderline personality organization would meet criteria for that. And then PTSD is something that is really kind of a whole different set of symptoms. You have that criterion A, the exposure criterion to life or limb threatening event. And then you have the avoidance symptoms, the hyper arousal symptoms, the negative alterations in cognition and mood and the intrusive symptoms.

You also mentioned the need fear dilemma in borderline personality disorder, and I am gonna ask a follow up on that. I think I understand the need fear dilemma. I think you described it really concisely there. How does that relate to this double bind phenomenon that you talk about? I'm [00:09:00] fascinated by the double bind.

Yeah. Yeah. So, so this is, this is really the, the bulk of my, my writing and my interest right now is, is linking classic communication theory, the work of Gregory Bateson and his colleagues in the mid 20th century with object relations theory. So a brief, brief summary in the 1950s, Gregory Bateson, who was an anthropologist writing with.

Don Jackson, Jay Haley and a few others formulate a double bind theory of schizophrenia in which contradictory communication in childhood results in the splitting of the psychical functions that results in schizophrenia. And the classic example that they gave was a little boy who goes up to his mother, tries to hug his mother, hug the, the mom backs away like she doesn't wanna be hugged.

The little boy releases his arms and then she looks down at him and says, what's the matter? Don't you love me anymore? She's simultaneously communicated to contradictory things. And so Bateson and colleagues argue that this type of communication, this type of pattern, it frequent enough in childhood would lead [00:10:00] to the development of severe psychopathology.

We now know that schizophrenia is far more complicated than a series of double bind communications in childhood. Uh, interestingly though, uh, a sizable percentage of people who were being diagnosed with schizophrenia in the 1950s were actually patients who have, uh, by today's standards borderline personality disorder.

And so I, I actually think that, uh, uh, contradictory, uh, communication is both prevalent when you look at the language used by patients with borderline personality disorder. And I actually have a, uh, a study that was just published with a psychologist that Austin Riggs, that shows that it patients with personality pathology may engage in ways that are consistent with double bind communication.

Uh, and I also think that, um, they may have experienced ENT trapping situations in early life. So the psychiatrist James Masterson, you know, he, he argued, uh, that, uh. Patients who go on to develop borderline personality disorder had some issues during a, a developmental phase, [00:11:00] uh, called separation individuation.

And so he said basically that, uh, it, it might be caused by, for instance, a mother who would communicate to a child, you know, I want you to do your own thing. I want you to be your own person and, and to become an individual. And then when the child would pursue. His or her own goals, uh, and, and adopt an interest that perhaps the the mother or the father didn't like, then love would be withdrawn.

And so this would lead to a vacillating in relationships to use Roy drinker's term, the person would vacillate like a yo-yo in interpersonal relationships, and we see this all the time in the lives of borderline patients, right? They vacillate back and forth between loving and hating people and in terms of closeness, their proximity.

Uh, in, in terms of their love relationships and other relationships, including the treatment relationship. And so I, I've tried to bridge this. I actually have a paper that is now under review with Gerald Kreisman, uh, who wrote, I Hate You, don't Leave Me In 1989. It's, I think it's, uh, [00:12:00] there's been a couple of additions since then, but, uh, just the title of that book, I Hate You Don't Leave Me, captures the Paradox of Borderline Personality Disorder.

And so, you know, it's long been, been recognized that there's something very paradoxical about the disorder. And so I'm, I'm, I'm attempting to sort of incorporate some of this older work on the double bind and paradoxical communication. Hearing you talk about these things, I'm kind of amazed at myself because I've had a lot of these conversations about similar topics and I don't get as effectively aroused.

But hearing these no win situations that these, let's say, young children are placed into where they truly can't win, um, there really is no way to both follow the instructions and succeed and get their needs met. And these children who have no real example of what clear effective communication looks like and reliable attachment figures feel like it's so painful.

I mean, I can my, that my, my. Hair is [00:13:00] standing up on the back of my neck because I can just not, my heart breaks right to be placed in that situation all the time. Um, so let's now take that thumbnail sketch of BPD and that little tangent that we gave there. And I, you did a great job cutting to the core of how that must feel for someone.

And let's take that thumbnail sketch of PTSD and let's place those to the side now, and I'm gonna ask you to paint now a thumbnail sketch of this concept of complex PTSD. So what is called Complex P ts D. So, I, I, I'm gonna begin by saying that I, I'm not necessarily sold on the idea that this is a, a valid, uh, construct.

And I, I, I'm sure we'll get into that, but you know what people are calling Construct, PTSD is some combination of classic post-traumatic symptoms that we see in PTSD and also some. Borderline person disorder symptoms with the key distinction of patients with C-P-T-S-D, [00:14:00] um, tend to avoid, uh, interpersonal relationships.

Uh, they tend to avoid them more so than patients with BPD. So patients with BPD tend to seek relationships. They, they tend to, uh, seek an ideal object that will solve, you know, their, their issues and their problems. Patients with. What, what, what people are calling C-P-T-S-D are more avoidant of relationships, but, but you see problems with identity.

