[REVIEW]

Why Psychiatrists Are Reluctant to Diagnose Borderline by JOEL PARIS, MD

Dr. Paris is a Professor of , McGill University, Institute of Community and Family Psychiatry, SMBD-Jewish General Hospital, Montreal, Quebec, Canada.

ABSTRACT Clinicians can be reluctant to make a diagnosis of borderline personality disorder (BPD). One reason is that BPD is a with symptoms that overlap many Axis I disorders. This paper will examine interfaces between BPD and depression, between BPD and , and between BPD and psychoses. It will suggest that making a BPD diagnosis does more justice to patients than avoiding it.

WHAT IS BORDERLINE PERSONALITY DISORDER? Borderline personality disorder (BPD) is a diagnosis with an unusual history. The idea that patients might fall on some sort of “borderline” between and neurosis dates back to 1937, at which time the syndrome was first described.1 BPD patients do have quasipsychotic or micropsychotic symptoms, such as voices telling them to kill themselves, paranoid feelings, and depersonalization.2 However these cognitive symptoms are not essential features of BPD. The core of the syndrome is a striking instability of mood, accompanied by a wide range of impulsive behaviors, particularly self-cutting and overdoses, and with ADDRESS CORRESPONDENCE TO: Joel Paris, MD, Professor of Psychiatry, McGill University, Institute of Community and Family Psychiatry SMBD-Jewish General Hospital, 4333 chemin de la côte ste. catherine, Montreal H3T 1E4, Québec, Canada; E-mail: [email protected] intimate relationships that are impulsive, stormy, and chaotic.3 KEY WORDS: borderline personality disorder, psychiatric diagnosis

[JANUARY] Psychiatry 2007 35 Since BPD begins early in life and with stigma. It is an unfortunate category, producing a heterogeneous can continue over many years, it is reality that a diagnosis of BPD can group. classified as a personality disorder. indeed lead to rejection by the It would be better to identify However, BPD differs from other system. If BPD were crucial features without which the categories on Axis II in that it is to be reclassified as, for example, a diagnosis should not be made. One associated with a wide range of , patients would tend can group the current DSM criteria active symptoms.4 Moreover, BPD is to be seen as having a biological into affective, impulsive, one of the most common clinical illness instead of having a interpersonal, and cognitive problems psychiatrists see in problematical personality. However, components. Patients should have practice. One study found that half of stigma cannot be removed by most or all of these features to merit all patients with repetitive suicide reclassification. Patients who are the diagnosis. That approach has attempts in emergency rooms meet chronically suicidal and who do not been used in a research measure, the criteria for this diagnosis.5 Due to form strong treatment alliances will Diagnostic Interview for Borderlines suicidal threats and actions, BPD continue to be just as difficult, even (DIB),13 later revised as the DIB-R.14 patients are often admitted to under a different diagnostic label. This semistructured interview scores hospital.6 BPD cases are also common each of four areas of pathology on in out-patient settings,7 where the COMORBIDITY AND DIAGNOSTIC four sub-scales (0–2 for affective and pathology is often serious enough to PROBLEMS cognitive symptoms and 0–3 for use a large amount of clinical Patients with BPD frequently impulsive and interpersonal resources. meet criteria for multiple Axis I symptoms), using an overall cutoff diagnoses.10 Considering that the point of eight out of 10 for positive WHY CLINICIANS ARE RELUCTANT disorder is associated with so many diagnosis. Patients who meet DIB-R TO DIAGNOSE BPD symptoms, this level of comorbidty criteria are much more Structured interviews pick up should not be surprising. Changing homogeneous, as shown by studies many cases of BPD missed in the diagnosis of a patient with BPD, demonstrating that this instrument ordinary practice.7 This finding shows however, to one of these comorbid distinguishes them from patients that practitioners are not consistently disorders focuses on only one aspect with other Axis II disorders, and making this diagnosis. There are a the syndrome and fails to account diagnosis achieves similar specificity number of reasons why clinicians for BPD’s broad range of clinical if one requires six or seven criteria may be reluctant to recognize BPD. phenomena (affective, impulsive, rather than five.15 First, Axis I diagnoses are more interpersonal, and cognitive). familiar to most professionals. Making While it is tempting to conclude BPD AND PSYCHOSIS an accurate Axis II diagnosis requires that diagnoses such as major The original concept of BPD as experience. Personality disorders depression are the “real” problems in lying on a border between neurosis often seem to lack precise BPD, similar symptoms can derive and psychosis found a parallel in the symptomatic criteria, since many of from entirely different causes. diagnostic term pseudoneurotic their features describe problems in Clinical phenomena, such as low .16 The concept was interpersonal functioning that require mood or unstable mood, are no more that patients with such a wide clinical judgment for accurate specific than fever or inflammation. variety of neurotic symptoms could assessment. All that “comorbidity” says is that be latently psychotic. However, this Second, resistance to diagnosing there are enough symptoms in one diagnosis confused personality patients with a personality disorder patient to meet criteria for more disorders primarily affecting mood may be based on the idea that these than one DSM category.11 Moreover, and impulsivity (like BPD) with conditions are untreatable,8 or at overlap is common in the DSM categories that primarily affect least not treatable using the system—major depression has at cognition, such as schizotypal pharmacological tools that have come least as much comorbidity as any personality.17 Neither family history to dominate the treatment of so Axis II disorder.12 studies nor biological markers many other disorders. While there is Another source of confusion is support a link between BPD and good evidence for the efficacy of that the description of BPD in DSM- schizophrenia.18 Nonetheless, some psychotherapy in BPD,9 not every IV-TR is not specific.4 The definition cases are challenging for differential clinical setting has the resources to introduced in DSM-III was an diagnosis, since the cognitive provide that form of treatment. advance because it operationalized symptoms of BPD can occasionally Simpler constructs such as major diagnosis using observable criteria. be florid. However, these phenomena depression lead to more familiar As with other disorders, DSM are transient and -related, treatment options, particularly instructs the clinician to make a while insight is retained, as the pharmacotherapy. diagnosis when five out of nine following case example illustrates. Third, clinicians may wish to criteria are met. The result is that Case example—Patient 1. Bill avoid making diagnoses associated many permutations lead to the same was a 25-year-old man under

