A free eBook – 4X4 for Nons
|
A little while ago, I posted an study about the over-lap between Major Depressive Disorder and Borderline Personality Disorder. The last sentence of this study was “In the meantime, the clinician treating major depressive disorder would be wise to assess for borderline personality disorder, even as currently defined.” That was because the study found a large correlation between the two disorders. Today, I was reviewing an article by Marsha Linehan called “Two-Year Randomized Controlled Trialand Follow-up of Dialectical Behavior Therapyvs Therapy by Experts for Suicidal Behaviorsand Borderline Personality Disorder” which I had planned to write something up about. I’ll have to do that later, but the reason these thoughts of MDD and BPD came to mind is that in the first paragraph of Linehan’s article she states:
“SUICIDAL BEHAVIOR IS A BROAD term that includes death bysuicide and intentional, nonfatal, self-injurious acts committed with or without intent to die. It is associated with severalmental disorders, including depression, substance dependence, and schizophrenia. Borderline personality disorder (BPD) is 1 of only 2 DSM-IV diagnoses for which suicidal behavior is a criterion.“
The emphasis is mine. I thought “what’s the other disorder that suicidal behavior is a criterion?” The answer: Major Depressive Disorder. So, today I am posting the DSM criteria for Major Depressive Disorder. It’s fairly long and I’ve included the “Major Depressive Episode” to clarify. If you’d like to get the full criteria, follow the “continue reading” link.
Continue reading Major Depressive Disorder and BPD →
“Much of it comes from self-destructive behaviors that are used to stop the horrible pain of dysphoria; anxiety, rage, depression and despair. When an individual behaves out-of-control, in a manner that’s inconsistent with their beliefs or normal choices, terrible self-hate develops. Additionally many individuals had low self-esteem and related problems since childhood and are in an environment that causes self-hate to flourish.” – from the interview
Bon: I found an interview with Dr. Leland Heller about Borderline Personality Disorder. He does a good job explaining the pain associated with the disorder… Here are some excerpts. The entire interview can be read here.
Diagnosing Borderline Personality Disorder And Finding Treatment That Works
Dr Heller: Good evening, It’s great to be here. I have a way of explaining the Borderline Personality Disorder in layman’s terms that might be useful. It’s how I explain it to patients and their families.
Imagine you had a pet dog and it runs into the street and by accident it’s hit by a car. The dog’s leg is broken and it limps off into an alley to lick it’s wounds. A friend of yours sees the dog and comes over to help. The dog is now feeling trapped and cornered – a “wounded animal” – and misinterprets the friend’s attempts to help. The dog snaps at the friend’s hand who is trying to help. The BPD (Borderline Personality Disorder) is a malfunction in the brain’s trapped or “cornered” animal area. Under stress, a seizure develops in that area. That’s why under stress, while raging, a borderline will say to him or herself: “Why am I doing this” – yet be unable to stop it. It’s a seizure – nerve cells firing inappropriately and out of control.
David: And the cause of Borderline Personality Disorder?
Dr Heller: The BPD has many causes including head trauma and brain infections, but it appears that emotional hurts literally damage the brain. Most likely the brain’s support cells – the 90% of brain cells called “glial cells” – are damaged by traumas, causing the person to overreact to stress once puberty strikes. During puberty the brain’s limbic system goes into “overdrive” and adolescents are at their highest risk of seizures in their lifetime. “Sticks and stones may break my bones…but names cause brain damage.” So does incest, abuse, severe trauma, head injuries, attention deficit disorder, and other causes.
David: From my understanding, one of the biggest difficulties facing individuals who have BPD is maintaining stable relationships. This is a great cause of consternation for those people who are on the other side of the relationship. What causes this?
Dr Heller: There are a number of problems. The three most significant are 1) inappropriate mood swings; 2) misinterpretation of motives; and 3) remembering those misinterpreted motives as real. Oftentimes self-fulfilling prophecies occur, and self-hate eventually leads to a significant other coming to the same conclusion – that the individual isn’t worth being with.
…
janet: Would you please tell us more about the self-hate characteristic and how that damages the BPD or his/her relationships?
Dr Heller: Much of it comes from self-destructive behaviors that are used to stop the horrible pain of dysphoria; anxiety, rage, depression and despair. When an individual behaves out-of-control, in a manner that’s inconsistent with their beliefs or normal choices, terrible self-hate develops. Additionally many individuals had low self-esteem and related problems since childhood and are in an environment that causes self-hate to flourish.
crazy32810: How is self-injury related to BPD?