You see, um, problems with, um, uh, self, uh, destructive behavior. You see interpersonal problems. You see, um, uh, you know, many, many of the, of the classic core borderline symptoms. And you also see symptoms of PTSD, uh, in this group of patients that people are now referring to as having, uh, complex P ts d. I think one of your initial points was essentially that there is no consensus definition of complex post-traumatic stress [00:15:00] disorder, whereas we have a very clear consensus on criteria for PTSD and criteria for borderline personality disorder.

If nothing else. I think both of us have our critiques of the DSM system. The DSM is. Relatively simple and easy to use, user-friendly, probably to a fault. Right. Probably a lot of the problems that most of us have with D sm is that the criteria are almost too easy to apply such that they can be applied in a wonton fashion and in areas where they may not be clinically useful or should not be applied.

Right. But we have those clear criteria in their DSM. Is that cor, is it correct to say that for ccp, PTSD, there really is no consensus criteria? Um, you know, I, I, I think that's, that's fair to say. Um, we can sort of get into my criticism of the DSM, uh, but I think, um, it's, it's fair to say that there's no, I, I don't think there's a universal consensus as to what really constitutes complex ptsd.

Yeah. Gotcha. So, um, in thinking about this. Concept of [00:16:00] CPSD, the best that we can understand it, the way it's currently being used in the vernacular. And I'll add that the VA has a webpage on complex PS, which I feel like gives it a certain level of, I won't use the word validity because that would be an improper use, but recognizability or, um, I'll just say clout, right?

If you have a webpage of the va, someone thinks that it's a serious phenomenon. How do you think that we should be picturing CPSD in relation to borderline personality disorder and PTSD? Should it be like a Venn diagram where someone can have either BPD or PTSD or maybe the middle where they meet is both?

Uh, is this a phenomenon where you should be able to diagnose all three? Should it be a diagnostic hierarchy thing? Um, and maybe you wanna reject this question entirely and just get into why you don't think CPSD is a valid construct at all. I think the best answer to this is we, we ought to allow the science to sort it.

I think we, we should take a step back and I, I wanna say [00:17:00] a few things just about validity and psychiatric diagnosis and, uh, I think there's so much confusion about this. And, you know, the, the diagnoses that we use in the DSM that, that are listed in the DSM, many of them are, are there because they're pragmatically useful, not because they have strong empirical validity.

So this really gets to all sorts of, you know, fundamental questions about what is a diagnosis, what is a disease in psychiatry. Um, and I'm just gonna briefly, you know, sort of talk about this because it's really fundamental to these questions about BPD and C-P-T-S-D. So in 1972, psychiatrists at Wash U in St.

Louis published a paper on establishing diagnostic validity in psychiatry Robinson Gze. And it became a very. Very, very well, well known and widely cited paper. And they establish a way of, of basically determining, is this a real illness? Is this a [00:18:00] valid illness in psychiatry? Because there's no biological tests in psychiatry.

And so we really can't, we can't really send anyone for an MRI or a blood test. And so they, they establish a way, a system for doing this. And there has to be convergence in terms of symptoms, symptom specificity, discriminant validity. Can the disorder be delimited from other disorders, genetics, and or biological markers, treatment response, right?

So if you have convergence and these are validators, then we can say it's a valid disease or a valid diagnostic construct. If you apply this, you know, in psychiatry you see that there's maybe 12 or 15 illnesses or conditions that really are valid disease states and, and probably the most well-known defender of this.

Uh, today is, is my colleague at Tufts Nas Iami, right? So in 1978. The research di domain criteria is published and it lists, uh, a handful of, of, [00:19:00] of valid psychiatric disorders. Two years later, DSM three is published and it lists 268, I think, different disorders. And there's a wonderful book written on this history by Hannah Decker at the University of Houston.

She's a historian and talks about really all the political compromises that were made between the biological people and the psychoanalysts and the fighting, and should we include neurosis and should we, uh, include homosexuality or excluded. And, and so a lot of what we have in the DSM really is political compromise.

It's, it's not, it's not as scientific as a lot of people think. And so I am a realist. Philosophically, I think we need to talk about what's real, what's valid. And so when I say that, I don't know whether. Complex PSD is a valid condition. I'm not denying the effects of trauma, and I think we're gonna get into this, but I'm not entirely sure [00:20:00] that complex PTSD has discriminant validity can be delimited from borderline personality disorder, whether it's really different from BPD and or BPD with some PTSD symptoms.

So, Mary Zini, who's a well-known borderline personality disorder researcher at Harvard, wrote a paper on sub syndromal borderline personality disorder, uh, which, um, which showed that these, these patients who don't meet full criteria for borderline personality disorder, but they have a sub syndromal condition.

Actually tend to avoid relationships. And so my, my thought, uh, and I have a, a paper that's about to be published in the Journal of Social Work with one of my old professors, Christina New Hill. What we argue that, uh, that, that what's called complex, PTSD may really be sub syndromal borderline personality disorder, comorbid with PTSD.

And so when I, you know, when I say, [00:21:00] you know, I'm not so certain that we're dealing with a valid construct. I'm not saying that trauma hasn't affected people and, you know, and, and that we shouldn't be trauma informed. Uh, I'm saying that I'm, I'm not sure that this is, that this is really a unique entity. We ought to recognize as distinguishable from what we already have.