36 Psychiatry 2007 [JANUARY] IT IS AN UNFORTUNATE REALITY that a diagnosis of BPD can indeed lead to rejection by the mental health system....However, stigma cannot be removed by reclassification. Patients who are chronically suicidal and who do not form strong treatment alliances will continue to be just as difficult, even under a different diagnostic label. treatment for chronic suicidality, common in families than mood antidepressants were no longer unstable relationships, and mood disorders.18 Another argument was considered necessary. instability. He also had paranoid based on commonalities in biological ideas, sometimes thinking that markers, such as REM latency.19 BPD AND THE BIPOLAR neighbors were plotting against him. However, it has never been shown SPECTRUM All these thoughts, however, were that these markers are specific to It has been proposed that of real situations and DSM categories. borderline pathology falls within the never had the bizarre quality of There is an important spectrum of bipolar illness,22 based . Bill also heard critical phenomenological distinction on a wish to expand the narrower voices in his head when stressed, but between temporal patterns of diagnostic construct of bipolar knew that such experiences were depressive symptoms in depression disorder into a much broader range imaginary. Bill received a DIB-R and BPD.21 In classical depression, of conditions termed the bipolar score of 9/10. mood is stable over weeks and is spectrum. In this model, the range Nonetheless, Bill was initially relatively unresponsive to the of bipolar spectrum disorders would diagnosed with schizophrenia and environment. In contrast, mood in be extended to include bipolar III treated for psychosis for over five BPD is highly mercurial. Moreover, (antidepressant-induced years with injectable mood can be strikingly unstable in hypomania), as well as bipolar IV medication. Bill actually liked the course of a single day, depending (ultra-rapid-cycling bipolar attending this clinic and getting the on life events. Patients have a disorder). The last category, bipolar injections, since it gave him a reason mixture of affects—not only sadness IV, describes mood swings typical of to come in every two weeks and to or , but also , brief BPD (i.e., rapid shifts over hours). talk with a nurse. However, as his life periods of elation, and feelings of This expanded definition might stabilized, Bill’s micropsychotic numbness. On a more practical note, include many, if not most, patients symptoms eventually remitted, along depression in BPD does not respond with BPD. with his impulsive and affective in the same way as classical The issue is whether the lability of symptoms. By age 30, Bill stopped depression to antidepressant drugs, mood seen in BPD is identical to taking neuroleptics and never had a as the following case illustrates.9 phenomena observed in mood relapse of paranoid ideas or Case example—Patient 2. disorders, such as bipolar II.23 . Susan was a 24-year-old woman Hypomanic episodes have to last for under treatment for chronic at least four days, and this BPD, DEPRESSION, AND depression, with rapid shifts of consistency of mood is rarely seen in mood, usually to anger and rageful BPD. Instead, affective instability Depression is a common reason outbursts. She also had a history of (AI) is a characteristic feature that for clinical presentation in patients self-cutting and repetitive overdoses. distinguishes BPD from classical with BPD. It has been suggested that Susan received a DIB-R score of bipolar disorder (as well as from the BPD is an atypical form of 10/10. other personality disorders). unipolar depression.19 BPD is Nonetheless, Susan was diagnosed Emotion dysregulation is a similar associated with chronic lowering of with major depression and treated concept.24 mood, particularly dysthymia with an with a variety of antidepressants Other lines of evidence have also early onset.20 One argument in favor from several classes, none of which failed to support the idea that BPD of BPD as a form of major had any lasting effect. Each and bipolar disorder reflect the same depression was based on the medication change led to short-term underlying .25,26 To frequency of family history of improvement for a few weeks summarize, there is no evidence for depression in BPD patients. followed by relapse to her previous a common etiology, family However, impulsive disorders, such state. Once Susan became engaged prevalence data shows that as and antisocial in psychotherapy, however, she impulsive disorders are more personality, are actually more improved to the point that common than mood disorders in the

