[REVIEW] Why Psychiatrists Are Reluctant to Diagnose Borderline Personality Disorder by JOEL PARIS, MD Dr. Paris is a Professor of Psychiatry, 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 complex syndrome with symptoms that overlap many Axis I disorders. This paper will examine interfaces between BPD and depression, between BPD and bipolar disorder, 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 psychosis 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 mental health 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 mood disorder, 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 schizophrenia.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 stress-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 exaggerations 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 delusions. 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 antipsychotic 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