Friday, May 14, 2010

Rerun: Piecing Together the Borderline Puzzle

More on borderline personality disorder, from last year ...

May is Borderline Personality Disorder Awareness Month. Our story so far:

In 1980, borderline personality disorder received formal recognition as a diagnosis with its inclusion into the DSM-III. The catch was that the illness was consigned to "Axis II," widely regarded as psychiatry's wrong side of the tracks. As an editorial by John Oldham MD of the Menniger Clinic in this month's American Journal of Psychiatry explains:

The decision derived from the belief that borderline and other personality disorders were "caused during early development by parental neglect, abuse, or inconstancy." The prototypical image of a patient was that of an angry volatile individual prone to reject help, blame others, and behave self-destructively. "Too often, this behavior was seen as willfully oppositional, and borderline personality disorder patients were spoken of as dreaded pariahs."

Our current clinical and scientific knowledge, Dr Oldham advises, is changing those perceptions. Core "heritable endophenotypes" of affective dysregulation and impulsive aggression have been identified. Brain scans reveal specific abnormalities, namely a hyperactive limbic system, in particular the amygdala (which mediates arousal and fear). Thus, certain individuals are primed to overanticipate and overreact when their personal dealings hit a snag.

This state of emotional overdrive is difficult to extinguish, owing to impairment in the cortical areas to inhibit this limbic-driven emotionality or impulsivity.

As if this isn't bad enough, this phenomenon of "brain gone wild" interferes with forming emotional attachments during child development, which may be magnified by lack of adequate parental support. As Dr Oldham describes it:

"These combined etiological factors produce arrested, distorted, or incomplete integration of aspects of self and others, resulting in early onset and persistence of profound interpersonal difficulties. Normal early development becomes derailed, and the crucial developmental milestone of basic trust is not achieved."

No wonder no one has come up with a med to treat borderline patients. As a second editorial - by Otto Kernberg MD and Robert Michels MD of Cornell - explains, only 30 percent of patients with borderline respond satisfactorily to meds over the long term.

(Editorial sidebar: Psychiatry has unofficially used response to meds as an indicator of whether the illness is biological or merely a construct of the mind. Thus, borderline gets nowhere near the same respect as schizophrenia, which - ironically - evidences similarly low and perhaps even worse response rates.)

Dialectical behavioral therapy and other talking therapies produce beneficial results in the short term, but Drs Kernberg and Michels caution that "basic underlying chronic personality dispositions may remain unchanged."

Thus, years and decades after completion of therapy, individuals with borderline may still face major challenges in personal satisfaction with how their lives are going. On one hand, borderline has been dubbed the "good prognosis diagnosis," based on research showing an 80 percent remission rate over ten years. But the authors caution that these findings are focused more on DSM symptoms, "and much less on the subtle and permanent features of their difficulties in work, love, social life, and creativity."

The bad news is that despite the significant gains in our body of knowledge, "the relationships between clinical symptoms, deeper psychological structures, and underlying neurobiological systems are, as yet, to be explored."

The good news is we are learning as we go. As the authors conclude:

"Borderline patients have long been to psychiatry what psychiatry has been to medicine - a subject of public health significance that is underrecognized, undertreated, underfunded and stigmatized by the larger discipline. As with psychiatry and medicine, this is changing. New knowledge, new attitudes, and new resources promise new hope for persons with borderline personality."

Further reading from mcmanweb:

Borderline Personality Disorder
Those who live with individuals with borderline describe the experience as akin to walking on eggs. By contrast, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, and the ground beneath her could collapse any second.

"It’s like demons possess me," she related. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.

She emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"). Anne concluded with reference to her favorite bumper sticker, "Don’t believe everything you think."

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