[JANUARY] Psychiatry 2007 37 PHARMACOTHERAPY FOR DEPRESSION is less effective in the presence of any personality disorder, and patients with BPD respond inconsistently to antidepressants9...Unfortunately, such results do not always lead physicians to reconsider diagnosis and therapy—all too often, BPD patients are tried on a variety of medications or given nonevidence-based polypharmacy. first-degree relatives of patients with The problem is the assumption that with symptoms that do not occur in BPD, the longitudinal course of BPD trauma is the primary cause of BPD, isolation. BPD is a construct that can rarely shows evolution into bipolar rather than one among many risk account for the co-occurrence of a disorder, and treatment studies have factors. Research shows that wide range of affective, impulsive, failed to show that mood stabilizers biological, psychological, and social and cognitive symptoms in the same have anywhere near the same factors are all involved in the patient.4 efficacy in BPD as they do in bipolar etiology of BPD, that severe trauma The second advantage concerns disorder. histories are only found in about a prediction of outcome. BPD has a The following case demonstrates third of cases, and that most people characteristic course over time, some of the problems in differential exposed to child abuse in community beginning in adolescence, with diagnosis between BPD and bipolar samples have neither BPD nor any symptoms peaking in early disorder. other diagnosable psychiatric adulthood, followed by gradual Case example—Patient 3. Lisa disorder.28 recovery in middle age.29 This had been self-cutting since age 16 Case example—Patient 4. Lisa outcome pattern provides a useful and presented to a clinic with came for treatment of chronic frame for therapy. chronic suicidal ideation, irritability, suicidal ideation, multiple overdoses, The third value of diagnosing BPD and rages. Lisa received a DIB-R and unstable intimate relationships. lies in predicting response to score of 9/10. She also had transient episodes of treatment. Pharmacotherapy for Nonetheless, bipolar II disorder depersonalization. Lisa’s DIB-R score depression is less effective in the was diagnosed on the basis of Lisa’s was 8/10. presence of any personality disorder, mood swings, as well as repeated A previous therapist had and patients with BPD respond episodes in which she impulsively diagnosed Lisa with PTSD, and Lisa inconsistently to antidepressants.9 became involved with men—flying did have serious problems resulting The problem is that drugs are not as thousands of miles to meet them from having been sexually abused by effective in BPD as they are in the after an initial internet contact. At her stepfather between ages of 7 and disorders for which they were certain points of her illness, Lisa also 12. It was interesting, nonetheless, to originally developed. In several of the showed quasipsychotic symptoms, note that her older sister, who was case examples presented above, the such as an intense fantasy that she abused in precisely the same way, patients were treated with was Jesus’s sister who had been sent never experienced psychological pharmacotherapy based on an Axis I to earth with a mission. Yet lithium, problems to the extent that she ever diagnoses, without obvious benefit. prescribed for a full year in adequate sought treatment. While the issue of Unfortunately, such results do not doses, had no affect on her child abuse played an important role always lead physicians to reconsider symptoms. Instead, all of these in her psychotherapy, Lisa’s diagnosis and therapy—all too often, problems came under control within symptoms resolved gradually over patients are tried on a variety of weeks once Lisa entered time as she was able to find regular medications or given nonevidence- psychotherapy and formed a solid employment and become involved in based polypharmacy. therapeutic alliance. more stable, less demanding The fourth advantage, closely relationships. related to the last point, is the strong BPD AND POSTTRAUMATIC evidence that psychotherapy can be STRESS DISORDER POSITIVE REASONS FOR an effective form of treatment for The concept that BPD might be a DIAGNOSING BPD BPD.9 We now know that several “complex” form of posttraumatic What are the advantages in forms of cognitive and dynamic stress disorder (PTSD) has been making the diagnosis of BPD? The therapy are at least as effective, if suggested by frequency of childhood first concerns the recognition of not more effective, than drugs in abuse histories in these patients.27 complex forms of psychopathology relieving the symptoms of BPD. If

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