Serendipity Disorder — La Finale

mex_borderFinally, if you’ve fol­lowed this far, you knew it was com­ing as Nas­sir Ghaemi, MD asks: “What does it mean to be bor­der­line?” and it was inevitable. And in my esti­ma­tion bold.

Bor­der­line” was orig­i­nally refer­ring to patients who lacked the under­ly­ing chaos, dis­or­ga­ni­za­tion, and the absence of real­ity test­ing as in psy­chotic dis­or­ders, but were like­wise also miss­ing the inte­gra­tion, sta­bil­ity of rela­tion­ships, and reg­u­la­tion of affect of the non-psychotic, “neu­rotic” patients — there­fore said to be walk­ing the “bor­der­line” between the two. Always shift­ing, always unsta­ble, always poly­symp­to­matic of any num­ber of what were referred to as Axis I dis­or­ders in the DSM muti-axial sys­tem 1 . Now, as I noted in the first part of this series, from DSM-III for­ward, it was con­sid­ered an Axis II, clus­ter B Per­son­al­ity Dis­or­der, “fixed and per­va­sive.” incor­po­rated into the makeup of the individual.

Otto Kern­berg, MD is asso­ciate chair­man and med­ical direc­tor of The New York Hospital-Cornell Med­ical Cen­ter, Westch­ester Divi­sion, and pro­fes­sor of psy­chi­a­try at the Cor­nell Uni­ver­sity Med­ical Col­lege. He is also train­ing and super­vis­ing ana­lyst of the Colum­bia Uni­ver­sity Cen­ter for Psy­cho­an­a­lytic Train­ing and Research. There is no ques­tion that he is the first author­ity to come to mind when any seri­ous stu­dent of clus­ter B Per­son­al­ity Dis­or­ders dis­cusses BPD. He pub­lished Bor­der­line Con­di­tions and Patho­log­i­cal Nar­cis­sism in 1975 as either a “sem­i­nal achievement,”“to be savored like a fine wine, not read over night,” or a dra­mat­i­cally effec­tive sleep­ing aid. I do recall fondly that as his affil­i­a­tion was with the “Westch­ester Divi­sion” (i.e. White Plains), he actively par­tic­i­pated in the Fri­day morn­ing Grand Rounds, and actu­ally walked the half stage dur­ing the Q&A to answer my ques­tion regard­ing “pro­jec­tive iden­ti­fi­ca­tion” and bor­de­line patients (he has an espe­cially thick Aus­trian accent, and I could not under­stand him through the PA!). But it seems that even as Ghaemi was reluc­tantly respect­ful in con­clud­ing his arti­cle,

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.
many of his respon­dents were not:

Bor­der­line Per­son­al­ity dis­or­der is a diag­no­sis that is com­monly diag­nosed by the Psychoaanalytical/Psychodynamic ori­ented Psy­chi­a­trists and mostly in North East where you have more num­ber of Psychoanalytical/psycho dynamic ori­ented Psy­chi­a­trists. Kernberg-West chester, Gun­der­son — Boston area Typ­i­cally the Psychoanalytical/Psychodynamic ori­ented Psy­chi­a­trists failed to demon­strate basic logic/reasoning in their pre­sen­taions and dis­cus­sion of clin­i­cal data. Logic/reasoning is alien to them and these groups still con­trol APA and this is the rea­son the progress of psy­chi­a­try is arrested in Medieval times. I rarely diag­nosed a patient with the diag­no­sis of Bor­der­line Per­son­al­ity disorder.
I am try­ing to write some­thing, but basi­cally I am shocked, beyond shocked that peo­ple who are sup­posed to be applied sci­en­tists destroy lives by resort­ing to mostly fan­tasy labels such as Bor­der­linePsy­cho Ana­lysts and the Psy­cho­dy­namic ori­ented Psy­chi­a­trists are the one who cre­ated that Bor­der­line Per­son­al­ity dis­or­der diag­no­sis. Amer­i­can Psy­chi­atric Asso­ci­a­tion is con­trolled by those Psy­cho Analytical/ Psy­cho­dy­namic ori­ented Psy­chi­a­trists Psycho-Analysts and Psy­cho­dy­namic psy­chi­a­trists are any­thing but Sci­en­tific. They don‘t even think like physi­cians. Interestingly,for your info, one of the most pop­u­lar psy­chother­a­pies for the treat­ment of Bor­der­line per­son­al­ity dis­or­ders is DBT and DBT was invented, designed,and prop­a­gated by a women psy­chol­o­gist who as a patient spent very long time in the State Men­tal Insti­tu­tion because of chronic thoughts of sui­cide, depres­sion, and cut­ting herself.
Oh my! This can’t be right! But wait,
Heal­ing Rela­tion­ship con­struct applies when the dis­ease is iden­ti­fied by dis­rup­tion of rela­tion­ship. In psy­cho­dy­namic model (psy­cho­dy­namic clas­si­fi­ca­tion, eti­ol­ogy, pathol­ogy, and treat­ment) Gunderson’s approach might be accept­able. Indeed, if one focuses on rela­tion­ship and strives to recover it, then any improve­ment in this direc­tion would be ther­a­peu­tic suc­cess. In con­trast, bio­log­i­cal model focuses on psy­chobi­ol­ogy of BPD, specif­i­cally, affec­tive insta­bil­ity, exec­u­tive func­tion deficit (poor impulse con­trol, poor affec­tive con­trol which is not the same as insta­bil­ity, and weak judg­ment), and also poor real­ity test­ing. Improv­ing rela­tion­ships is sequen­tial and sec­ondary (tem­po­rally, not by impor­tance) to bio­log­i­cal improve­ment of emo­tional equi­lib­rium (mood sta­bi­liza­tion), exec­u­tive func­tion (increase in focus and impulse con­trol), real­ity test­ing (decrease of delu­sional think­ing). When these are taken care of, maybe a patient be intel­li­gent and ver­bal enough, sta­ble enough, Eng­lish speak­ing enough, hav­ing time and money enough to ben­e­fit from state of the art psy­chother­apy. Gun­der­son does not appre­ci­ate these com­plex­i­ties and instead jux­ta­po­si­tions phar­ma­co­log­i­cal and psy­chother­a­peu­tic approaches while brow­beat­ing any­one who doesn’t embrace whole­heart­edly his ide­ol­ogy. He is not con­vinc­ing (to put mildly).
“… The gra­tu­itous slaps at psychosocially-oriented psy­chother­a­pists show by some read­ers are excel­lent indi­ca­tions of peo­ple who are unsci­en­tific, illog­i­cal reduc­tion­ists who don’t know what they are talk­ing about. Per­haps they should read about epi­ge­net­ics and neural plas­tis­tic­ity — not to men­tion the entire attach­ment lit­er­a­ture or the huge lit­er­a­ture in social psy­chol­ogy. Too busy read­ing pro­pa­ganda from Shire Phar­ma­ceu­ti­cals?“
”””””‘
What a nasty and igno­rant lit­tle dia­tribe, yet so typ­i­cal from the apol­o­gist of failed psy­choso­cial dogma. More use­less the scheme — more vitu­per­a­tive is rhetoric, always wav­ing “entire attach­ment lit­er­a­ture” with­out any rhyme or rea­son. I’ve read it , now what. And at the end — wan­ton insult and insin­u­a­tion. As if Kohut’s dri­vel is any­thing but pro­pa­ganda. How bor­ing. At least Shire sells some­thing that works.
And finally, my favorite,

Bor­der­line PD = Angry PTSD

I love when when gifts like this arrive at my door! One group of knuck­le­heads on another site speak of the gift of ther­apy and the those who have devoted them­selves to heal­ing as “appa­rat” and Soviet, and many more speak of psy­chi­a­try as a mind­less devo­tion to pen­ning scripts and billing insur­ance com­pa­nies for the priv­i­lege of ten min­utes of inanity. What­ever. I always laugh when I recall the car­toon from the New Yorker, “Take the blue pill for angst, and the pink pill for ennui.” And so we get by.

Notes:

  1. And per­ti­nent her as well, the research indi­cated that treat­ing the co-morbid Axis I sysp­toms, such as depres­sion or acute anx­i­ety, fre­quently dimin­ished the Bor­der­line symp­toms as well.

