Interview with Dr. Suzanne Wallach, DBT Specialist on Narcissism vs Borderline and the Signs Everyone Gets Wrong

Dr. Suzanne Wallach’s conversation with Dr. Thais Aliabadi and Mary Alice Haney deals with serious mental health topics, including personality disorders, self-harm, suicidality, trauma, and emotional dysregulation. If these subjects feel activating or overwhelming, please pause and seek support from a qualified mental health professional or local crisis resources if needed.

We hear words like narcissist, borderline, bipolar, and gaslighting constantly now. They get thrown around in relationships, on social media, and in everyday conversation, often without much precision. That creates a lot of confusion, and honestly, a lot of harm.

So we wanted clarity. What is actual narcissism? What is borderline personality disorder? How do trauma and childhood environment shape these patterns? Why are women so often mislabeled? And what does real, effective treatment actually look like?

To answer all of that, we sat down with Dr. Suzanne Wallach, a specialist in Dialectical Behavior Therapy, or DBT, for a nuanced and deeply practical conversation about personality disorders, emotional regulation, relationships, parenting, and recovery.

Table of Contents

• Understanding the cluster B disorders
• Narcissism is more than just being self-centered
• What borderline personality disorder actually looks like
• Why women are often misdiagnosed
• Suicidal ideation, self-harm, and what clinicians actually worry about
• Why DBT has become such a powerful treatment
• Why trauma is not always the first thing treated
• BPD vs bipolar disorder: why they get confused
• The TIPP skill: a DBT tool that can help fast
• Parenting, praise, and how not to raise a narcissist
• What to remember if someone you love is difficult
• FAQ
• A more useful way to think about all of this

Understanding the cluster B disorders

Can we start with the basics? What are cluster B personality disorders?

Yes. Personality disorders are often grouped into three broad clusters. In this discussion, our focus is on cluster B, which includes:

• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder

These are the diagnoses most associated with emotional intensity, unstable relationships, impulsivity, and difficulty with attachment. But one of the most important things Dr. Wallach emphasizes is that these conditions are often misunderstood, overpathologized, and weaponized.

Her perspective is that many of these disorders, especially within cluster B, are deeply tied to trauma and invalidating early environments. That lens matters because it shifts the conversation away from simple blame and toward understanding what happened, how someone adapted to survive, and what healing can actually look like.

Narcissism is more than just being self-centered

What is an actual narcissist?

This is where so many people get it wrong. Narcissism is not just vanity, arrogance, or being inconsiderate. To truly meet the criteria for narcissistic personality disorder, there is something more structurally embedded going on.

Dr. Wallach describes it as involving delusions of grandeur, a deeply distorted sense of self-importance, and often explosive rage when someone touches what she calls a narcissistic wound.

And that wound matters. One of the most fascinating points she makes is that narcissism is often built on top of shame, not confidence. The grandiosity is not evidence of a healthy self. It is a defense. A false self. A polished outer shell built to cover something painful underneath.

Narcissism is often created to cover a shame-based self.

That is an important reframe. It does not excuse abuse, cruelty, manipulation, or gaslighting. But it does explain why narcissistic behavior can feel so reactive and so brittle. If the entire structure is built to defend against shame, then criticism, rejection, or even ordinary accountability can feel intolerable.

Is narcissism caused by childhood trauma?

According to Dr. Wallach, most of the time, yes, narcissistic patterns are rooted in childhood trauma or an invalidating early environment.

She sees a recurring pattern in many male narcissists: a mother who idealizes them and a father who shames, rejects, or is absent. In her clinical experience, that push-pull can create a powerful internal split. One part of the child is being told he is extraordinary. Another part is being made to feel worthless.

That combination can be fertile ground for a grandiose false self. The child learns to chase perfection, control appearances, and protect against the crushing possibility that the shaming voice might be true.

Her broader point is that personality disorders are not simply something people are born with. They are often adaptations formed in environments where emotional needs were not met, emotions were not mirrored, or safety and consistency were missing.

So how do we know if someone is a narcissist or just an asshole?

Dr. Wallach is blunt here. If someone is treating you badly, the label is not the most important thing. If they are an asshole to you, leave. If they are a narcissist and abusing you, also leave.