Well, and uh, I, I think that's a fundamental point. I, I don't think we, we we're, we're not used to speaking in terms of validity in psychiatry and psychopathology. We're used to speaking the language of pragmatism, which is a point that Dr. G makes all the time. We, we've gotten into a, a sort of postmodern, you know, relativistic sort of mode where, you know, if, if it's helpful to give a diagnosis, then we give the diagnosis, but we're not really all that concerned about whether our diagnoses actually point to real psychopathological states that really exist.

And so I, I think, um, I, I think we've [00:22:00] gotta think a little bit harder about some of these things. That's a lot to chew on and you're giving a lot of threads to pull on there. I'm gonna. Go back to maybe one of the most fundamental pieces that you just shared and ask, what is the difference between validity in your mind, or shall we say discriminant validity from interrater reliability?

Because for me, one of the things that makes the DSM useful or that may DSM three useful, where its predecessors were not useful, is that interrater reliability. How does that relate to validity? Or does it. Well, the, the founders or the framers of DSM three wanted a reliable document because reliability in psychiatry was awful.

In the sixties and seventies, you sat two psychiatrists down in front of the same patient. They rarely agreed on the diagnosis, and if you sat a psychoanalyst down and a biological psychiatrist, they almost never agreed on the diagnosis of the patient. And so. And psychiatry was [00:23:00] starting to look a little silly with the Rosenhan study and some of the Antip psychiatry stuff with Thomas SAS and Irving Goffman.

And so they want, they needed to rescue psychiatry, and so they wanted a reliable document. What's the difference between reliability and validity? Well, mark, you and I could come up with a good definition of a unicorn. Uh, we could say it's a white creature that looks like a horse. It's got this thing coming from its forehead, and we could probably come up with, uh, with a good definition of a unicorn, and we could probably reliably agree on what's a unicorn and what's not a unicorn.

If we saw pictures of them. The problem is that unicorns don't actually exist in the world. It's not a valid construct. It's a reliable construct, but it's not valid. That's the difference is that, uh, a a lot of the diagnoses are reliable constructs, but they don't actually have convergence on, in terms of the diagnostic validators of.

Symptom specificity, discriminant validity is this different from other disorders, genetics, course of illness, which is ail, kreins, [00:24:00] contribution to psychiatry. Does this have a, does this have a unique course over time? And then treatment response. And if you have convergence on those validators, this was Robinson Gazes, great contribution, then we can say we have a, we have a, a real illness, we have a real entity here.

But if you have a disorder that we, you know, describe, but the symptoms can't really be differentiated from. You know, another disorder. We're really just talking about a subset of patients who have this other disorder. We're just labeling them, right? So I gave an example one time of like, if I wake up on Monday mornings and I don't want to go to work.

And I get, uh, I get transiently depressed, uh, before going to work on Monday mornings, but I'm also prone to depressions. Uh, and I've been prone to depressions throughout my life that are at least two weeks long. Let's just say I don't have a new illness called Monday morning Illness, right? I just have depression, right?

And so Monday morning illness doesn't have discriminant validity. It's not a [00:25:00] valid construct. And so I would argue that a lot of what we see in the DSM is the old term would be secondary. Uh, it would be secondary to, and, and this is a little off topic here for our podcast, but I think a lot of this has to do with the DSM not having a diagnostic hierarchy.

And so what we see is a proliferation of diagnoses and lots of patients being diagnosed with four or five different conditions. And I, I think that that's ahistorical. If you look historically. That was never really the case before DSM three. The idea was, um, you know, you, you give the patient a single diagnosis usually that, that explains their presentation and that doesn't really happen anymore.

And I think that's because we don't have a hierarchy and diagnosis. So we see patients who are diagnosed with a mood illness and anxiety disorder, a personality disorder, um, insomnia, and uh, and you know, and, and PTSD when they really may have a, a personality disorder. You've given us a lot to think about, and this is a bit of a tangent, but it, because at the core of, I mean today we're talking about [00:26:00] should there be a new diagnosis and what's their relationship.

So you have to have some understanding of these fundamentals in order to really begin having this conversation. So I appreciate you bringing us back there. And by the way, we're in charge so we can always rename the episode. Um, we're gonna take a quick break and when we come back, we're gonna pick up right where we left off.

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All right. Welcome back to Psychiatry Bootcamp. So Dr. Ruffle, you're talking about essentially you're indicting the whole DSM system here, right? You're talking about how there might only be, I think you gave the number 11 disorders [00:28:00] that have this discriminant validity that you're talking about. I'm left feeling like we are having a discussion in the realm of Plato right now that we're talking about these platonic forms of disorders, and I think I've seen very, very few patients that I could place onto a platonic form of a disorder, right?

People are complicated, and I think that's probably a part of the pragmatic approach to the DSM uh, larger 0.2. Would you agree then that let's say C-P-T-S-D were to be added to DSM six even though you don't think it should be? Would that be par for the course then in the current DSM system? Right? If we accept this pragmatic approach with 200 to 300, maybe we're gonna get higher than 400 someday labels that we can put on people and maybe someone meets criteria for 11 different disorders because they have a thousand different symptoms.

