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 ....