The Devil’s in the Details

taviI was dri­ving to get blood­work, vaguely lis­ten­ing to the voice of Kai Ris­dal of Mon­ey­Mar­ket on NPR inter­view­ing Tavi Gevin­son, now 17 years old, who at age 11 began the web­site Rookie review­ing music, cloth­ing, “trends,” and such. Life is good, it stands to get bet­ter, she looks for­ward to the day peo­ple no longer honk at the fact it is a “teenager’s” accom­plish­ment, but rather sim­ply an “accom­plish­ment,” Oorah, say I, with thoughts that I shall check this out later. Rea­son, artic­u­la­tion, art, and lit­er­acy are to be admired wher­ever and when­ever they are found.

The next day, when I finally get around to seek­ing out Rookie, I run into a cover pic­ture of Dylan Far­row with the head­ing, “Sat­ur­day Links: We’re With Dylan Edi­tion.” I imme­di­ately closed my eyes and said, “Let me just con­jure up every silly, white-goose, aro­matic, ikky-thump, cringe-worthy stereo­type I can imag­ine; let them choke me so vig­or­ously I feel just short of vom­it­ing into my own lap. Then, like an IV bolus of Palonosetron, I will look up to dis­cover I wor­ried for noth­ing. No such luck. Instead are links to a bucket of trite “essays” and “opin­ions” and the req­ui­site enti­tled iVic­tim. Now, let me be emphatic here: I begrudge no one their opin­ion, but fair is fair. Some opin­ions are more learned and more valu­able than oth­ers, it’s a fact. For exam­ple, sim­ply being a vic­tim of any­thing imparts no spe­cial insight, in and of itself; it is equally likely to be a hin­drance in allow­ing the pro­jec­tion of one’s own expe­ri­ence as a gen­er­al­iza­tion or expec­ta­tion onto oth­ers. The field of chem­i­cal depen­dency treat­ment — as opposed to self-help — quickly learned the inad­e­quacy of “only addicts can help addicts.” Then we read of “rape cul­ture” and “power in hol­ly­wood,” assorted crank that white-geese with money — who can afford to not attend Fash­ion Week in lieu of some­thing more ethe­real — would have to patiently “spell out” to the dumb wait­ress from my side of New York.

Once I’ve com­pleted read­ing the actual “opin­ions” of the read­ers, I thought I would leave a com­ment to the effect that I legit­i­mately have some expe­ri­ence on both sides of this con­flict, hav­ing actu­ally pro­vided treat­ment to vic­tims — chil­dren and ado­les­cents in a hos­pi­tal set­ting — and con­ducted hun­dreds of diag­nos­tic assess­ments of felony child sex­ual preda­tors in prison. I noted that my point was not to crit­i­cize anyone’s cri­tique from the side­lines, as it were, but to appre­ci­ate the com­plex­ity. Ms. Gevin­son her­self responded:

Dylan Far­row spoke out, and peo­ple wrote essays so that her story would not go buried. We have linked to arti­cles that I believe do jus­tice to the extra­or­di­nary com­plex­ity of the sit­u­a­tion, and to the way we as a cul­ture talk about it. I will reit­er­ate what has already been said mul­ti­ple times in these com­ments: a sur­vivor has spo­ken, and we express sol­i­dar­ity with her. Again, this is not about what we all as out­siders think of it as a legal case, but about the way sur­vivors of abuse are con­sis­tently silenced, and how cru­cial it is to make sure Dylan’s story is not swept under the rug.