Um, would inclusion of ccp, SD and DSM six be par for the course for where American Psychiatry is right now? It would totally be par for the course. In fact, I, I [00:29:00] totally expect it to happen because DSMs a largely cultural document, and so I, I would expect it to be added. I, I would expect there to be a fad around C-P-T-S-D.

There already is a fad around C-P-T-S-D. And so, um, uh, yeah, it, it would be par for the course. I would expect it to become a very popular diagnosis, and I think it would have some consequences. What do you think those consequences would be? Well, um, you know, my, my real, my real concern is that if patients are misdiagnosed with C-P-T-S-D, when they have borderline personality disorder, they may be referred for or given inappropriate treatment.

I'm, I'm big on treatment selection, patient selection, matching the patient to the appropriate treatment In psychotherapy, it's not really taught very much in the psychotherapy world. Um. But I think what would end up happening most [00:30:00] likely is patients would be given a generic sort of trauma therapy and the core borderline pathology would be left untreated.

And I think that would probably lead to more problems in the long run. And, and I think frankly, it, it could lead to a, a, a reinforcing of, of some of the, of the problems of the borderline pathology. So, you know, when we think about borderline conditions there, there tends to be an externalizing. Defenses in essence are defenses that are used to, to blame others for the problems that exist in, in one's life and one's world.

I think a, a trauma centric formulation. Encourages that, which is certainly not to discount or downplay the fact that many patients with borderline personality disorder have experienced trauma. This is a complicated topic. I think we're gonna get into this, but I think that would basically be what would happen if this is added to the manual.

I think we have to consider [00:31:00] this very, very cautiously. Appreciate that. So shockingly, you're telling me that as a healer, you want to help people and not make them worse and not reinforce maladaptive problems and also not avoid problems. Right. I can see a world where giving the diagnosis that a patient wants, even if you don't think it's the right diagnosis, can lead, have everybody leaving the office with a smile, even though it might not lead to meaningful behavioral change and improvement for the patient.

Here's a question that I hope gets at, uh, what you're referring to here. I think there's a lot of patients, especially on social media and in my clinical practice and even just my friends, people that I know that would much prefer a diagnosis of C-P-T-S-D two, borderline personality disorder, all other things being equal, symptoms being equal.

People that I think just based on the. Just based on stigma, alone stigma reject that BPD diagnosis and clinging to the C PTs D diagnosis. [00:32:00] Why do you think so many people prefer the complex PTSD TS diagnosis to the borderline personality disorder label? Yeah, it, it's such a good and important question.

Stigma is a big problem with borderline personality disorder, and I think that it's complicated. I think often discussions of stigma are oversimplified. First off, I think the changing of a name is usually insufficient to deal with stigma. Gregory Bateson said, you know, the map is, the map is not the territory, and the thing is not the thing named.

I think part of the stigma, in fact, perhaps a large part of the stigma around borderline personality disorder is the result of the fact that patients with this condition can act in ways that are disturbing and troubling. To those around them. And so, regardless of what the condition is named, I think there will likely be some stigma attached to [00:33:00] the disorder.

Now, that's not necessarily a very popular thing to say, and I'll likely be criticized for saying that, but I do believe it's true. Beyond that though, let's assume that, you know, there is a proposal just to change the name of the construct we call BPD to complex PTSD. Alright, just let's just change the name, where we're talking about the same construct, the same symptom constellation.

Yeah. Let's just make people feel better. Let's just change the name. Let's take it out of the personality disorders chapter and let's put it in the, you know, uh, another chapter, the dsm, the trauma, uh, chapter of dsm. The problem with that is that what we call BPD, this construct is caused by. A variety of factors, not just trauma.

In fact, there are some patients with borderline personality disorder who have no history of trauma. And when you look at the empirical research you saw, you, you see that it's, um, a complex interplay of temperament, biology, [00:34:00] genetics and environment. Um, and in fact, the, the most important, uh, environmental variable is neglect, not trauma.

And so to flatten all of that complexity and just call it complex trauma is, is really, I think to do a disservice to the patient. And the disservice to the clinician because it, it zeros them in on only one of those variables. And so the research on personality disorders was really greatly influenced around the year 2000 with work coming out of Scandinavia by SP Torgerson who was working on psychiatric genetics and, and established the heritability of borderline personality disorders being somewhere between 40 and 50 or 55%.

And so, borderline personality disorder has a significant heritability. We don't talk about that. We just think of it as being an environmentally caused condition, but I tend to see it as a, as a disorder that is, uh, caused in part by biology and in park by environment. And, uh, John [00:35:00] Gunderson, who was the father of the borderline diagnosis, was very adamant on this point and would make the point that the child comes into the world with a temperament, with a built-in biology that might affect and shape.

How they were reared. And to negate that, to deny that, uh, as some theories do, I think is, is, is frankly unscientific and unhelpful. And so my problem with, with this framing is that it just flattens all of that complexity, just flattens it all. It may be more palatable to patients. It may feel good to have their experience validated, but I think there's a way to do that without changing the name of the disorder.

