Saturday, May 28, 2011

Borderline Personality Disorder - A Diagnosis in Search of Respect

As well as May being Mental Health Awareness Month, May is also Borderline Personality Disorder Awareness Month. Coincidentally, I am in the middle of reworking my one mcmanweb article on borderline into three. Following is some pieced-together extracts from my draft ...

In 2005, I joined the board as an officer in a state DBSA group back east. There, I came across behavior I could not ascribe to bipolar disorder – extremely abusive verbal attacks, explosive meltdowns, public outbursts, poison pen emails, delusional self-centeredness, love and light one minute-on their shit list the next.

Yes, bipolars can behave badly, but this was different. For my own self-preservation, I got out of this toxic environment and cut off all ties with the state organization. I literally wound up hating these individuals and their illness. But I also recognized how lonely life must be for these individuals. None of them was married or in a loving relationship. None of them had children. None of them was employed. All of them engaged in frightening behavior. All were serious accidents waiting to happen.

The illness is called borderline personality disorder. On the surface, the emotional volatility, impulsivity, depressions, mood swings, high drama, and destructive behavior of individuals with this diagnosis resemble bipolar disorder. The suicide rate is in the bipolar ballpark, and the pain and isolation individuals with this illness experience is similar, if not more so.

Yes, the people I encountered may have had bipolar disorder, but something else was going on here, and they were not being treated for it. Their psychiatrists were sending them out into the world with mood stabilizers and false hope. I needed to find out more. The 2006 American Psychiatric Association annual meeting was approaching, and I made it a point attend the few sessions they had on personality disorders.

Is Borderline Real?

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, then 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.

Axis II Grind

Joel Paris MD of McGill University is one of the leading authorities on borderline and other personality disorders. In 2006, at the same venue, he spoke to a largely empty hall. The name of his talk said it all: "Personality Disorders: Psychiatry’s Stepchildren Come of Age."

Significantly, Dr Paris was not about to let Dr Akiskal go unanswered. Referring to Dr Akiskal’s long-standing views concerning borderline personality disorder, Dr Paris let it be known, "I would say that is wrong."

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.

Alas, deep in the heart of psychiatry, Dr Paris was a voice in the wilderness.

Knock Me Over With a Feather

Three years later, I had the Twilight Zone experience of attending a packed session on borderline at the 2009 APA. Earlier John Gunderson of Harvard had spoken to an SRO crowd. The APA program booklet revealed that instead of three or four sessions on personality and personality disorders there were 18, about equal to those on mood disorder (I counted 20). During a break in the proceedings, I turned to the psychiatrist next to me.

What was going on? I asked. Why were things so different this time around? What had changed in the last three years?

More to come ....


Willa Goodfellow said...

I don't have a dog in this fight, having divorced decades ago the guy who was half a criterion short of three different personality disorders. Indeed, it would be miserable to be somebody who fit the criteria.

I have often thought this section of the DSM could be called "Why-your-therapist-doesn't-like-you disorder." In fact, is this how counter-transference works? When the therapist finds that he/she doesn't like the mood disorder client, does the therapist reevaluate the diagnosis?

So I'm also wondering -- that interpersonal therapy issue called "personal deficits" that Frank and company use for mood disorders -- is that code for personality disorders?

Gina Pera said...

Hi John,

You are amazing, to keep churning out these thoughtful, well-written posts. Hats off!

For what it's worth, my two cents on borderline personality disorder:

Remember that APA conference where we met? I was absolutely gobsmacked by the proliferation of presentations on borderline personality disorder and yet not one on ADHD.

I sat in those presentations, hearing psychiatrists reel off ADHD symptom after symptom, but never acknowledging the connection between ADHD and poor self-regulation, mood lability, poor impulse-control, etc. That is, the symptoms of borderline personality disorder.

Actually, it sickened me. My sense was that these psychiatrists found borderline personality disorder so much more interesting than ADHD, so much more complicated and more of an intellectual challenge to their self-perceived superior intellects. Oh, and that the patients's narratives are so....compelling.

Their first mistake is thinking that ADHD is simple; just throw a stimulant at it and you're done. What's interesting about that? It is absolutely not simple. Especially when the diagnosis comes later in life, and misattributions and cognitive distortions are almost hard-wired.

Dr. Russell Barkley has recently given the ADHD's emotional dysregulation component of ADHD its due with a new clinician guide.

Dr. Joseph Biederman, a few years ago, associated borderline personality disorder with childhood ADHD symptoms exacerbated by trauma. When ADHD is predominant in a family, trauma and chaos can be repeated generation after generation. Other reports I've read point to specific brain anomalies.

Dialectical behavioral therapy is the clinical treatment for borderline personality disorder, right? The people I know with ADHD and bpd symptoms have found DBT helpful but only when they are also receiving medical treatment for ADHD symptoms. In their case, mostly it is stimulants that help to regulate mood, not "mood stabilizers."

The others (those not taking medication) report that DBT is helpful only when they continuously receive it, which is impractical for most people due to the time and money investment. Some want to get on with their lives. Surely they deserve that.

What I've learned in 10 years of advocacy is that "territoriality" is strong in the medical field and psychiatry, in particular. Sometimes this seems due to competition for grants and published papers, but I also think this is due to too much "deep but narrow" thinking -- people who can't connect the dots. Also egos.

Keep up the good work, John!


John McManamy said...

Hey, Willa. This is definitely the "therapist doesn't like you disorder." At the APA bipolar session I referred to, Frederick Goodwin actually goaded Dr Akiskal in a friendly way. He said in effect, "C'mon. What do call patients you don't like?"

I think the "personal deficits" is part code. I've used the term "personal issues." We all have them. This is why I urge everyone to delve deeply into borderline and the other personality disorders. We may be nowhere close to borderline or antisocial or narcissism etc, but we all have "stuff" going on that holds us back. Researching the full-blown versions gives us insight into our stuff.

As for the guy half a criterion short of three different personality disorders - the DSM-5 is coming up with new dimensional criteria based on the five factor model (FFM). My guess is all the lights in this guy would have gone off with the FFM.

Low agreeableness, low openness to experience, low conscientiousness, high neuroticism(includes moodiness and anxiety), introversion.

I have issues with the FFM, as the ideal seems to be superficial glad-handing Rotarians while traits such as introspection and creativity aren't valued.

The FFM stresses conformity to the dictates of the majority while devaluing the very traits that make us unique. Still, it's a workable rough guide.