Still, some patterns can help you recognize narcissistic abuse more clearly. She points to:

• Gaslighting
• Chronic refusal to take accountability
• Constant criticism or subtle put-downs
• A sense of superiority over others
• Rage when challenged or ignored
• Refusal to engage in therapy or couples work

Narcissistic abuse often sounds like:

• “I never said that.”
• “You’re too sensitive.”
• “This is your problem, not mine.”
• “You’re doing it wrong.”

The effect is destabilizing. You start doubting your own reality, your own memory, your own judgment. That is part of why these relationships become so psychologically damaging.

What borderline personality disorder actually looks like

How is borderline personality disorder different from narcissism?

Where narcissism often involves difficulty attaching and a grandiose false self, borderline personality disorder, or BPD, tends to revolve around:

• Intense fear of abandonment
• Unstable relationships
• Impulsivity
• Black-and-white thinking
• Fragile or unstable self-image
• Chronic feelings of emptiness
• Self-harm and high suicidality risk

Dr. Wallach uses one of the most powerful descriptions of BPD from Marsha Linehan, the creator of DBT. She says it is like walking around with third-degree burns, or living without emotional skin.

That image explains a lot. A comment that might mildly annoy one person can land as devastating, rejecting, or deeply painful to someone with borderline personality disorder. And once that pain is activated, they may act quickly and intensely in an effort to communicate distress, prevent abandonment, or regain control.

That might look like repeated texting, escalating conflict, rage, or impulsive behavior that ends up making the situation worse. The intention is often not manipulation in the cold, calculated sense people assume. Often, it is pain expressed in ways that are desperate and ineffective.

Why do borderlines and narcissists often end up together?

Because they fit into each other’s wounds in a way that can feel intensely magnetic, at least at first.

Dr. Wallach explains that a person with BPD often wants intense attachment, reassurance, closeness, and emotional fusion. A narcissist often struggles with real attachment, but enjoys admiration, attention, and having their ego inflated.

So the borderline partner may pour themselves into the relationship, even changing themselves to fit the other person. Dr. Wallach describes this as a kind of chameleon effect. The person with BPD may absorb the interests, style, priorities, or identity of whoever they are attached to because their own sense of self feels fragile.

At first, that can feel intoxicating to the narcissistic partner. But when the narcissist pulls away, the borderline partner often chases harder. Then, if the borderline partner finally starts setting boundaries, perhaps through therapy, the narcissist may suddenly re-engage because they cannot tolerate being ignored.

That creates the exhausting push-pull dance so many people recognize. One partner withdraws. The other pursues. Then the roles partially reverse. The cycle can continue for years.

How is borderline different from dependent personality disorder?

This is an important distinction. Dependent personality disorder is not just clinginess or fear of being alone. It involves a profound inability to make even ordinary decisions without someone else.

As Dr. Wallach describes it, a person with dependent personality disorder may feel paralyzed choosing furniture, deciding where to shop, or functioning independently in everyday life. Borderline personality disorder is different. A person with BPD may struggle intensely in relationships and emotional regulation, but they are not necessarily globally incapable of making decisions.

Why women are often misdiagnosed

Is borderline personality disorder underdiagnosed in women?

Dr. Wallach actually argues something more controversial and very important: it is often overdiagnosed in women.

She is direct about the sexism she sees. In her experience, women who are highly emotional, distressed, grieving, angry, or anxious are too quickly labeled with BPD, especially by clinicians who are not taking the full context into account.

A woman going through a brutal divorce, a breakup, betrayal, or intense life stress may present with tears, panic, suicidal thoughts, and dysregulation. That does not automatically mean she has a personality disorder.

There is such a thing as appropriate emotional pain. There is such a thing as appropriate anxiety. Appropriate heartbreak. Appropriate despair. Not all suffering is pathology.

That distinction matters because the BPD label carries heavy stigma. Many therapists refuse to treat it. Some patients are told flatly that they are too difficult, too risky, or need to be referred elsewhere. That can be devastating, especially for people who are already in pain.

Suicidal ideation, self-harm, and what clinicians actually worry about

Are people with borderline personality disorder at higher risk of suicide?

Yes. Very much so. Dr. Wallach underscores that BPD carries a high risk of both self-harm and suicide. That includes cutting, burning, suicide attempts, and chronic suicidal ideation.