To make sure Dylan’s story is not swept under the rug?” Are you refer­ring to Dylan Far­row who has free access to The New York Times Edi­to­r­ial Page? Read it again, Ms. Gevin­son: The New York Times Edi­to­r­ial Page. This is the most “unburied” story I have ever read! In two replies to Ms. Gevin­son I inquired as to how many oth­er­wise unknown, unpub­li­cized women of color or dis­abled who are sur­vivors and have also “spo­ken” has she joined in “sol­i­dar­ity” to ensure their sto­ries “would not go buried?” I invited her to a day behind the one-way mir­ror to observe treat­ment of the “prey” and one day to observe the “preda­tors.” Like­wise, I offered to fill pages of her blog with sto­ries of the bro­ken, the shamed, those unlikely to heal, those who will never have a voice. And Ms. Gevinson’s solu­tion was to sweep me under the rug and delete my posts from her la-de-da sol­i­dar­ity with the last per­son on this earth that needs another enti­tled silly white goose. Some peo­ple just don’t don’t know when to haul their laun­dry in, and sort of enjoy that it annoys the neigh­bors. As an old men­tor of mine used to mock, “Let’s go feed the poor, but please, be back promptly by 4:30 for the wine and cheese reception.”

Serendipity Disorder — Au Milieu

mex_borderAnother 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. 1

[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). 2 3

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?

Preva­lence:

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 4

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)]?” SURPRISE! “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.

Notes:

  1. Gun­der­son, J. “Reori­ent­ing a depressed datient to dddress udnder­ly­ing BPD.” Online at http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1815075
  2. Shanks C, Pfohl B, Blum N, Black DW. Can neg­a­tive atti­tudes toward patients with bor­der­line per­son­al­ity dis­or­der be changed? The effect of attend­ing a STEPPS work­ship. J Pers Dis­ord 25(6):806–812, 2011
  3. Skodol AE, Grilo CM, Keyes KM, Geier T, Grant BF, Hasin DS. Rela­tion­ship of per­son­al­ity dis­or­ders to the course of major depres­sive dis­or­der in a nation­ally rep­re­sen­ta­tive sam­ple. Am J Psy­chi­a­try 168(3):257–264, 2011
  4. Ghaemi, N. “Treatment-resistant depres­sion: The bor­der­line claim” On-Line: http://boards.medscape.com/forums?128@225.BPGTa1YHGvE@.2a5bd02b!comment=1&cat=All

Serendipity Disorder — Prologue

mex_borderA friend of mine who works in a parole out-patient clinic emailed me as to my opin­ion of an his­tor­i­cal diag­no­sis of Anti­so­cial Per­son­al­ity Dis­or­der for a guy who just com­pleted 19.5 years in prison for mur­der­ing a rival gang mem­ber as a youth. What are we talk­ing about here when we speak of per­son­al­ity dis­or­ders? Accord­ing to the DSM-V, these are “endur­ing pat­terns” of impair­ment that develop early in life that “devi­ate markedly from the expec­ta­tion of the indi­vid­u­als cul­ture” and are “per­va­sive and inflex­i­ble” impair­ments that incor­po­rate them­selves into the indi­vid­ual. And what is “anti­so­cial?” It is a “per­va­sive and inflex­i­ble” pat­tern of “fail­ure to con­form to social norms,” mean­ing legally, finan­cially (often referred to as a “par­a­sitic lifestyle”), and inter-personally (e.g. indif­fer­ence to the rights, safety, prop­erty, etc. of others).

A fur­ther cat­e­go­riza­tion is reserved for those foren­sic patients who dis­tin­guish them­selves for the vicious­ness of their cru­elty, ser­ial repet­i­tive­ness, and the extent of their depraved indif­fer­ence, and this is referred to as “psy­chopa­thy.” Typ­i­cally, this term is best typ­i­fied by indi­vid­u­als such as Ted Bundy, the BTK Killer, and Richard Ramirez, but seems equally applic­a­ble to some­one like ser­ial finan­cial vic­tim­izer Bernie Madd­off. In a fas­ci­nat­ing inter­view with New York Mag­a­zine in 2011, Mad­off takes great excep­tion to being ref­er­enced to in the media as a “mon­ster,” despite being respon­si­ble for the finan­cial ruin of thousands:

And so, sit­ting alone with his ther­a­pist, in the prison khakis he irons him­self, he seeks reas­sur­ance. “Every­body on the out­side kept claim­ing I was a sociopath,” Mad­off told her one day. “I asked her, ‘Am I a sociopath?’ ” He waited expec­tantly, his eye­lids squeez­ing open and shut, that famous tic. “She said, ‘You’re absolutely not a sociopath. You have morals. You have remorse.’ ” Mad­off paused as he related this. His voice set­tled. He said to me, “I am a good per­son.”
And finally, there is also a cat­e­go­riza­tion for what is termed Adult Anti­so­cial Behav­ior which is not a men­tal dis­or­der in and of itself, but what the DSM-V terms “Other Con­di­tions That May Be a Focus of Ciini­cal Atten­tion, in this case, “adult anti­so­cial behav­ior that is not due to a men­tal dis­or­der (e.g., con­duct dis­or­der, anti­so­cial per­son­al­ity disor­der). Exam­ples include the behav­ior of some pro­fes­sional thieves, rack­e­teers, or deal­ers in ille­gal sub­stances.” In other words, crime! Not to bela­bor the point, but I was dis­missed from jury duty because a pros­e­cu­tor believed men­tal health pro­fes­sion­als are inca­pable of dis­tin­guish­ing between men­tal dis­or­der & crim­i­nal behav­iour. As I departed, I was able to dis­tin­guish for her the dif­fer­ence between a jack­ass and a don­key. Back to the story…

Attached to my friend’s email are the com­ments of her for­mer super­vi­sor (for good mea­sure?) adviz­ing admin­ster­ing the Hare PCL-R, the only val­i­dated instru­ment to rate psy­chopa­thy in a male foren­sic pop­u­la­tion, “and get the diag­no­sis to stick.” Prison is the only place on earth where the pur­posely short-term dis­tinc­tion “rule out” can last years and the ratio­nale for sug­gest­ing the need to con­sider the diag­no­sis long dis­ap­peared. For exam­ple, amidst the mun­dan­ity, I see in the file of a new patient that he was diag­nosed with Tourette’s Syn­drome, a neu­ropsy­chi­atric dis­as­ter of spas­tic tics and shouted obscen­i­ties. STAT request by psy­chol­ogy to psy­chi­a­try. Holy Cow! I’m wait­ing all day for this guy and… noth­ing. More tics on my dog. He tells me, “I used to have this habit of crack­ing my neck,” he sort of flinches left (crack), then right (crack), “but I stopped doing it. Some­body said I’d get arthri­tis.” Boy, and you can just hear Gun­nery Sgt. Hart­man to Cow­boy, “This ain’t your daddy’s shot­gun, Pvt. Cow­boy. Move the rifle around your head, not your head around the rifle…” Back to the story…

Despite the fact that the Diag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders pur­ports itself to be, in fact, a “sta­tis­ti­cal” and epi­demi­o­log­i­cal doc­u­ment, it is thin to say the least:

Preva­lence: Twelve-month preva­lence rates of anti­so­cial per­son­al­ity dis­or­der, using cri­te­ria from pre­vious DSMs, are between 0.2% and 3.3%. The high­est preva­lence of anti­so­cial per­son­al­ity dis­or­der (greater than 70%) is among most severe sam­ples of males with alco­hol use dis­order and from sub­stance abuse clin­ics, pris­ons, or other foren­sic set­tings. Preva­lence is higher in sam­ples affected by adverse socioe­co­nomic (i.e., poverty) or socio­cul­tural (i.e., migra­tion) factors.
“Greater than 70%” twelve-month preva­lence rates in pris­ons? What? We’ll return to this…

