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Aug. 30, 2021

How Borderline Personality Disorder Tests Work

How Borderline Personality Disorder Tests Work

Borderline Personality testing can clear up the confusion between BIPOLAR and dependent personality disorders. This episode we discuss BPD symptoms and treatments.

The hallmark trait of this diagnosis is an intense fear of abandonment. People who struggle with borderline can often become quick to anger, as well as experience rapid mood swings.

This episode is sponsored by BetterHelp. Receive 10% off the first month of therapy. 

Show Highlights

Borderline Personality Disorder

  • Borderline Personality Disorder Traits
  • Understanding BPD Tests
  • Interview with Dr. Corey Nigro
  • Stigma Associated with BDP
  • CBT vs DBT Treatments

Borderline Personality Disorder Symptoms


Borderline Personality Disorder is today’s show topic. I’ll be joined by Dr. Corey Nigro, an expert in the field of diagnostic testing. You know, I'm very excited to have him on the show today because right now in this current social climate, every therapist I know is booked full and unable to see new people. My goal with today's show is to shine a light on borderline personality and remove some of the stigma that's associated with it. Remember folks, you can read all kinds of great, interesting articles on mental wellness. 

Episode sponsored by Better Help

Treatments for Borderline Personality Disorder

You know, over the years, I've had the opportunity to be a therapist for both men and women who struggle with borderline personality. In my experience, most of them have this very intense, very extreme fear of being abandoned and just couldn't fathom the idea of being alone, not even for just a short period of time. Some of these people and not all just the slightest notion of rejection or abandonment can lead to an intense acting out episode. Let me give you an example of what I'm talking about, of what I've commonly seen. Let's say, for example, someone who is struggling with borderline personality disorder decides to send a text message to their partner in the middle of the day. For whatever reason, this partner can’t quickly respond to that message, perhaps they're at work or they're in the middle of doing something. For a person with BPD the fact that the partner didn't respond fast enough can be perceived as a total abandonment and cause the person to become very, very angry in a short period of time.

In my experience-the person with borderline has these automatic thoughts, which tell them that they've been rejected, and it happens fast. Now everyone is different, but this is just one example of how hard it is for people with borderline to handle distress tolerance. You might be wondering, what is distress tolerance? It's basically a clinical term that essentially means the ability of a person to experience feeling uncomfortable and everyone has their own threshold. to make matters more challenging. A lot of the patients I've worked with would come to my office with their own self-diagnosis before we even started therapy. For example, many of my patients would tell me that they thought they were maybe codependent, or they were suffering from anxiety or depression. And while all those symptoms were there, somehow along the way, they'd never been evaluated for a personality disorder. 

Understanding Personality Disorders

Having said that just because someone is codependent doesn't mean they automatically have borderline personality. It doesn't work that way. Likewise, just because someone gets mad when their partner doesn't respond fast enough to a text message that also doesn't automatically mean that they have borderline personality disorder. With that caveat BPD has a lot of stigma around it in both the general population and unfortunately, in the mental health world. there just needs to be more education about this subject, because I think it's getting in the way of people getting help. I have to tell you that sadly, there is many individuals out there right now at this very second that are telling themselves that they are so severely broken or so badly damaged, that they can never get better.

And I want you to know if you're thinking that to yourself right now, it's simply not true with the right treatment and a willingness to do the self-work you can feel better. You can make progress in your life, even if it seems slow. Things can definitely get better. Now, before we get started with the interview with Dr. Nigro, here's just a little bit of information about BPD before we get started. Borderline personality disorder is one of nine personality disorders in the DSM five. If you're new to this show, the DSM is the diagnostic statistical manual of mental disorders. And it's what all clinicians use to make a diagnosis. 