But she also makes a crucial distinction. Not every thought about death means the same thing.

What is the difference between suicidal ideation and imminent suicide risk?

Any suicidal thought should be taken seriously. Full stop. But clinically, it matters whether someone is saying:

• “I am in so much pain I wish I were dead.”
• or
• “I want to kill myself, I have a plan, and I have the means to do it.”

Dr. Wallach pays close attention to whether the thought feels ego dystonic, meaning it feels foreign, frightening, or disturbing to the person. If a suicidal thought feels alarming to someone, that is one thing.

What worries her more is when the thought starts to feel peaceful, relieving, or inevitable. Statements like “People would be better off without me” or “Why won’t anyone just let me die?” are major red flags.

She also notes that the people clinicians sometimes worry about most are not always the loudest. Sometimes the quieter, more resolved person is at greater danger.

Assessment involves asking about:

• Means, such as access to guns or stockpiled pills
• Motive
• Intent
• A concrete plan
• Past attempts, which significantly raise future risk

Why DBT has become such a powerful treatment

What is DBT, and why is it so effective for borderline personality disorder?

DBT stands for Dialectical Behavior Therapy, developed by psychologist Marsha Linehan in 1989. Dr. Wallach calls her “Mother Marsha,” and with good reason. Linehan created the treatment after her own struggles, institutionalization, and deep dissatisfaction with what was missing from standard therapy.

Traditional CBT, or cognitive behavioral therapy, is based on the idea that if you change your thoughts, your behaviors will follow. DBT takes a different stance. It recognizes that we do not always control what thoughts pop into our minds, but we can learn to control how we respond to those thoughts.

That shift is huge for people who feel emotionally flooded, impulsive, reactive, or chronically out of control in relationships.

Comprehensive DBT usually includes:

• Weekly individual therapy
• Weekly skills group
• 24/7 skills coaching in crisis moments
• A structured, evidence-based model

Dr. Wallach’s clinic offers in-the-moment coaching because when someone is severely dysregulated, waiting days for the next appointment can be too late. The point is to help them use skills before they blow up their life.

What are the four core DBT skill areas?

DBT teaches practical tools in four main categories:

• Mindfulness
• Emotion regulation
• Distress tolerance
• Interpersonal effectiveness

Mindfulness here does not just mean meditation. It means noticing what is happening in your body and in your environment in real time. Am I getting activated? Am I angry? Is this setting triggering me? Do I need to step away?

Emotion regulation involves learning how to care for the basic physical conditions that make emotions harder to manage. That includes sleep, food, illness, exercise, and substance use.

Distress tolerance is the ability to survive emotional pain without making everything worse. Can you tolerate criticism, rejection, discomfort, or frustration without lashing out, self-harming, quitting, or detonating the relationship?

Interpersonal effectiveness is exactly what it sounds like. How do we ask for what we need, argue without destroying everything, set boundaries, and sustain relationships over time?

One of the reasons this model resonates so strongly is that the skills are surprisingly concrete. Dr. Wallach says many of the same things we try to teach little kids. The problem is that people with deeply invalidating childhoods often never learned them, or learned the opposite.

Why trauma is not always the first thing treated

If so much of this starts with trauma, why not begin there?

Because timing matters. This is one of the most clinically important points in the entire conversation.

In DBT, the first target is life-threatening behavior. If someone is suicidal, self-harming, or highly unstable, diving straight into trauma work can actually make things worse.

Trauma processing often increases distress before it brings relief. If someone does not yet have enough distress tolerance and emotion regulation, opening up traumatic material can overwhelm them and raise risk.

So Dr. Wallach’s approach is to first build a foundation. Get the person safer. Help them stabilize. Teach them skills. Then, when they can tolerate emotional intensity more effectively, move into trauma work and deeper emotional processing.

That sequencing can save lives.

Can medication or ketamine help?

Yes, and Dr. Wallach is open about having seen medication help many patients, especially SSRIs, mood stabilizers, and, in some cases, ketamine, particularly for acute depression and suicidality.

She is also careful to emphasize that these decisions should be made by qualified medical professionals. When ketamine is used responsibly, in a clinical setting, with appropriate psychiatric oversight and therapeutic support, she has seen it be profoundly effective.