Mur­der, after all, is mur­der and I cer­tainly do not wish to appear cav­a­lier or to min­i­mize or mit­i­gate the act, but a youth­ful offense com­mit­ted in the con­text of a vio­lent street gang is sig­nif­i­cantly dif­fer­ent than the psy­cho­pathic plan­ning and facil­i­ta­tion of ser­ial tor­ture and mur­der. Like­wise, if we accept that a per­son­al­ity dis­or­der is a fun­da­men­tal “incor­po­ra­tion” of an endur­ing and inflex­i­ble pat­tern of anti­so­cial malig­nancy into the makeup of an indi­vid­ual, how is it pos­si­ble this indi­vid­ual has man­aged to “con­tain” his char­ac­ter­is­tic social non-conformity for nearly twenty years? At the same time, I can make the argu­ment that a prison envi­ron­ment is nec­es­sar­ily an envi­ron­ment of adult anti­so­cial behav­iour. Some exam­ples. Both the DSM and the PCL-R weigh highly the symp­tom of deceit/lying/alias assumption/conning as clas­sic to ASPD/psychpathy. Nev­er­the­less, there is absolutely no value placed on hon­esty in prison. None. In fact, it is much more likely to cause you prob­lems. Say any­thing that is vaguely incrim­i­nat­ing, threat­en­ing, or crim­i­nal on the phone, in the mail, or in earshot of any staff and some­body look­ing for a “bar­gain” and, buddy, you will find out the real mean­ing of “any­thing you say can and will be used against you.” You’re tagged a SNITCH? You have the shelf-life of a “sell by yes­ter­day” car­ton of milk. Chris Rock asked how the mil­i­tary could find Sad­dam Hus­sein in some obscure vil­lage hid­den in a hole under a piece of ply­wood, but the cops couldn’t find one wit­ness to who shot Tupac Shakur on the Vegas Strip on a Sat­ur­day night? Answer: some folks have been to prison.

The prob­lem, how­ever, is that anti­so­cial behav­iour is aggra­vat­ing like you can’t imag­ine. As the diag­nos­tic cri­te­ria states, it is founded in a pat­tern of behav­iour “occur­ring since age 15,” and has his­tor­i­cally been asso­ci­ated with Con­duct Dis­or­der of child­hood. In the DSM-V, all of this is now gath­ered into the sin­gle super-annoyance of “Dis­rup­tive, Impulse-Control, and Con­duct Dis­or­ders.” So, from instinct, when we feel the aggra­va­tion, the provo­ca­tion, the limit-testing of ASPD, it is not dif­fi­cult to relate it to every punk who made our col­lec­tive child­hoods mis­er­able by humil­i­a­tion, intim­i­da­tion, or worse, with­out the slight­est bit of acknowl­edge­ment or remorse. Or per­haps equally telling, I recall co-facilitating an in-patient ado­les­cent fam­ily group where a par­ent screamed at her Con­duct Dis­or­dered son, “I just want to come over there and slap you,” and another parent’s feed­back to this mother was, “I just want to come over there and slap you.” Now, there are numer­ous ways to test this the­ory, but the one I have seen that best makes my point is any effort specif­i­cally exerted to impede “the count.” The count is exactly what it implies, sev­eral times a day, every­thing comes to a halt while cus­tody staff ver­i­fies that every inmate who is sup­posed to be there is, in fact, present and accounted for. Want to mess with the whole show? Be late from work/clinic/whatever, drag your feet, “board up” (i.e. cover your win­dows so you can’t be seen), be disruptive/argumentative, cause a disturbance/distraction, etc. dur­ing the count and it will find its way to your chart. Add to this the inabil­ity to deal with grief at the death of a loved one, forced divorce or ter­mi­na­tion of sig­nif­i­cant rela­tion­ship, etc. with accom­pa­ny­ing reac­tion for­ma­tions, blah, blah, blah and anti­so­cial behav­iour cer­tainly seems “per­va­sive and fixed.”

What is my point with all this? It stands to rea­son that most any­one who is placed in an envi­ron­ment guided by adult anti­so­cial behav­iour will assume anti­so­cial behav­iour to sur­vive. With the pas­sage, for exam­ple, of the “3-Strikes Law” in Cal­i­for­nia, there are a sig­nif­i­cant num­ber of rel­a­tively younger indi­vid­u­als serv­ing life-sentences with­out the pos­si­bil­ity of parole, mak­ing it all the more rea­son­able to sus­pect an endur­ing future atmos­phere that will be more patho­log­i­cal and more anti­so­cial. At the same time, Cal­i­for­nia is under a fed­eral appeals court man­date to reduce over­crowd­ing and has been forced to release offend­ers early back into the com­mu­nity. It would like­wise stand to rea­son that if ASPD has not become a “slo­gan” for typ­i­cal prison behav­iour reframed as per­son­al­ity dis­or­der, we would be inun­dated with crimes typ­i­cal of those inca­pable of con­form­ing to soci­etal norms. We have not not. So, how did I respond to my friend? This is the per­fect exam­ple of why we main­tain a pro­vi­sion to rule out con­di­tions or des­ig­nate clin­i­cal con­cerns “by his­tory.” Twenty years is a long time to wear the coat of ASPD — which he may never have sus­pected — but mur­der + ASPD and no one believes your name with­out pic­ture ID, and even then…