High Functioning Borderline Personality Traits

As a therapist, I've noticed that people who struggle with BPD have the following characteristics, not all of them, but these are just a few. Number, one poor self-image. They can't seem to recognize their own self-worth because it's dependent on someone else. I like to call it this kind of imposter syndrome. Number two, difficulty directing decisions for themselves. It's hard for these people to make their own decisions about their lives. Number three, impulsive and self-sabotaging behaviors like destroying relationships before the other person can hurt them. Number four, intense and often fast mood swings, number five, feeling emotionally empty or quick to anger, especially when there's this kind of sense of rejection. Number six, paranoid or irrational thoughts when stressed. Number seven, fear of abandonment and that's the big one. Maybe that's the biggest one on this list of characteristics and number eight unstable relationships. 

All right, you have some of the characteristics of BPD, and I'm just going to tell it to you straight. In my opinion, that term borderline is way, way outdated. It should be replaced. Here's why, the term borderline was first used in 1938 as a way to describe people who were on the borderline of treatable, neurosis, and a psychotic disorder known as schizophrenia. But things have changed an awful lot since the 1970s in the field of mental health and a lot of therapists, including myself, believe that the term needs to be replaced with something more accurate. none the same, that word borderline or the term borderline personality is with us, at least for now.

Borderline Personality Movies and Media Depictions

Now maybe you've seen movies about people with BPD, like "Girl Interrupted" with Winona Ryder and Angelina Jolie that was a great one. Or the 1987 thriller "Fatal Attraction" with Glenn Close. While these movies were really good they don't really get down to the nuts and bolts of borderline. In fact, there's a lot of misinformation out there on the subject. And again, I want to use today's show to help educate people with facts. If you're listening to this show on apple podcast or iTunes, please do me a favor and leave a review. I guess the more reviews we have, the more the show is shared with the algorithm, and then it comes up better in the search results. 

Okay, let's get onto the interview about borderline personality disorder. My guest today is Dr. Corey Nigro, just a quick disclaimer before we begin. This show is not a replacement for mental health counseling and I'm not your personal therapist.

Interview on Borderline Personality Disorder Testing

Hello, Dr. Nigro. It's an honor to have you on our program today. I listen to your show all the time. Can you tell our listeners a little bit about your background and about your podcast?


Sure. Nice to talk to you, Frank. My name is Dr. Nigro. I am actually originally from Chicago. Still consider my hometown. I ordered a little Mel noughties and have bona beef shipped out and Portillo's. I am a clinical neuropsychologist and I focus primarily on diagnostics, full neuro-psych evaluations and I tend to be overly anal when it comes to testing because most neuro-psych evaluations are 10, 12 pages minor 60 to 150 depending on the complexity of it because in doing diagnostics many people that come through the door are underdiagnosed, over diagnosed misdiagnosed. And it's not really because anybody is making a mistake. I think this is where managed care gets to be problematic. You know, doing therapy, you get 45 minutes or an hour and you have to come up with a preliminary diagnosis to bill insurance.

About Personality Disorders

My wife is a psychiatric prescriber, and she does our podcasts well, which is called psychology unplugged. We talked about just a variety of topics I do it on Sundays. She does some with me we do sometimes I just do it on my own. A lot of people that want to come on the show for a variety of reasons, but the whole premise of what I do is what it comes down to is my job is to figure out what's wrong. And that's what testing is basically designed to do. It is not designed to figure out people's strengths. It's not designed to figure out or really be able to delineate why it can tell you what. It can tell you what with such specificity, that I could be seeing somebody in therapy for two years and there was no way I would be able to know or understand the complete psychological architecture of individual without having the nuances of the testing. Especially when you get into tests like the war shock or the thematic apperception tests and even the MMPI. 

Cognitive Behavioral Therapy

So I I'm a staunch proponent in, a philosophy that I espouse, which is I think therapy and medications without testing is very similar to surgery without an x-ray. And this is the vehicle that I would strongly encourage anybody struggling with mental health to really get the diagnostic clarification, because it's only going to help your therapist and help your prescriber in customizing and enhancing your treatment plan.

Okay. Thank you for answering that. So everyone, when you get a chance, make sure you check out psychology unplugged because it's a great show. I listen to it myself. So Dr. Nigro, now I have some experience working, with patients who have borderline who've been diagnosed at least before they even came to me. And I wanted to ask you, why do you think there's such a stigma around this diagnosis in both like the general population, but even amongst mental health providers?

