Is Borderline Personality Disorder Real?

A mood disorder may be the least of your problems.

Borderline personality disorder. 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.

No wonder they are drawn to depression and bipolar support groups, I realized. We have a lot in common. Unfortunately, there is only so much we can do to help them. Only one of the individuals I encountered openly acknowledged the diagnosis. The others, I assumed, had not been diagnosed. Yes, they 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.

My curiosity was aroused, particularly when I started connecting the dots to other individuals I had encountered in my life. 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.

Dr Akiskal, the leading proponent of the mood spectrum, has been badmouthing borderline for decades. A 1985 article he co-authored had this title: "Borderline: An Adjective in Search of a Noun." Dr Akiskal has made a study of personality, but in the context of temperaments distributed along a continuum ranging from benign to affective illness.

In a 2005 article on mixed depressive states, Akiskal and Benazzi observed that whereas hostility and anger do not even rate as a subtype of depression, they are cardinal features of borderline personality disorder. No wonder Dr Akiskal disses this diagnosis.

Axis II Grind

Joel Paris MD of McGill University is one of the leading authorities on borderline and other personality disorders. In 2006, he was one of a handful of APA honorees delivering an award lecture at the annual meeting. Ironically, Dr Akiskal delivered an award lecture a year earlier. But unlike Dr Akiskal from the year before and the bipolar II symposium, Dr Paris’s lecture was far from packed. The name of his talk said it all: "Personality Disorders: Psychiatry’s Stepchildren Come of Age."

Clearly, Axis II is not psychiatry’s favorite child.

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.

Here’s Where You Come In

So here you are. Your first antidepressant has either failed you or has achieved only a partial result. Your psychiatrist now has three broad, and not necessarily mutually exclusive, options:

1. Assume for the time being your depression is unipolar, and try a second antidepressant or augment that antidepressant with another medication.
2. Probe for evidence of bipolar disorder or for bipolar characteristics in unipolar depression (such as mixed states and cycling), and consider trying a mood stabilizer.
3. Investigate for personality features that may have an impact on outcome, and consider referral to a talking therapist or combined meds-talking therapy.

Just to illustrate how far psychiatry has to go, the APA’s "Practice Guideline for the Treatment of Patients with Major Depressive Disorder" only considers the first option. The Guideline does state that before treating with antidepressants the bipolar diagnosis must be ruled out.

A number of articles here on mcmanweb devote considerable space to the possibility of option two. What about the third option? Can we turn to the personality disorders experts for some guidance?

Michael Bagby MD of the University of Toronto spoke at an even smaller venue at the 2006 APA annual meeting. Dr Bagby has investigated depressed patients using the five-factor model. In a 2002 study, he and his colleagues examined 58 patients with major depression who had responded to treatment. Twenty-six were identified as having underlying chronic minor depression. This group, after the major depression had resolved, still had higher hostility scores and lower agreeableness scores than those without the underlying minor chronic depression.

Dr Bagby and his study co-authors cited the pioneering diagnostician Emil Kraepelin in support of the proposition that, historically, minor depression was thought to exist on a spectrum with personality. He also speculated that these individuals "may define a group who are pessimistic, disaffected, and frustrated, perhaps because they see their illness as an intractable and enduring part of their selves."

So forget the antidepressant and go with psychotherapy, right? Not so fast, said Drs Bagby and Paris in their talks. For one, it is often difficult to form a therapeutic alliance with an angry or hostile individual. Moreover, SSRIs decrease anger and hostility while mood stabilizers work for impulsivity. Dr Bagby suggests first going with meds for a patient who scores high on neuroticism, then talking therapy.

But what is borderline personality disorder? On to the next article: Borderline Personality Disorder Gains Respect

McMan's Depression and Bipolar Web