Dr Heller: We all injure ourselves to stop noxious neurological sensations. Interestingly we do it in a linear manner, ripping the skin. A common noxious neurological sensation is the toxins released with an insect bite. BPD dysphoria is about as bad as it gets. The pain is horrible. Many individuals have broken major bones and declared the pain of the fracture was nowhere as severe as dysphoria. When an individual with the BPD discovers that self-mutilation, or other techniques of self injury, work to temporarily stop the pain of dysphoria – they’ll do what it takes to stop it. This is no different than the individual with a fracture wants pain medication. I broke my shoulder last December and I tried to deal with it without taking narcotics. I was foolish and wrong. The pain was so bad it needed to be treated medically. Once individuals with the BPD have their chronic symptoms stabilized, and have safe medication options that work for dysphoria, the self-destructive patterns are no longer needed to stop their pain.
One of my twitter followers posted the original Daily Star article about Amy Winehouse and Borderline Personality Disorder (BPD). Of course, I’d had Amy on my Celebrities with Possible BPD list for many years. If you want to read all of my articles about Amy Winehouse click here. I have no idea why the title includes ‘Mental Illness’ in quotes. Maybe it was because they were quoting the relative or maybe it brings up the question as to whether BPD is an actual mental illness. Here is the text of the article (and my comments below):
TRAGIC AMY WINEHOUSE HAD ‘MENTAL ILLNESS’
TROUBLED Amy Winehouse suffered from an undiagnosed mental illness, a relative has revealed.
The talented soul singer could have been struck down by the little-known Borderline Personality Disorder.
Sufferers have feelings of anger, emptiness, shame and guilt and become emotionally volatile.
And it can also push them into substance abuse and eating disorders, both of which Amy succumbed to.
Yesterday a member of the Back To Black star’s family said: “It was never diagnosed, because unfortunately she would never agree to a proper diagnosis.
“I’m not an expert, but from what I’ve read on Borderline Personality Disorder it kind of fitted with her.”
Meanwhile Amy’s dad Mitch, 61, said he wished his daughter, who died in July aged 27, had sought counselling.
He said: “She never stopped trying.
“She hated the way she was when she was drunk and when she was ill.
“And you know, the way I look at it, she died trying.
“She didn’t give up. She died trying to make her- self better.”
This article, although short, points out several interesting things about people with BPD. Since there’s no guarantee she had it, I’m going to generalize a bit. First of all, it is tragic that BPD is “little known” because it is much more prevalent than bipolar disorder. The article says: “Sufferers have feelings of anger, emptiness, shame and guilt and become emotionally volatile. And it can also push them into substance abuse and eating disorders, both of which Amy succumbed to.” This is very true. A person in extreme emotional pain will do anything to stop the pain. The article ends with “She died trying to make her- self better.” I’d like to amend that statement to “She died trying to make feel her-self better.” That’s the nature of the disorder and that’s what many non-BPDs do not understand. It’s all about his/her feelings (IAAHF) and not about controlling, manipulating or calling for attention.
| List Price: |
$13.98 USD |
| New From: |
$8.84 In Stock |
| Used from: |
$11.02 In Stock |
Release date December 6, 2011.
|
|
Recently read an article in Psychiatric Times in which the author of the article argued that the new DSM-V “dimensional” approach to borderline personality disorder specifically and personalty disorders in general would be much too time-consuming to implement than the criteria of the ICD-10. Here are the ICD-10 criteria:
F60.3 Emotionally Unstable (Borderline) Personality Disorder
A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.
Impulsive type:
The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.
Includes:
- explosive and aggressive personality (disorder)
Excludes:
- dissocial personality disorder
Borderline type:
Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).
Includes:
- borderline personality (disorder)
The proposed DSM-V changes to the criteria for Borderline Personality Disorder (BPD):
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
An article from ABC News about Casey Anthony’s pathological lying and the disorder from which it may arise. Before I supply the text here, I want to discuss this quote:
Two of the potential issues Anthony could suffer from are border personality disorder and psychopathology, the experts said. The main thing these issues have in common is a total lack of empathy, according to LeslieBeth Wish, a psychologist and licensed social worker in Sarasota, Fla.
“They can turn a person into a non-person,” Wish said. “Borderline personalities have more emotional regulation problem and often use lying to get away from something and not ever feeling like they’re responsible.”
