Friday, May 7, 2010
This from last year ...
Yes, the heading is real, and it's about time. In April, 2008, in response to public advocacy efforts, the US House of Representatives unanimously passed House Resolution 1005 supporting the month of May as "Borderline Personality Disorder Awareness Month."
The resolution stated that "despite its prevalence, enormous public health costs, and the devastating toll it takes on individuals, families, and communities, [borderline personality disorder] only recently has begun to command the attention it requires."
I came across this nugget of information late last night while quickly scanning this month's American Journal of Psychiatry, where I was flabbergasted (a good sign) to find two editorials and three articles devoted to borderline.
Minutes before, I had been clicking through a PDF of the program book of the American Psychiatric Association's upcoming annual meeting which I will be attending in San Francisco in two weeks. The topic index to the program book lists 20 sessions devoted to mood disorders and 18 sessions devoted to personality disorders.
Knock me over with a feather. In the seven years I have been attending APA meetings, you would hardly know borderline and related illnesses fell under the purview of psychiatry. Three years earlier, with the intention of bringing myself up to speed on borderline, I found but three or four sessions on the program devoted to the illness. In fact - at a session on bipolar II at that particular meeting - two of the panelists and some of the audience questioned the validity of the borderline diagnosis in the first place.
A lot as changed since then. For starters, we know that the illness cannot be written off as mere bad behavior or as a variant of a mood disorder. Rather, it is abundantly clear that we are dealing with a serious medical illness that condemns four percent of the population to tortured lives, with suicide rates on a par with depression and bipolar.
Individuals with borderline face extreme difficulty responding to their environment, a process that science is showing to be mediated by the biology of the brain.
We also know that individuals with borderline respond well to certain types of talking therapy, and that their long term outcomes are exceptionally favorable. The only reason that meds work less well for those with borderline is because it is patently obvious we haven't come up with the right meds.
A very strong case can now be made - indeed, an undeniably airtight one - that the highest priority for the next DSM is to shift borderline personality disorder from Axis II - psychiatry's version of Siberia - to Axis I, in the same company as depression, bipolar, schizophrenia, and other illnesses the profession takes seriously.
NAMI has been successful in promoting public awareness for borderline while the NIMH has invested greater resources in research. In January this year, Time magazine devoted a feature article to the illness, and over the past two or three years we have witnessed a number of popular new books on the topic.
So, back to last night: In the space of ten minutes, from two different sources, I came up with undeniable evidence that psychiatry is finally starting to give borderline the respect it deserves. This is the result of incremental changes over a long period of time rather than an overnight sensation.
But - overnight - it suddenly occurred to me that this new professional respect, combined with public awareness, has to be one of the three most significant mental health events I've encountered since I began writing about my illness ten years ago, equal to the recognition of bipolar in young kids and to the mind-boggling advances in brain science.
The effect is bound to significantly improve the lives of countless individuals, long neglected and even held in contempt by professionals who should have known better. It is also likely to generate a backlash, particularly if people start perceiving borderline as a fad diagnosis.
I will pay a return visit to this months AJP for a long deep perusal, plus check out other sources, and will be reporting back in a series of blog posts this week. Stay tuned ...
Update May 7, 2010
In Feb this year, the DSM-5 Task Force released a proposed revision that would eliminate the artificial distinction between Axis I and Axis II disorders. In addition, as well as the curent "categorical" approach that separates out borderline from antisocial and other personality disorders, there would also be a "dimensional" element that acknowledges the overlap. More on this in upcoming blogs ...
Further reading from mcmanweb:
Borderline Personality Disorder
In true Axis I depression, Dr Paris explained, when patients come out of a depression, they are nice people again. Individuals with personality disorders, by contrast, can come out of a depression and still have problems with life. Unfortunately, clinicians prefer not to want to hear about personality. It means trouble. They would rather throw more meds at the problem.
The world is complicated, Dr Paris noted, but we want it simple, and therein lies the challenge: In the bipolar II symposium, the presenters were discussing difficult-to-treat depressions. The depressions they were talking about were those that acted suspiciously like bipolar, which strongly implies using mood stabilizers instead of antidepressants.
Dr Paris was also talking about difficult-to-treat depressions, but the ones he described pointed to personality issues and a long course in talking therapy. These patients are not going to get better fast, he warned. Clinicians have to plan for chronicity. Moreover, in a true personality disorder, the course of the illness is different. These individuals are not going to become bipolar over time. ...