I, I think that you can be a very sensitively attuned, compassionate, empathic treater and believe in the construct of borderline personality disorder. And call it that. In fact, most, most experts, by the way, on, on [00:36:00] BPD agree that, that we ought to give the diagnosis, we ought to, we ought to tell the patient about the diagnosis.

And, and so, uh, I think that's important to, uh, to let listeners know about. And that's gonna be my next question for you is tips When actually having that conversation, when actually giving the diagnosis. I appreciate you. I I love that phrasing of simply externalizing the cause for a longitudinal pattern of behavior as being due to this external phenomenon.

It really oversimplifies an extremely complex behavioral phenotype that is influenced by inborn temperament. Yes, environmental factors, but also genetics and. Maybe a virtually infinite number of other, uh, influences that weigh upon someone through development. It was your work actually, that initially exposed me to the idea that people don't parent in a vacuum.

People don't, can't parent all [00:37:00] children the same way children bring their own. Style, their own personality into the world. And that is feedback to the parent. And that's a different substrate that the parent has to deal with. And I think it's just such an important point when considering how personality organizations develop in that bi-directional way.

I'll also say that I. And, you know, may I'm, I am sure I shouldn't even say this because probably more than half my listeners are gonna roll their eyes at this, but I think it's super brave of you to spend your career on this topic as an academic because this is not a topic that you specialize in. If you want to live a comfortable life laying on your chase lounge, petting your greyhound, and not worrying about the world, right?

Um, this is a really, this is a topic where people who are deeply suffering. Have very strong feelings about it. And I know from reading your work over years now, that you care deeply for these patients and that your intention in expressing your [00:38:00] feelings about complex PTSD versus borderline personality disorder is not to invalidate these patients or to push them further away from psychiatry.

And I hope, I'm sure you'd agree with me, that I think this is a failure of American psychiatry and the way that it's practiced. And our commodified, I think commodified is a word, corporate, um, capitalist economy where the incentive for people, if your incentive of an occupation is to make money. The way to make the most money in American psychiatry is to see the most patients in billing and complexity.

And so if you can do 60 10 minute appointments, let's say you can make a lot more money than taking 10. 60 minute appointments and you can help a, you can, you can see a lot more people and you probably help a lot less. And in fact, you might hurt because you're making people feel like they're nothing more than a list of criteria and that you as a psychiatrist are nothing more than a diagnostician robot and psycho-pharmacology [00:39:00] vendor.

And so I, I, I admit that in, in our environment right now, the way borderline personality disorder is treated and the way diagnoses are communicated, people have a reason to feel the way they feel, and we cannot blame them. I think you're pointing out there would also be risks to adjusting our diagnostic framework based solely on the fact that psychiatry is practiced so poorly in so many places.

Would you agree with that? I feel like I just put words in your mouth. Yeah, no, that, that, that's for really, really well said. Dr. Mullen. I approach these questions from a sort of empirical, scientific, sort of a, uh, you know, again, questions about validity, you know, standpoint, I understand that many patients who receive these diagnoses and, and have these issues, um, don't always get good treatment.

In fact, the treatment they receive is, is often very poor. Many patients I see are either put on a carousel of medications, misdiagnosed, given the diagnosis in a, in a very, [00:40:00] in a, in a way that's quite pejorative and demeaning. And so I can understand why there is resistance to this diagnosis. Now. Now that is to me a very separate question from whether the illness exists.

Okay. Um, those are two very, very different, uh, questions. One is, one is a scientific question and one is, is a question of how we should treat people and, and, and a, a humanistic question. Um, and, and I, I don't think that we should confuse the two. Um, if that makes sense. Totally. We've talked a lot about stigma, and I think stigma is always a challenge of making a diagnosis, especially one of these diagnoses, and I think that some critics would even take it further and argue that psychiatric diagnoses in and of themselves might harm a patient.

So just as an example, we can take a diagnosis of narcissistic personality disorder and say that when you're giving that. To a person who, um, has narcissistic personality disorder is experiencing narcissistic personality disorder, it might really [00:41:00] shred your therapeutic alliance with the patient and that can push them further away from healing.

So it's a very critical moment to making a diagnosis, especially when you have a strong suspicion that the diagnosis you make may not be met favorably by the patient, but you think that because you are tethered to reality and to providing the patient with treatment that you think can actually meaningfully improve their life, you need to make the diagnosis anyway.

How do you suggest providers approach this diagnostic conversation getting really concrete with us? Are there any clinical pearls that you can share with our listeners across the world about how to be successful in navigating this conversation? This is a, this is a great question. I already said that, uh, you know, the, the agreement is, is, is pretty wide on borderline personality disorder.

I've done some training in transference, focus, psychotherapy, vir. Virtually everyone agrees you should give the diagnosis, in my experience, if the diagnosis is given in a way that's empathic. You sort of, um, explain that there's a way to understand your [00:42:00] symptoms and your suffering. You know, we have a, we have a term that captures this.