Why is Borderline Personality Disorder Misdiagnosed?

 Because people don't understand it. It's interesting. I look at the analytics from, all the episodes I've done so far, and I don't necessarily know the answer to this. The episodes I've done on borderline have been the most popular. They're the ones that I've gotten the most calls on, and, you know, I'm very humbled and for the grace of God, I got people flying in from all over the country to have me do neuro-psych evaluation on them, to see if they have borderline personality disorder. And I'm just a voice on iTunes or Spotify. There's also a stigma around personality disorders that a lot of mental health professionals don't understand. 

Personality disorders except for antisocial personality disorders, nowhere in the diagnostic manual does it say that they cannot be diagnosed before age 18? And a lot of people, I have diagnosed kids with personality disorders. Personality theory, the personality if you break it down it's really my belief about myself, my belief about other people, my belief about the world in general, and the conclusions and the therefore that I draw that's personality. So a lot of people say, I don't want to put a label they are only 11. Well, I think you're doing a disservice if they meet the diagnostic criteria letting them walk around. It's almost like letting them a personal walk around with cancer saying, you know, I can't treat you for another five years until you meet this age.

Psychology has this demarcation. Like if you look at PJ's model, you know, you go through a sensory-motor, pre-operational, concrete-operational leader, stages of cognitive development. And then, you know, at 12 years old, you just don't open a box and all of a sudden you have formal operational reasoning. They're able to think at a higher cognitive level. So the media has done a very poor job in terms of depicting borderline personality disorder labeled as crazy. It's often confused with bipolarity you can't have both. One is a pharmacological treatment that bipolarity, whether that's bipolar one bipolar two, or a cycle seismic disorder, which is where you don't meet the full criteria for a major depressive episode or the full term criteria for a manic or hypomanic episode. 

Related: 5 Histrionic Personality Disorder Traits 

BPD Testing

So there a is high comorbidity, but the testing is able to delineate that. And again, borderline is a therapy modality. Bipolar is therapy, obviously add medication to stabilize the, fluctuations in what we call like mood lability.

Okay. And, you know, to follow up on that, what do you think Dr. Nigro, do you think that people are born with this borderline personality? Or do you think that it's some kind of trauma that happens and it develops.

No People are not borderline- we're born with what's called a temperament and the work of Thomas and Chess temperament is our biological predisposition to reactivity. So if we just kind of use arbitrary numbers say I'm born into the world with a temperament of 60. And Frank is born into the world with a temperament of 80. A certain situation happens or certain stimuli it only goes to a magnitude of 40, neither one of us are going to respond. If a stimulus gets to a magnitude of 60, I'm going to respond Frank isn't. If it gets to a magnitude of 80, we both respond. So that's our biological predisposition. 

Related: 5 Ways Cheating Husbands Cause Anxiety 

So personality in terms of borderline, the hallmark criteria is intense fear of real or imagined abandonment. And it manifests really, in insecure attachments early on in childhood. And they could be idiosyncratic, It doesn't always have to be a parent. It could be a friend where a person that has actually perceived some type of loss and a realization that people do leave.

BPD Characteristics

Yes. And, you know, I've noticed with working with, my own patients with borderline that they've come in and they've actually said to me, they sort of self-diagnosed, oh, I think that I have dependent personality, or I have general anxiety or even have depression. And my question about this is why is it that people who struggle with borderline personality experienced such high anxiety?

Because They are so emotionally dysregulated. they lived their lives as chameleons because they give the keys to the universe. They give the keys to their self-esteem, to other people, and it's a constantly, it's a perpetually living a life of psychological survival. And there's a level of anxiety because you're constantly gauging what are the reactions of other people and borderline personality and dependent, even though there are two different clusters are incredibly similar. The differentiating factor between borderline and dependent is dependent doesn't have anger. It doesn't have the- because they're so afraid of that other person leaving they're not going to lash but borderline will. 