Since the DSM-V now offers some gen­der and culture-specific data, I thought I might check as the com­men­tary avail­able for ASPD:

Anti­so­cial per­son­al­ity dis­or­der is much more com­mon in males than in females. There has been some con­cern that anti­so­cial per­son­al­ity dis­or­der may be under­diag­nosed in fe­males, par­tic­u­larly because of the empha­sis on aggres­sive items in the def­i­n­i­tion of con­duct dis­or­der.
That’s it? C’est ça au total. For what it’s worth, I can tell you that I do not recall ever see­ing a woman in a Cal­i­for­nia prison diag­nosed with ASPD. BUT, with­out look­ing, do hap­pen to recall the graphic that began this post? It’s a “bor­der” marker to refer to Bor­der­line Per­son­al­ity Dis­or­der, which is where we’ll head next.

Houston, Il y une couille dans le potage…

lynching-optA friend of mine, a mem­ber of the clergy, was in town Sun­day, some­one I have known since col­lege, so we went to visit my mother and watched the San Diego Charg­ers for­sake us to the Den­ver Bron­cos, while my wife went scuba div­ing in La Jolla Cove. We were talk­ing about all sorts of things, rem­i­nisc­ing, catch­ing up, when he said to me, “Have you heard about this priest so-and-so?” a name that I had never heard — not that it was be sig­nif­i­cant — and he went on to say that he was a monas­tic and a mil­i­tary chap­lain who dropped both to very pub­licly marry another man. Really? It takes all kinds… But even this wasn’t enough, “And you want to guess who was his ‘spir­i­tual men­tor,’ who ordained him and ton­sured him a monk?” I plead­ingly look up as Philip Rivers goes down to hear, “Met­ro­pol­i­tan Jonah.” Obvi­ously I laugh — at the irony of the sit­u­a­tion, but clearly because it por­tends more to the story — “Some of the Synod had been informed by SVS class­mates of this man who knew he was gay, ask­ing the Bish­ops to talk some sense into Jonah who was dead set on ordain­ing him.” Oorah! “When they asked Jonah, he assured them there would be no prob­lem.” I shouted, “I can name that tune! Pat­terned after a hieromonk in Wash­ing­ton DC who liked the odd com­bi­na­tion of alco­hol, firearms, and date-rape!” “But name the tune!” “STINKBOMB!” For­tu­nately, being that my mother is 85-years old, she has poor hear­ing; she watched the NFL play­off, seemed to enjoy us laugh­ing, but escaped the piti­ful real­ity of the dis­cus­sion. And piti­ful it was.

But it is now Wednes­day and I was sit­ting in the front office with some of the recep­tion staff at 1:56 am when I received an unrec­og­nized email which I nearly erased as spam with­out open­ing. Read­ing it, how­ever, an indi­vid­ual claim­ing to be a class­mate of the for­mer priest at the cen­ter of this scan­dal said he is one of sev­eral who informed the Bish­ops of what Jonah was propos­ing to do and sought their inter­ven­tion. He reported details of OCA life to me that I know are not widely dis­sem­i­nated — which on the one hand makes me very angry, but on the other hand sug­gests an accu­rate rep­re­sen­ta­tion of details. In any case, I am not inter­ested and I don’t much care. But what is inter­est­ing is his rea­son for writ­ing me in the first place: he responded to sev­eral creeps on the Mono­makhos site and received an email from the site owner say­ing that he would be “in mod­er­a­tion” until his accu­sa­tions could be ver­i­fied! Ver­i­fied? Mr. Michalop­u­los is the Cal Wor­thing­ton of verac­ity (and heaven only knows to what the writer refers when he says to Mr. Michalop­u­los, ‘I see from your pro­file pic­ture you are a doc­tor?’ Yikes!).