There's been research that's been done on this, uh, type of condition. Most patients are, are, are more than accepting of the diagnosis. In fact, I, I don't think I've ever had a patient in my office here who has rejected the diagnosis of borderline personalities. Were. There's less agreement on whether the patient with narcissistic personality disorder should be informed of the diagnosis, uh, at least in the transference focused community.

So I'll tell you a little bit about how I introduce the diagnosis to the patient. I usually say something like this, uh, narcissism is something that exists within all of us. All of us have have some degree of narcissism, which is in essence self-love. Some of us have a lot of it. Others have, uh, less of it.

And like any human trait or condition, it exists on a spectrum, on a dimension. And so, uh, there are healthy or [00:43:00] normal levels of narcissism. Uh, and then there are levels of narcissism that seem to be unhealthy. They seem to cause problems in someone's life where, you know, the self-love often leads. To an inability really to fully love others and to care in a deep way for other people.

I think that maybe some of these issues, uh, apply to you. And so, you know, so, so what I do there is I sort of normalize narcissism. It's something that exists within all of us. All of us have some degree of it. It's just a matter of degree. Some people have a lot of it, and that's what Kornberg calls, uh, malignant narcissism where it's fused with, uh, psychopathy.

But when you talk about things dimensionally, especially narcissism, it, it becomes a little less threatening. And often you will see that the patient will agree with you that, uh, yeah, you're right. Uh, I can be very, very self-centered. And you're right, [00:44:00] I, uh, I do have a hard time really loving people. I tell people that I love them, but.

Um, you know, and, and so, uh, so if the diagnosis is delivered that way, I think, um, I think you can get the patient on board with treatment and they can take a hard look at themselves. And so, um, I think there's ways to, to deliver personality diagnoses, um, without coming off as threatening to the patient. I do sometimes wonder how, you know, because so much of the discourse on, on the internet is, is, is, is so negative about this.

But frankly, I, I, I don't, I don't think I've ever really had a negative reaction from a patient when I've revealed a, a personality diagnosis to them. And it doesn't mean that, that I'm some spectacular therapist. I, I just, I just do wonder sometimes about what, what is going on when, when doctors or therapists are delivering these, these diagnoses, if they're really doing it in a really authoritarian way.

I, I imagine that perhaps some of them are, so I have to have to question what's going on there. I think it's, I'll take the bait [00:45:00] there. I think it's a couple of things, and it's definitely one major reason why I started this project a few years ago. I think a, you have a enormous amount of training and, um, you committed to that training before you, uh, decided to treat patients independently.

And so that shines through. And, um, two, and this is really sadly simple, is you take the time, you're not delivering that diagnosis. And by the way, that was so beautifully said. I mean, I could feel, I could experience myself opening my mind to possibilities of ways that I might think about, um, how that influences my life, even though this is just a role play.

But, you know, it takes time to get to know someone. It takes time to develop rapport enough that someone who has a very set way of coping with reality might trust you enough and might feel like you could understand them enough to offer useful insight, especially when. Just so I just, you know, I, as a patient just so happened to be smarter than everybody else who is really stupid, right?

It's gonna take someone who takes, sure, [00:46:00] let's put a number on it, takes an hour with me and listens to my story. And I think it's impossible to deliver that diagnosis that you just gave if someone has not invested the time with the patient to get the patient's buy-in initially and feel understood. And so, I, for me, I think that just a function of time and the way our system is set up would be one major reason why that is so poorly.

Well, we'll say why the internet feels like that's so poorly done. Yeah. Yeah. I think that's, I think that's good. I, I, one other thing that, that reminds me, you know, I think, I think when delivering these types of diagnoses, I generally advise that it shouldn't be done the first time you meet a patient, unless the patient comes in and they have very clear symptoms.

And they say, I think that I have borderline personality disorder. What do you think? And you meet with them for an hour, hour and a half, and you get a good history. I might make an exception there, but, but, uh, when the, when the picture's unclear and you have a sense that, that maybe the patient is not quite ready to hear it.

I, I would wait until you have met the patient at least [00:47:00] several times before you, um, reveal the diagnosis to them. In psychodynamic therapy, you know, the evaluation stage of the treatment may be several weeks. It's, it's not just a single meeting with the patient. You may take several weeks before you even decide whether you wanna treat the patient, um, or refer them somewhere else.

So thank you for saying that. Yeah. I work on consults and so that's different. Having an hour with someone to psychodynamic psychotherapy. Reminds me of a phenomenon that happens a lot on our academic teaching service, which is a patient comes in having, uh, let's say, made some bad decisions and prioritized their relationship with a mood altering substance a lot more than their relationship with their occupation or the people who love them in the world.

And often I will have a learner open the DSM and read the criteria for personality disorder and say, Dr. Mullen, this person doesn't just meet these criteria. This person demonstrates every single one of these criteria for much [00:48:00] longer than the timeline acknowledges. And I have to admit that based on what we know about the patient, they're right.

But I also, I also point out that. In a way it's indistinguishable from a substance use disorder because it is their relationship with the substance that is driving these maladaptive personality behaviors. And so we don't give a personality disorder diagnosis usually on the first time I'm meeting someone.