Related: Why Dating Apps are Bad for Guys

I'm not meaning to like reduce people to a specific label just for the sake of conversation and explaining it because in with borderline personality, same with major depressive disorder, there are 120 combinations of these disorders. So you have to meet five out of nine criteria. And the statistical combination is five times, four times, three times, two times one is 120. And again, the advantage of testing is to be able to delineate with such specificity. How does, if you have borderline, how does it manifest in you? And people think that anybody who cuts, they have borderline only 40% of people with borderline personality cut 60% don't. And I see so many people that therapists like jump on that cutting, I think you have borderline, that's not true.

Exactly. I experienced that when I from other therapists or in consultation groups they think that it has to be cutting, but that's not necessarily true. And with some of the people that I've worked with in the past, I mean, some of them are very high functioning would never even think in a million years. And I've noticed that they can't see their own value, their own self-worth. It's almost as if they're getting it from others some how.

They have none, their self-worth is dictated by the reactions of other people. They live their lives at the behest of the reactions or perceived reactions from other people, because the whole goal is what borderlines do we kind of call them the mercurial styles. There are dysregulated thermometer, and why borderline has the highest success rate of treatment. And I've said this in my own podcast, borderline personality disorder can be cured.

I was going to ask you about that. Dr. Nigro how is it treated? I know there's different modalities. I've actually heard you and your wife, Julie, sort of have a little banter back and forth about-

Dialectical Behavior Therapy (DBT)

My wife and I have different perspectives. She went to a mass general, which is a part of Harvard, and McLean, which is Harvard or mass general, psychiatric hospitals in Massachusetts. And they have a dialect behavioral therapy model. I am not a proponent of dialect behavioral therapy at all. I was trained by the experts in cognitive behavioral therapy. And there's a reason it's an and emotions are a huge part of DBT. And everybody thinks you have borderline personality and need DBT. My philosophy and perspective is there's a reason it's not called cognitive behavioral emotional therapy. It's called cognitive behavioral therapy because everything starts with a thought which leads to emotions and behavior, which thoughts lead to behaviors and emotions are just the by-product of it. 

The model for DBT was predicated to be done on an inpatient unit. which I think is great that you would have 24 hour access to a therapist If you have thoughts of self-injurious behaviors, thoughts of suicidal ideations. I think that's a phenomenal model and it does work really, really well. On an outpatient basis the Massachusetts there are groups popping up all over the place. It's so focused on emotion. And the best way I can explain the difference. DBT is about helping you to learn how to accept who you are. Cognitive therapy is about changing who you are.

As you said, because it starts, everything starts with that initial thought.

Right. And DBT goes to the emotional piece, which I just think, you know I say this to people. I said, I don't care about your emotions, but, I do I care from an empathic standpoint, but we're not going to focus on that because that's just the by-product, what are you thinking? Or what are you doing? That's resulting in you feeling this way and working with borderline there's so much emotional dysregulation.

Exactly. That emotional dysregulation and they have a low distress tolerance level. So Dr. Nigro, a moment ago, you said you've seen that people with borderline can be cured, but that's not an overnight process right? That takes self-work.

It takes work. It takes a few years. You know, people will come in with depression, anxiety, and I kind of explain if there's a personality disorder, the depression, the anxiety, the panic, maybe the OCD. Think of those as the branches, you got to treat the root system, which is the personality. You have to treat that. And the others start to dissipate and borderline is generally medicated like bipolarity. And there's a reason, you know, Julie will say all the time, you'll constantly hear people tmy meds, aren't working, my meds, aren't working. They're not going to work because it's not a neurochemical issue.

Dr. Nigro, are you finding out in your area out there in Massachusetts for here in Chicago pretty much every therapist, including myself is booked full. We have no openings-

Oh same here.

Is it the same there? Okay. Because I've also tried to refer to some of the people I work out, just to groups, even just a men's or a women's group, just for some kind of support there isn't any. Now I think I heard you mentioned on your own show that you've started maybe the first-ever deep borderline group.