Let me just say that when I actu­ally went to the Monom­ahkos site to see this fellow’s com­plaint, it turns out it’s noth­ing but another slow day at the Star Trek con­ven­tion, summed up by the pro­pri­etor of the joint like this:

How can you blame a bishop for ordain­ing one bad apple? Are you sure you want to go down that trail and dredge up all the other bish­ops who ordained known homo­sex­u­als to the priest­hood some 30–40 years ago? Some of whom mar­ried women and then divorced them to live with their catamites while still being in the priest­hood? Some of whom are lauded by the Syos­set Set?

What I am see­ing in my mail is a very real fear by the Syos­set Set that the jig is finally up and they’re scram­bling to find some­body to blame for this priest’s actions. It’s not going to work, Jonah is no more respon­si­ble for this man’s spir­i­tual mal­for­ma­tion than the man on the moon. Instead what is becom­ing more appar­ent is that his for­ma­tion took a decided turn for the worse while at SVS. And as we can see from the hun­dreds of kudos, the field was very fer­tile on the East Coast for such a shift in attitudes…

Irony of ironies: while Jonah was will­ing to “reimag­ine auto­cephaly,” peo­ple at SVS were will­ing to “reimag­ine mat­ri­mony.”

And there you have it. Who would have imag­ined that the ever-increasing jin­go­isms of Star Trek Nation would include l’andouillette reimag­in­ing auto­cephaly; the self-imposition of a lobbied-for cha­peau blanc, unearned and unde­served? And col­lat­eral lives ruined in the wake. “I love the smell of napalm in the morn­ing. It smells like vic­tory.” Il y une couille dans le potage… Fig­ure it out. I don’t know who you are, dude, but I have actu­ally looked indi­vid­u­als in the eyes who awaken in the morn­ing and no longer smell napalm. Their eyes are clear. Their anx­i­ety & fear left with Jonah.

Now, when I read the self-righteousness of the anony­mous en peu un dur Lex­car­tis, “The pro­fes­sor and two stu­dents must be cor­rected and brought to repen­tance. Who’s going to do it?” and “Assem­ble those of whom you speak and see the Chan­cel­lor and Dean and demand action or with­draw en masse”; when I read Sick of the Hypocrisy,“A priest “groom­ing” a young sem­i­nary stu­dent? What hap­pens if this “match made in heaven” as some OCA clergy and sem­i­nary pro­fes­sors have declared, goes bad? Much to con­sider here and much more still to be revealed”; and Alexan­der, “Pub­lish the names. All of them. Why hide? And if there are pic­tures, pub­lish them too. Deco­rum involv­ing the cabal long since left the room,” yet sees no irony in hid­ing him­self; and who could for­get the enculé de première, Thomas Barker, who rolls the word sodomy from his mouth like Parisian Bear­naise, I get so angry with right­eous indig­na­tion, I just want to string some­body up! Scroll back to the top! Rest easy, Ortho­dox Cham­pi­ons of True Virtue! I took care of it for you. Under all that blus­ter, you are still name­less, face­less cowards.

All things are weari­some; Man is not able to tell it. The eye is not sat­is­fied with see­ing, Nor is the ear filled with hear­ing. That which has been is that which will be, And that which has been done is that which will be done. So there is noth­ing new under the sun. Is there any­thing of which one might say, “See this, it is new “? Already it has existed for ages which were before us.… (Ecc 1:8–10)
I noticed that Mr. Michalop­u­los wrote recently, “When we started this blog some three years ago, it was to be an enter­prise devoted to cul­tural and polit­i­cal polemics, Chris­t­ian apolo­get­ics, and more or less what­ever else suited our fancy. We cer­tainly didn’t envi­sion that it would become a blog that would fer­ret out cor­rup­tion, esp­cially (sic) in the Church.” He does an excel­lent job dis­prov­ing his own fer­rets. Camus said it best: “Don’t believe your friends when they ask you to be hon­est with them. All they really want is to be main­tained in the good opin­ion they have of them­selves.” Some­times “mod­er­a­tion” lasts forever.

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