Another friend in the parole out-patient service sent me an article published in the Psychiatry News in its “From the Experts” series that was simply titled, “Reorienting a Depressed Patient to Address Underlying BPD.” The gist of the case is a young man, medication-refractory major depression, following a non-lethal overdose that led to an ER visit. The reporter and expert is the consultant, who “reframes” or from the title, “reorients” the medication-refractory major depression and suicidal gesture into Borderline Personality Disorder. Wow.
[Patient] illustrates a common clinical problem. Many patients really have major depressive disorder (by DSM definition) and seek help, but if medications fail, they become fearful about whether to expect a recovery. Often they have not been introduced to the important role of psychosocial factors in creating or perpetuating their depressed mood. Moreover, as with Dr. [Referrer], many psychiatrists prefer by training, if not by orientation, to adhere to prescribing medications, and most psychiatrists avoid treating patients with BPD (Shanks et al. 2011). These facts are particularly relevant to cases like [Patient], insofar as BPD represents the major source of chronic “treatment-resistant” depression (Skodol et al. 2011).
Now if you have no clue as to the significance of what is being said here, let me explain: Dr. Gunderson, a designated “expert” in the matter, suggests that “medication-refractory major depressive disorder” (i.e. major depression that doesn’t respond to the typical anti-depression medications one would prescribe) may be depressed, but it is co-morbid and symptomatic to his primary clinical concern which is Borderline Personality Disorder. And what is Borderline Personality Disorder? According to the DSM-V,
BPD is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.
What they so euphemistically refer to as “instability” was forever referred to as a labile affect
indicating “off-centered,” but unpredictable, oppositional, wide (and wildly)-ranging affect to the point of appearing contrived. But more importantly, inappropriate &
exaggerated in proportion to the circumstance. Further, BPD
, like Antosocial Personality Disorder, is more often than not co-morbid with alcohol and/or drug related problems, major depressive disorder, anxiety disorders, and so on. And most importantly, because of the correlation between mood-altering drugs and completed suicide, patients with BPD
produce the most suicidal gestures
, but also the most completed suicides.
What does the DSM-V suggest as to the prevalence of Borderline Personality Disorder?
The median population prevalence of borderline personality disorder is estimated to be 1.6% but may be as high as 5.9%. The prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. The prevalence of borderline personality disorder may decrease in older age groups.
Now, if you read precededing post, the DSM
points out that the diagnosis of ASPD
is “predominately among males,” and acknowledges underutilization as perhaps related to the historic prerequisite for Conduct Disorder, simply reflecting a reluctance to apply a “harsh” diagnosis to female adolescents. So it simply states, “Borderline personality disorder is diagnosed predominantly (about 75%) in females.” This
is the corollary to my observation that I have never seen a woman diagnosed with Antisocial Personality Disorder in the forensic setting: I have never seen a man diagnosed with Borderline Personality Disorder in the forensic setting. Never. Alex Forrest
, meet Dr. Hannibal Lecter
Interestingly, a quick diversion here: my wife, a clinical social worker, walked in at this point and asked what I was writing. I briefly explained and she reminded me that I had given her Robert Hare’s Snakes in Suits: When Psychopaths Go to Work, described as “a compelling, frightening, and scientifically sound look at exactly how psychopaths work in the corporate environment.” Oh, right, that I did. Hare has always maintained that only 30% of psychopaths are actually incarcerated. She said, “I just don’t believe women are as adept or believable at the characteristics of deceit, lying, and conning for profit as men… (pregnant pause) although my supervisor who we thought was borderline had lied on her resume and lied about her work experience…” Thank you, Madame.
What is fascinating is that Nassir Ghaemi, MD, another expert, but this time on mood disorders, picked up on Gunderson’s “reorienting” the medication-refractory MDD patient in the first place
What does it mean to be borderline? I suggest that sexual trauma and dissociation are central features to the concept, just as Drs Gunderson and Otto Kernberg have taught for so long. Some research in outpatient depression indicates that it is exactly these features that distinguish borderline personality from depressive illnesses.
But to ignore those central features, and diagnose the condition in any 22 year-old depressed male, who also has interpersonal problems and mood reactivity and irritability, is not supported at all by the empirical psychopathology literature on depressive illnesses nor on the borderilne concept, based solely on scientific evidence (as opposed to the politically and socially-based definitions of DSM revisions, as discussed and documented in previous posts).
Well, lord knows somebody
had to do it, and if you do not recognize the name Otto Kernberg, you will in part three. The most interesting comment of Dr. Ghaemi is that, “In other words, perhaps Dr Gunderson thinks all depressed persons are borderline because the DSM
criteria, which he helped write ever since 1980 and the third revision
, allow him to make that equivalence.” [Emphasis mine] Holy Cow! But wait, says Dr. Ghaemi, “What are the most common among [a] list of risk factors or causes for [“treatment-refractory depression” (TRD
! “By far, the most common cause according to a number of studies is misdiagnosed bipolar illness, especially type II
.” Who’d have thought? And with an, “I’ll close the book, buddy,” Ghaemi finishes, “By refusing to diagnose bipolar illness, as is the case with Dr Gunderson, the problem is not that the patients are “treatment-resistant” but that psychiatrists are “diagnosis-resistant.”
For the moment, Ghaemi rests, but the discussants consider:
“In my experience, the differentiation between Bipolar II Disorder and Borderline Personality Disorder is highly problematic and subjective. Interestingly, both Gunderson and the writer of this paper are connecting emotional deregulation and unstable self– experience with TRD.” [Emphasis mine]
“The confusion is understandable and directly attributable to inadequacies of DSM classification. Both disorders BPII and BPD share unstable/cyclical mood. But that’s where similarities end. BPD, in addition to labile mood (relatively moderate, as in cyclothymia) has executive function and reality testing deficits. In addition, BPD has unstable arousal. BPII, OTOH, has longer, less unstable, and deeper mood fluctuations and when presented in “pure form” without executive deficit or cognitive component. Psychobiological model makes distinction between various “unstable mood” disorders in consideration of various neurobiological circuits involvement, DSM classification doesn’t. If we put labile mood as a core dysfunction, then “bipolar disorders” will cluster together and differ from each other only by associated (neurobiological) features, and will not be spread all over classification as in DSM. Subsequently, we can have ‘natural’ classification of the disorders with core deficit in arousal system, executive system, ToM system, etc. very similar to classification of medical disorders: disorders of GI, CVS, GU system, etc. Instead, if medical classification was written DSM style, we would be doing differential diagnosis for moderate febrile disorder with rash type II vs. severe cyclical febrile disorder with lots of rash type I vs. disorder with chronic rash, chronic fever, and frequent runny nose … Absurd, isn’t it?”
“Whew! Does this not make the point that we desperately need biomarkers for accurate diagnosis in psychiatry?? At present, we take constellations of symptoms and attempt to synthesize a diagnosis.
We then spend months dosing pharmaceuticals with varying mechanisms of action and significant side effects hoping we are acting on the appropriate neuroreceptors for the appropriate diagnosis! As good as we all think we are, the current state of psychiatric diagnosis lags all other specialties. It is not unlike shooting a dart at a dartboard.You say BPII, I say BPD?? This is not only expensive but unacceptably dangerous. We must advance research in the genetics, laboratory and radiologic diagnosis in our field.”
“Missing the point? Commentary on the comments. Science does not demand that we are right, it underlines the fact that we must think — and not blurt out biased assumptions when ever the world does not behave the way we want. Tnx again dr Ghaemi for stressing this!”
Somehow I envision Sartre, Camus, Genet, & De Beauvoir around a small table arguing, and smoking, smoking, smoking.