Julie and I do it We started a cognitive behavioral therapy group on Wednesdays I've tested the individuals in the group. So I have I see them all individually for therapy. I mean, there's the one disorder I always enjoy treating was trained very gratefully trained very strongly in that. And the group has been phenomenal, but, you know, they all know my perspective if we were not, you know, not talking about emotion or changing thought patterns. So, you know, start starting with a small sample, but it's the same here. Like I used to be able to text my colleagues like sending you Joe Smith for therapy or to my colleagues who are prescribers sending Amanda, no one is taking any new patients.

Exactly It's the same here.

So, I mean, I've been doing, you know, for the grace of God, I'm doing two full neuro psych evals a day, six days a week. It's just, the waitlist to get, to see a neuropsychologist. A lot of like larger organizations is they're until like 20, 23, 20, 24 it's and a lot of the prescribers and therapists aren't even taking new patients. They don't have waitlists.

That's the case for myself and the other therapists that I know. Dr. Nigro one last question here, and I so much appreciate your time. On one of your episodes. I believe you described borderline as maybe going into the darkness or spending time into the darkness. Something to that effect, can you get-

In the space, I'm a huge Springsteen fan our house is, I've been collecting Springsteen a lot of different musicians, autographed guitars. So I did an episode called like a borderline personality treatment the space I use a Springsteen titled the darkness on the edge of town. And this is really the crux of treating borderline personality disorder is the space. First, let's go back to why people change. There's only one reason people change and it's not because they want to. It's not because they have to. It's not because a judge is telling them, a spouse is telling them, a partner or a probation officer, a good friend, people only change when they're uncomfortable. If you think about adjusting yourself in the chair you go from a state of perceived discomfort to a state of perceived comfort. From a psychological psychiatric standpoint, until you get to a place of saying, I'm tired of thinking, acting and feeling this way, that's the necessary ingredient for any type of change to take place.

So I did this episode and I use this with my patients called the space. This isn't a clinical term. It's just something I tend to use as a, I use a lot of metaphors working with patients. So the space is really, if you're a Seinfeld fan, think of this as like opposite George.

I remember that episode.

Doing the opposite of what you are inclined to do. So for example, if that space is I am- So if you just take abandonment for an issue and I text my boyfriend and he doesn't text me back, I start just texting just shooting, text one after the other. My recommendation is, can you, can you hold off one minute? Can you just stand in that space of distress tolerance for one minute? And if you go ahead and shoot your texts celebrate that one minute. Celebrate the fact that you were able to be in that uncomfortable spot and realize, look at the evidence that you didn't fall apart, but that you were able to get there and to  celebrate, the small successes.

I think when you make goals, especially with the personality disorders, so grandiose and so big, like, well, don't text him, you're setting the person up for failure. It's like getting into a swimming pool, the hotel that, you put that one foot in the water, the goal is to get the whole body in the water, but we don't do that. I'm sure that, there are some people out there that's going to jump in, but you know, the analogy is you're going to get in the water and realize I'm not freezing.

If you can stay in that water for a while Great. If you feel you need to run out that's okay. Celebrate the fact you got into the water, into that space that was uncomfortable. That's breaking those old neuronal connections and building the new ones. It doesn't mean you may not go back to old patterns because personality is so ingrained. But until you start changing the thought patterns and the behaviors, you're not going to engage in those uncomfortable things. And that's okay. And you have to kind of, you know, kinda give yourself credit for it because it's scary and it's uncomfortable. You don't want to do it, but you're also at the same time, like, I don't want to live like this anymore, but that's where the work comes in.

It sounds a little bit, just a little bit in the sense of, for example, I'll work with patients who are with borderline, and they also drink a lot to self-soothe. And if we can get them to drinking one beer instead of six beers at night, that's progress. That is-

The term we use, like harm reduction. 

Exactly. Yeah. There's some harm reduction. So I liked that being in the space for a little bit. And then if you have to move out of it, that's what you do, but there's still progress.

Yeah. And you know, if it's one minute, great, if you could increase it to five and then they start to feel like I have more power. And then-, you know, there's two things. If you asked my patient, what does he always say? Pay attention to your motivation and look for the evidence. So the evidence is you didn't text him and you didn't fall apart. And don't punish yourself. If we're just kind of stick with like abandonment is just an example of that.