Those two potential issues were the ones that I identified and opined on the other day. The second paragraph above is why I believe that Casey Anthony probably doesn’t have BPD. The reasons for the lies are not impulsive and reactive, as they seem to be most often in BPD. People with BPD are much more likely to “bullshit” (as a term of art not vulgarity) than to actually lie with proactive intent. They can make up some elaborate stories about themselves, typically to make their world a safer and more livable place when others think better of them. Still, most often BPD lies are to get through a painful moment. Very often as the lies collapse, they will admit everything and ask forgiveness. Casey did NOT do this. She maintained her lies even after the police were aware they were lies. In fact, she started lying to her parents LONG BEFORE Caylee went missing. She lied (by omission) about her pregnancy. She lied about having a job at Universal Studios BEFORE the cops got involved.
As for psychopathy…. I presented the guidelines of Hare’s PCL-R on the other page. Let’s look at them again and see which of these seem to match Casey Anthony, based on what we know from the press:
PCL-R items
The following findings are for research purposes only, and are not used in clinical diagnosis. These items cover the affective, interpersonal, and behavioral features. Each item is rated on a score from zero to two. The sum total determines the extent of a person’s psychopathy.
Factor 1
Aggressive narcissism – Hard to say for Casey Anthony. We don’t really know enough. We do know that, when in jail, she got angry about what this situation was doing to HER!
Glibness/superficial charm – Yes.
Grandiose sense of self-worth – Again hard to say. This is one factor that really separates BPD from the narcissism spectrum. People with BPD have a lot of shame and generally hate themselves.
Pathological lying – YES, YES, YES.
Cunning/manipulative – I’d have to say yes.
Lack of remorse or guilt – Again, I think we need to say yes here.
Emotionally shallow – Hard to say.
Callous/lack of empathy – Could be. Hard to say.
Failure to accept responsibility for own actions – Yes. It’s never her fault.
Factor 2
Socially deviant lifestyle – Party girl. One night stands.
Need for stimulation/proneness to boredom – Probably, but who knows.
Parasitic lifestyle – Yes. She was living off her parents and then off friends while pretending to have a job. Actually, it is interesting to note that she was telling her mother she had a job long before Caylee disappeared.
Poor behavioral control – Probably. Again, one night stands.
Promiscuous sexual behavior – Yes.
Lack of realistic, long-term goals – Yes.
Impulsiveness – Yes.
Irresponsibility – Yes.
Juvenile delinquency – well, some form of delinquency. She stole checks from her friend and passed them.
Early behavioral problems – unknown.
Revocation of conditional release – we’ll see.
Traits not correlated with either factor
Many short-term marital relationships – no, but many short-term boyfriends
Criminal versatility – it depends. She stole and possibly caused the death of her daughter. They couldn’t prove it in court to the satisfaction of the jury, but we may never know.
Ok, onto the article:
‘Dr. Judy’ Doubts Casey Anthony’s Penchant for Lying Can Be Cured
By CHRISTINA NG
July 19, 2011
Casey Anthony’s lawyers have said that Anthony has suffered “trauma” and will need counseling now that she is a free woman, but experts aren’t sure Anthony can be helped.
“It would be exceptionally difficult for anybody to treat her. There is no magic pill that’s a truth serum for a person who’s a pathological liar,” said Dr. Judy Kuriansky a psychologist from Columbia University, but better known from her radio show as Dr. Judy.
Kuriansky believes that Anthony likely feels that she has been rewarded for her lying with her acquittal and release from jail.
“Why would she want to go to therapy when she basically got what she wanted? There’s no motivation for her to seek help,” Kuriansky said. “If she had been sent to jail, maybe she would want to see somebody because her style didn’t work, but it did.”
Anthony, 25, is in hiding after being released from a Florida jail following her acquittal on murder charges for the death of her 2-year-old daughter Caylee. She has received death threats and as she left jail protesters changed “Caylee, Caylee.”
Casey Anthony Therapy Will Be ‘Challenge’
Anthony’s criminal lawyer Jose Baez has said, “It is my hope that Casey Anthony can receive the counselling and treatment she needs to move forward with the rest of her life.”
Her civil attorney Charles Greene was quoted as saying Anthony was “emotionally unstable” following the trauma of her daughter’s death and the grueling trial.
Psychologists interviewed by ABCNews.com agree that the desire to change is the key to successful treatment for pathological liars, which some believe Anthony may be.
While acquitted of murder, she was convicted on four counts of lying to police. One of her lies was that Caylee was kidnapped by a fictional nanny named Zanny. Zanny was one of a dozen bogus characters that Casey had created. She also lied about working at Universal Studios.
None of the psychologists who spoke with ABCNews.com have treated Casey Anthony, but spoke from observations and personal experience.