I would say definitely when you can't distinguish that personality disorder from a severe substance use disorder. And I have a resident that is smarter than me. His name's Brett Silverglate. Shout out to Dr. Silverglate, and we were having this conversation on rounds and he said, Dr. Mullen. Kaplan Sadek says that actually something like 90% of people with, uh, who are diagnosed with what is, what did he say?

Something like, A large percentage of people who meet criteria for antisocial personality disorder no longer meet criteria for antisocial personality disorder when they stop using the opioids that they were using. And so I felt, I felt very ggl very good that Dr. Silverglate, um, compared my teaching to Kaplan and Sadek.

But I [00:49:00] think the point is that we need to take this label, take this diagnosis seriously, and be sure that we have thoroughly understood the patient and are getting to a valid diagnosis. I'm gonna ask you to, the way you delivered that. Narcissistic personality organization may be In that case, uh, the way you communicated that was really impressive for me.

And I didn't know actually that treatment guidelines recommend diagnosing borderline personality disorder, or that's the clinical consensus and, um, not necessarily narcissistic personality disorder. That's intuitive to me. I think I'm probably doing that, but I, I appreciate hearing an expert like you say that so clearly since the consensus would be that you should give a borderline personality disorder diagnosis, could you do that same thing for me?

Could you give me my borderline personality disorder diagnosis in a way that you think would be helpful to me? Yeah, yeah. I'll, I'll do my best. Uh, so, uh, I might say something to the patient. Um, I, I usually like to focus on their [00:50:00] relationship life because usually it's the case that the patient comes in talking about some important relationship or relationships or history of relationships.

So I might say something like. We've been meeting now for three weeks, and I've gotten a sense from you that you've had some trouble in your, in your love life. You've had some partners that you've had a lot of hope in that things would work out. And all of these relationships seem to end in a very rocky and stormy way.

Lots of ups and downs. And at this point, the patient's usually, usually, uh, nodding yes. Yes, that's right. Uh, my relationships are usually very stormy. And also it seems like your sense of who you are in the world is fluctuates. Some days you really, you know, really feel, you know good about yourself. You feel pretty decent in the world.

And then other days you, uh, you don't even know who you are. You, you feel lost, you feel empty. Other days it may feel like you don't even wanna live anymore. And it seems like, uh, you have a [00:51:00] tendency when things are going well, uh, in your relationships, you have a tendency to undermine your relationships.

It's been a lot of. Research in the past 50 years in psychiatry and psychotherapy, and we have a name for, for some of these problems. And, uh, has anyone ever diagnosed you before with, with anything? And, uh, a patient may say no. Um, they say, you know, have you ever heard of borderline personality sort? Maybe the patient says yes, maybe the patient says no.

If the patient says yes, I'll ask them, what have you heard? And then I, I usually explain, well, it's a, it's a complicated condition it seems, uh, to have its roots in childhood, but not always. Uh, seems to be some genetic component to it. But it's, uh, it's really marked by a lot of the symptoms that you have.

There's been a lot of research done on this in the past, uh, 50 years and especially the past 30 years. And the results are pretty good. So I, I always say something about [00:52:00] prognosis with borderline personality disorder. A lot of people don't realize, even I've learned, even psychiatrists, uh, who've, who've been in practice for years don't realize that the prognosis of borderline personality disorder is, is generally pretty good.

The natural course of BPD is improvement over time, and so you tend to see the worst symptoms in patients in their teenage years and in their twenties. By the time somebody's in their thirties and certainly by their forties, a lot of the core symptoms of BPD in terms of impulsivity and self-injury kind of burn out.

You still may see some impairment in occupational functioning and some impairment in relationships, but a lot of the worst symptoms kind of die out. And so, you know, I might say something, a patient that, uh. A lot of patients tend to get better over time. And you know, we've done, there's some studies actually that follow patients over 50 years and there are, uh, Michael Stone did a 50 year study of borderline patients.

And, uh, and so I'll, I'll, I'll tell them a little [00:53:00] bit, uh, about some of those, uh, some of the research that's been done, and then, uh, I'll ask them what they'll think about, uh, what, what they think about the diagnosis. And, and usually at that point they will say something like, uh, well it's, it's really helpful to know that there's a name for what I've been experiencing and that other people suffer like me.

That's the rule, not the exception. Uh, that, that's usually how it goes. Um, in my practice at least. Yeah, I think I've had similar experiences. I think you described really well. I think that's a pretty fundamental piece of the good psychiatric management for borderline personality disorder that was developed, I believe, by John Gunderson.

And I agree with you. Uh, I think it's a reminder to us that the internet is not reality as well. I'm gonna ask you kind of one final big question, and this is, um, it might hurt your heart as a therapist a little bit because I'm gonna ask you to like really live in an imaginary world with me and oversimplify a really complicated part of your job.

But that's sort of the magic of psychiatry bootcamp that I, I get people who are [00:54:00] smarter than me and know a lot about a topic and I ask them, um, really simple questions and kind of see what they do with it. So here's one. If you think about a repeated pattern of behavior that you see in borderline personality disorder, you mentioned the double bind phenomenon that comes to mind the most for me because I've read so much of what you've written about it.