Exactly. Where they had that, as you said, this catastrophic thought that they're going to fall apart and then they last ike you said, a minute, two minutes, five minutes. And they realize, Hey, I didn't fall apart in there it's the evidence. Maybe I can do this another minute. 

Absolutely. Just building on those small successes. And I usually recommended, you know, starting off, maybe not in your most intense relationships, but kind of practice of maybe more your peripheral ones where, you know, it still bothers me, like maybe a good friend, doesn't text, you start with those. You're less likely to have the extreme, emotional distress versus like, you know, your steady boyfriend, your steay girlfriend, where there's a high degree of emotionality. I recommend like, kind of go on the periphery and practice where you may be a little frustrated, but you're less, probably you will stand in that space a little longer.

Absolutely. And so Dr. Nigro, before we finish today, can you tell our listeners how they can get a hold of you If they have questions?

You can get ahold of me through psychology today. You can get ahold of me through our podcasts I will even give you my cell phone number (617) 750-9411 Eastern standard time. So in Duxbury, Massachusetts, which is kind of like the south shore, Massachusetts kind of like the north shore of Chicago, the Highland park, that kind of stuff. So it's a different clientele, but you know, Julie asked me at one point, you know, talk about prevalence rates. And I said, I'm not sure I agree with the prevalence rates in the current DSM given with the pandemic and how many people have, the influx of telehealth. I think the prevalence rates would be, are going to be significantly higher for a variety of disorders. So telehealth is definitely here to stay. It's a, you know, I've seen some interesting and to doing telehealth, cause I'm sure Frank, you have. If you see people in their almost like, you know, dad walking around in his tighty whities and mom smoking a cigarette in the corner I'm thinking, no wonder your kid is acting up like that.

Absolutely. And you know it's interesting in a way, because I've noticed, so somebody, for example, has just say a baseline of anxiety or depression with the pandemic it increased that feeling that emotion 5 times ,10 times, because you were isolated

Especially with, kids because they have so little outlets. So, you know, as adults, even there wasn't much opening you know, we could jump in the car, go for a car ride, maybe go to Starbucks. You know, so a lot of kids have really gotten into substance abuse, you know, highly sexualized behaviors because they were on the internet, nobody was learning anything. You know, kids would log into the zoom class, you know, mom and dad are working at home. And then, they log out at 2:45 and God knows what they're doing. But it also, I think it brought a lot of people were this influx into the mental health system because we all had to live with each other.

Couples had to live with each other and start to see those things that traditional, you know, dad goes to work, mom, those work kids go to school, we have dinner, you stay in a routine now everybody's together and now you're starting to see what your kids going on to now, you're starting to see, you know, you're having that communication. So a lot of my colleagues are dealing with a lot of couples issues. A lot of kids, you know, kids who really struggled were kids with autism who lost like in-home behavioral therapy services, you know, the goal in Massachusetts is, you know, combining two years of education into one year.

Sure absolutely. Absolutely. For a lot of, as you said, kids, it didn't the online modality didn't work. For example, I have a four-year-old that was in preschool when we put the computer in front of her, she literally did a hand stand on the computer and she, was like, Nope, not doing this. 

For the grace of god we were able to work in mental health through the pandemic, but it was really challenging. You know I at least know from my colleagues, like, especially with kids getting them engaged, you know, and also if they're home with their parents there's issues with their parents, they don't really want to talk about it.

Well, that concludes my interview with Dr. Nigro from psychology unplugged about borderline personality disorder. I just want to mention that there seems to be a difference with a lot of therapists between providing CBT or cognitive behavioral therapy and DBT dialectical behavioral therapy. As for me, I'm sort of eclectic. I enjoy doing CBT with the patient, but if needed, I will refer them out to a DBT group. So, everyone's a little different, whatever works for the patient that gives tangible results.

Well, that does it for today's episode of the anxiety therapist podcast. Remember you can reach me directly by going to the website @anxiety From there you can follow on social media, or you can even leave a voicemail once again. Thanks for tuning in and look forward to sharing more episodes with you in the future.