Tuesday, May 5, 2009

Borderline Personality Disorder - Searching for Respect

In recognition of Borderline Personality Disorder Awareness Month, the second in a series:

Psychiatry has had one hell of a time trying to figure out borderline personality disorder, but we all know it when we see it. Case in point (from an article in this month's American Journal of Psychiatry):

"Ms A" told her therapist of an embarrassing episode in which she had shouted at a store clerk she perceived as rude. What set off the incident was the clerk would not accept her credit card.

Her therapist asked whether it was store policy not to accept credit cards or whether the clerk had singled out her credit card in particular.

"What difference does it make?" the patient responded in a fury. "Even if it was the policy of the store and not directed at me, he still should have been courteous!"

The patient then exploded into a screaming rage: "You’re not interested in empathizing with my feeling of being humiliated - only in figuring out how I caused the whole incident! It’s clear that you don’t care about me ... "

Yep, know it when we see it. Um - but what the hell is it?

As another article in the AJP (by leading expert John Gunderson MD of Harvard) makes clear, the very name borderline indicates various attempts at figuring out what the illness is NOT. In the words of outspoken critic Hagop Akiskal MD of UCSD, borderline over the decades has resembled "an adjective in search of a noun."

Back in the 1930s and into the 50s, it was thought that the noun had to be schizophrenia. According to the theory, it was believed that, in certain situations, some patients regressed into "borderline schizophrenia."

In the late 60s, those nouns became neurosis and psychosis. In a psychoanalytic framework, "borderline personality organization" occupied that nebulous middle ground between neurotic patients (who were considered treatable) and those who were written off as psychotics. "Neurotics who drive their shrinks crazy" would be another way to describe what clinicians observed in their offices.

Give psychoanalysis credit for bringing coherence to the phenomenon, including recognition of: emotional instability, need to attach to others, distorted sense of self and others, reliance on "splitting," and fears of abandonment.

From there, borderline progressed to a "syndrome," still within the purview of psychoanalysis. In 1980 - with the publication of the first modern DSM (DSM III), psychiatry formally recognized the diagnosis as "borderline personality disorder," but in the context of an endangered species consigned to a doomed habitat (Axis II).

Soon after, with the near-total collapse of psychoanalysis, borderline lost its chief group of champions, thereby leaving the diagnosis open to attack. Psychiatry's new generation of whizz kids reached for their chainsaws, along with the mandatory new noun. This time, the noun was depression, as in borderline being some kind of atypical depression.

But the diagnosis found support in new research that convincingly validated the illness, with a course that differed from schizophrenia and depression. Those with borderline showed clear signs of vulnerability to stress, but this - ironically - suggested yet another noun, PTSD (where there exists a substantial overlap).

The diagnosis entered the DSM-IV of 1994 virtually unchanged, though the question was raised about whether a patient could be considered borderline if he or she responded to meds. Against this backdrop emerged the hypothesis that borderline had to do with breakdowns in two key neurotransmitter systems, which translated to either: 1) difficulty in controlling impulses, or 2) emotional (affective) dysregulation.

Meanwhile (and predictably) bipolar became borderline's new candidate noun. Bipolar (with the new "bipolar II" diagnosis) was taking over territory formerly occupied by depression, and borderline was the next logical direction for expansion. But new studies pointed to critical distinctions between the two illnesses, including a failure in borderline patients to "mentalize," that is the capacity to relate to one's own mental states and the states of others.

Coincident with these findings was the success of the first therapy designed specifically for borderline patients, dialectical behavioral therapy. This brought on board a new generation of champions, which may have turned the tide in borderline's favor once and for all.

Still, as Dr Gunderson points out, for a highly prevalent, disabling, and deadly illness that virtually everyone these days acknowledges, borderline still has a long way to go before achieving respect. Psychiatrists receive virtually no training in the illness, few new investigators are entering the field, and proven treatments are often unavailable.

An upgrade to Axis I (in the company of bipolar, schizophrenia, etc) would be a step in the right direction. Says Dr Gunderson:

"It belongs on Axis I to signify its severity, its morbidity, and its unstable course. But it belongs there too to prioritize its usage and to underscore the need for its treatment to be reimbursed."

How about changing the name? Dr Gunderson kinda likes borderline, arguing that the term signifies the illness' "unclear boundaries while reminding us of an unwanted truth, namely, that psychiatric disorders, like other medical conditions, are heterogeneous and have flexible boundaries."

Me? I would go with "No-Noun Disease."

Further reading from mcmanweb:

Borderline Personality Disorder
Unexpectedly, the first borderline discussion there occurred during question time at a packed luncheon symposium on bipolar II. One of the presenters, Terence Ketter MD of Stanford, happened to say that as opposed to bipolar disorder, which is about MOOD lability (volatility), borderline personality disorder is about EMOTIONAL lability. As soon as they develop an emotion stabilizer (analogous to a mood stabilizer), he said, borderline personality disorder will become an Axis I disorder rather than Axis II.
Axis I disorders, as categorized by the DSM-IV, include bipolar disorder, depression, anxiety, schizophrenia, and other illnesses regarded as biologically-based and treatable with medications. Axis II disorders tend to get a lot less respect. As well as borderline personality disorder, these include antisocial personality disorder, narcissistic personality disorder, and a host of behaviors that impede personal and social function.
During the same round of questions, S Nassir Ghaemi MD of Emory University said that he thought borderline personality disorder was a "clinical condition" rather than a disease. As such, the condition is more appropriate for psychotherapy rather than medications treatment. Hagop Akiskal MD of the University of California, San Diego, was decidedly less accommodating: "I don’t have any use for the borderline diagnosis," he asserted.
Dr Akiskal, the leading proponent of the mood spectrum, has been badmouthing borderline for decades. A 1985 article he co-authored had this title: "Borderline: An Adjective in Search of a Noun." Dr Akiskal has made a study of personality, but in the context of temperaments distributed along a continuum ranging from benign to affective illness. ...

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