But even then, her view is not that ketamine replaces therapy. It works best in coordination with skilled psychiatric care and ongoing treatment.

BPD vs bipolar disorder: why they get confused

Why are borderline personality disorder and bipolar disorder so often mixed up?

Both can involve mood shifts, impulsivity, irritability, and instability. But they are not the same.

Bipolar disorder is a mood disorder. It has a stronger genetic basis and involves episodes of mania or hypomania along with depression.

Dr. Wallach describes:

• Bipolar I as involving full mania and at least one hospitalization for mania
• Bipolar II as involving hypomania, which is a milder elevated state, along with depression

With hypomania, a person may sleep less, become unusually productive, intensely creative, or unusually activated. But it is not necessarily the life-destroying, severe mania seen in bipolar I.

Borderline personality disorder, by contrast, is more closely tied to trauma, attachment wounds, and instability in self-image and relationships. The mood swings are often reactive to interpersonal stressors rather than occurring as distinct mood episodes in the same way bipolar symptoms do.

That is why careful assessment matters so much.

The TIPP skill: a DBT tool that can help fast

What is the TIPP skill, and when should we use it?

This is one of the most practical tools from DBT, and one that people can often use immediately when anxiety or panic spikes.

TIPP stands for:

• Temperature
• Intense exercise
• Paced breathing
• Paired muscle relaxation

The temperature piece is especially memorable. Dr. Wallach describes filling a bowl with ice water, bending over, and plunging the face so that the eyes and forehead are submerged for about 30 seconds. This can activate the body’s dive response, slow the heart rate, reduce physiological arousal, and interrupt panic.

Then comes paced breathing, often six counts in and eight counts out, followed by repeating the cold water plunge several times if needed.

The point of TIPP is not to solve the life problem in that moment. It is to bring the nervous system down enough that the brain can think again.

As Dr. Wallach explains, when someone is at an emotional 8, 9, or 10, they are not ready to problem-solve. Their prefrontal cortex is essentially offline. First, lower the distress. Then talk about the fight, the trigger, or the next step.

Parenting, praise, and how not to raise a narcissist

How do we avoid raising a narcissist?

Dr. Wallach’s answer is surprisingly grounded: validate, mirror, and be curious about your child’s feelings.

That means:

• Making time for your child emotionally
• Naming feelings without shaming them
• Allowing the child to have emotions even when you do not agree
• Helping them understand and regulate what they feel

But validation is not the same thing as indulgence.

Where is the line between healthy praise and overpraise?

This came up in a really relatable way. So many of us worry about getting this wrong. If we praise our kids too much, do we create entitlement? If we discipline too hard, do we create shame?

Dr. Wallach’s distinction is helpful. Praise is healthy. Encouragement is healthy. Telling your child they are loved, smart, kind, beautiful, or capable is not the problem.

The danger is when a parent communicates, explicitly or implicitly, that the child is perfect, beyond consequences, and incapable of wrongdoing.

Healthy parenting, in her framework, sounds more like this:

• “I understand that you’re angry.”
• “You still cannot hit me.”
• “I can see that you’re upset.”
• “You cannot talk to me that way.”

Validate the feeling. Set the boundary. Keep the consequence. That combination helps children learn emotional reality without shame or chaos.

What if we mess up as parents?

We all do. That was one of the warmest and most human parts of this conversation.

Dr. Wallach and the hosts all acknowledge the same truth: parenting is hard, none of us is perfect, and every parent will get some things wrong. One of the most powerful things a parent can do is simply say:

• I was wrong.
• I’m sorry.
• I made a mistake.

Repair matters. Love matters. Calm matters. Consistency matters. And as they point out, it is never too late to start doing better.

What to remember if someone you love is difficult

Should we have compassion for people with these traits?

Yes, and also boundaries.

One of the most grounded ideas in this conversation is that people who are cruel, explosive, manipulative, or dysregulated are often hurting themselves. They may be carrying trauma, shame, insecurity, or developmental wounds that were never addressed.

That does not mean we stay in harmful relationships. It does not mean we tolerate abuse. It does not mean we sacrifice our mental health in the name of empathy.