But any repeated pattern of behavior that patients with borderline personality disorder exhibit after successful psychotherapy with them. What is a win for you? Like what is a major, let's say, self-defeating pattern of behavior that when you begin to see a change in that behavior over time, what does that specific behavioral change look like that would make you, as a therapist say, I have served this patient effectively and I can feel like I've done my best as a therapist?

Yeah, that's, that's a great question. I think the best way to answer it is to say that what I tend to look for are improvements in the person's interpersonal [00:55:00] life. If the person starts to demonstrate greater stability in their love relationships and no longer seeks unconsciously to destroy love objects if they seem to be able to tolerate aloneness.

This was, this was Gerald Adler's. Great contribution to understanding borderline pathology. Gerald Adler was a psychiatrist in the seventies and the eighties who wrote a lot about BPD and his, his major contribution was that, um, borderline patients suffer from, uh, a deficit. Uh, they're unable to hold and soothe and comfort themselves when they're alone, and so they rely inordinately on other people to hold and soothe and comfort themselves.

They can't tolerate the, the feeling of being alone. And so when I noticed that the patient is able to go longer periods of time being alone without feeling so compelled to reach out [00:56:00] to someone, including myself, I think that that's usually a good marker. How well the patient is doing. You know, I, I don't do this because I, I I, I tend to, to practice these days more from, uh, sort of an object relations perspective.

But, but Dr. Adler, when he would go on vacation, he would actually send his patients a postcard. You know, he would write, uh, you know, I'll see you. When I returned Dr. Adler, the idea, you know, he was, he wasn't just being nice. The, the idea was that the patient would get the postcard and would have sort of something to, to look at that reminded them that Dr.

Adler existed in the world. This gets back to object constancy. Object permanence, right? And so borderline patients have a hard time holding people in their minds when they're not present. And so, you know, Adler's idea was that by doing something like this, the patient might be able to retain his presence in their mind while he was absent.

And so, but nonetheless, I, I think when the patient's able to tolerate. Being alone for longer periods of time. John [00:57:00] Gunderson wrote a paper actually in 1996 on this as well for those who wanna look at that. But, uh, that's, that's usually a good marker that the patient's getting better. That's a wonderful response.

Thanks for being game, for taking that on. And I know it's, it's just asking you to oversimplify something that can be impossible to achieve with patients. And I'm asking you to gimme an outcome without sort of telling us how to get there, because that would take years of psychotherapy to learn. Um, but I think that's, that's just beautiful and a really clear, uh, I, I hope that people listening to this who are experiencing these symptoms are able to imagine that goal for themselves and take some concrete steps toward.

Having that for themselves. Dr. Ruffalo, you've been really generous with your time. Thank you for making me your final podcast recording of 2025. Thank you for all the kind words. Thank you for the Greyhound recommendation and the general writings that you've done over the years that I've been privileged enough to enjoy.

Do you have any final thoughts for our psychiatry bootcamp audience? [00:58:00] Um, well first off, thanks for having me, Dr. Mullen. It's great. I love, I love your podcast and I'm, I'm really, uh, happy that we've connected. I think my, my final, uh, advice to psychiatry residents and medical students that wanna go into psychiatry and psychotherapists is, is read more history of psychiatry.

You'll learn so much by reading about the history of the field. You learn about why we use the diagnoses that we use about how the pendulum has swung back and forth in the history of psychiatry about how ideas come and go and how seemingly new ideas are really old ideas that have been recycled. And so read more history.

That's my advice. We'll just leave it there. We'll drop the mic. Thanks so much, and, uh, we'll move into our outro.

Thanks so much for listening to this episode of Psychiatry Bootcamp. Our guest today was Dr. Mark Ruffalo, and you can connect with Dr. Ruffalo on X at Mark l Ruffalo. If you love the show, we wanna know what you think. You can leave us a review on Apple Podcasts or a rating on [00:59:00] Spotify or Apple Podcasts.

You can contact me directly@psychiatrybootcamp.com. You can connect with the show on Instagram at Psych Bootcamp on TikTok at Psych Bootcamp, and you can connect with the rest of the Human Content Podcast family on Instagram and TikTok at Human Content Pods. Shout out to all of our great listeners for leading wonderful feedback and awesome reviews.

If you subscribe and comment, we are going to feature some of those comments and reviews on future episodes of the show. So you might hear your own Words on Psychiatry Bootcamp. Full episodes of the show are now available on YouTube. We also have video up on Spotify, and of course you can find us wherever you get your podcasts.

Thanks again for listening. I'm your host, Mark Mullen. Our episode was outlined by one of my wonderful medical students, Julia Palacios, and Season four was produced by another wonderful medical student. Matthew Braddock, executive producers of Psychiatry Bootcamp are Aron Korney, Rob Goldman, Shahnti Brook, and me Mark Mullen.

Our editor and engineer is Jason Portizo Arthur. Theme music was generously donated by a [01:00:00] favorite band of mine. Cave Radio. Find Cave Radio on Spotify. Our music is by Omer Ben-Zvi. To learn more about our program, disclaimer and ethics policy submission verification and licensing terms, and our HIPAA release terms, go to psychiatry bootcamp.com or you can contact us directly.

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