It means we can understand someone’s behavior without excusing it. We can have compassion without volunteering to be damaged by it.

That balance matters in romantic relationships, friendships, family systems, and parenting. As one of the hosts says, if somebody is lashing out, screaming, or bullying, they are likely the one hurting. We can see that clearly and still step away.

You can protect your own psyche and still have empathy.

FAQs

What are the main signs of borderline personality disorder?

Common signs include fear of abandonment, unstable relationships, impulsivity, black-and-white thinking, a fragile sense of self, chronic emptiness, self-harm, and suicidal ideation. Only a qualified clinician can diagnose BPD, but these patterns are often part of the picture.

What makes narcissism different from just being self-absorbed?

Narcissistic personality disorder is more than selfishness. It typically involves grandiosity, shame beneath the surface, difficulty with accountability, rage when criticized, and a need to maintain a false superior self. It often shows up as chronic gaslighting, control, and inability to tolerate being wrong.

Can borderline personality disorder be treated?

Yes. Dr. Suzanne Wallach strongly emphasizes that BPD is treatable and can go into remission, especially with high-quality dialectical behavior therapy delivered in an evidence-based format.

Why are women so often diagnosed with borderline personality disorder?

Dr. Wallach argues that women are often overdiagnosed because emotional pain, distress, or visible dysregulation can be misread as a personality disorder instead of being understood in context. Grief, divorce, heartbreak, anxiety, and trauma responses can all be mislabeled.

How is BPD different from bipolar disorder?

BPD is often tied to trauma, attachment wounds, and unstable identity and relationships. Bipolar disorder is a mood disorder with genetic roots and distinct episodes of mania or hypomania and depression. They can look similar on the surface, but they are clinically different.

What is the DBT TIPP skill?

TIPP stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. It is used when emotional distress is very high, and the goal is to calm the nervous system quickly enough to think clearly again.

Should trauma be treated first in someone with BPD?

Not necessarily. If someone is suicidal or highly unstable, DBT typically starts by addressing life-threatening behaviors and building emotion regulation and distress tolerance skills first. Trauma work often comes later, once the person is more stable.

How do we avoid raising a narcissist?

Validate your child’s feelings, stay curious, mirror their emotional experience, and set consistent boundaries. Praise is healthy. The problem is not praise. The problem is a lack of limits, no accountability, or treating a child as incapable of doing wrong.

A more useful way to think about all of this

If there is one takeaway we keep coming back to, it is this: labels matter less than patterns, safety, and treatment.

If someone in your life is critical, manipulative, raging, unavailable, or emotionally chaotic, you do not need to wait for a perfect diagnosis to take your own experience seriously. If you are struggling with mood instability, fear of abandonment, self-harm, panic, or impulsive relationships, you do not need to shame yourself or assume you are beyond help.

There is help. There are skills. Some frameworks actually work.

And maybe the most hopeful message from Dr. Wallach is that people who are often written off as too difficult, too damaged, or too much are frequently the very people who can heal in profound ways when they get the right care.

BPD is not a life sentence. Trauma responses are not moral failures. Emotional dysregulation is not a character flaw. And understanding the difference between narcissism, borderline personality disorder, bipolar disorder, trauma responses, and ordinary human pain can change the way we care for ourselves, our children, and the people around us.

If these patterns sound familiar in your own life, the next best step is not self-diagnosis. It is reaching out to a qualified mental health professional, especially one trained in DBT or personality disorder treatment, and getting an accurate assessment.

Clarity can be life-changing. So can the right support.

 

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Getting support (and finding the right provider)

If this conversation leaves you wondering what to do next—especially around emotional dysregulation, self-harm risk, trauma sequencing, or getting accurately assessed—consider reaching out to a qualified mental health professional with DBT training.

For additional context on why patients (including women) are sometimes dismissed or mislabeled and what “advocating for yourself” can look like in real clinical settings, see: advocating for yourself.

And if you’re looking for a practical, structured approach to care (building stability before diving deeper), you may also find these resources helpful as you seek support and assessment: women’s health conditions.

This article was created from the video Narcissism vs Borderline: The Signs Everyone Gets Wrong with Dr. Suzanne Wallach | SHE MD for Dr. Thais Aliabadi’s website.