Two of the potential issues Anthony could suffer from are border personality disorder and psychopathology, the experts said. The main thing these issues have in common is a total lack of empathy, according to LeslieBeth Wish, a psychologist and licensed social worker in Sarasota, Fla.
“They can turn a person into a non-person,” Wish said. “Borderline personalities have more emotional regulation problem and often use lying to get away from something and not ever feeling like they’re responsible.”
Continue reading ABC News Experts talk about Casey Anthony’s potential disorder →
An LA Times article about changes to the DSM for personality disorders:
latimes.com
BOOSTER SHOTS: Oddities, musings and news from the health world
Personality disorders category is likely to be dramatically revised for next psychiatry textbook
By Shari Roan, Los Angeles Times / For the Booster Shots blog
12:05 PM PDT, July 7, 2011
Several types of personality disorders will be dropped from the next edition of the Diagnostic and Statistical Manual of Mental Disorders. But one disorder previously proposed for elimination — narcissistic personality disorder — will likely remain in the text.
The American Psychiatric Assn. announced Thursday that the framework for personality disorders in DSM-5 will be a “hybrid” model that is substantially different from how personality disorders are diagnosed currently. Under the new system, personality disorders will be aligned with particular personality traits and levels of impairment.
The committee working on the personality disorders chapter of the DSM-5, which is due to be published in 2013, has proposed six types of disorders: antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal. They have proposed dropping paranoid, histrionic, schizoid and dependent personality disorders.
However, to qualify for a diagnosis, a patient would have to have a high level of impairment in two areas of personality functioning — self and interpersonal. Patients would be assessed for how they view themselves and how they pursue their goals in life, for example, as well as how they get along with other people and whether they think about the consequences of their actions. The new model is less rigid than the existing diagnostic model. It is designed to reflect that behavior can change over time while personality traits tend to remain stable.
“In the past, we viewed personality disorders as binary. You either had one or you didn’t,” said Dr. Andrew Skodol, chairman of the DSM work group on personality disorders, in a news release. “But now we understand that personality pathology is a matter of degree.”
The American Psychiatric Assn. also announced that a public comment period on DSM-5 proposals has been extended through July 15.
Here’s an interesting article from a woman diagnosed with Borderline Personality Disorder and her struggles to escape the stigma of the diagnosis.
Coming out of the Borderline Personality Disorder Closet (Without Hitting my Head on the Door Jamb)
By SONIA NEALE
Six years ago I was officially diagnosed by a psychiatrist in a psychiatric hospital as having…drum roll please…BORDERLINE PERSONALITY DISORDER. He said it to me in the same way he would announce he had a plague of rats infest his kitchen, discovered I had a sexually transmitted disease or that he had just found out I supported Tea Party candidate Sarah Palin. It was delivered with revulsion, disgust and contempt.
Today I proudly come out of the BPD closet and out myself as having one of the most reviled and hated personality disorders ever constructed by the most esteemed and eminent fundamentalist gentlemen writers of the Psychiatric Bible the DSM – Diagnostic and Statistical Manual.
If mental illness is stigmatised and discriminated against within the general community, then Borderline Personality Disorder is stigmatized and discriminated against within the mental health industry.
I was diagnosed as a BPD by a psychiatrist who had spent less than an hour talking with me around about the same time my clinical psychologist (of eight years at the time back in 2005) told me I was a schizoid personality disorder. These two personality disorders are diametrically opposed. One is excessive emotion (think Roseanne) and the other is no emotion at all (think Sheldon Cooper – Big Bang Theory).
I have had four psychiatric hospital stays over 15 years, the first when I was on Zoloft and had three children under five with post natal depression. The second was after dexamphetamine withdrawal; the third after a kidney cancer diagnosis and subsequent overdose of valium; and the last suffering with the excruciating side effects of akathisia from Zyprexa.
After the last visit, I decided pills were part of the problem, so I decided psychotropic medication was no longer an option for me. Previous to my diagnosis I researched BPD and discovered that I did fit somewhat into the nine symptoms, which include emotional dysregulation, abandonment issues, relationship problems, impulsive behaviour, suicide ideation, splitting into black and white, identity disturbance, emptiness and paranoia. But my clinical psychologist admitted she too suffered from much of the above at some point in her life but to a lesser degree, one which does not cause psychiatric issues in her life. Continue reading A Borderline Comes out of the Closet →
The NIAAA study begins to spread out and spur on new views of the findings regarding BPD. Here is a study about Major Depressive Disorder and BPD.
Can Epidemiology Translate Into Understanding Major Depression With Borderline Personality Disorder?
Myrna M. Weissman, Ph.D.
Epidemiologic surveys have mapped the terrain of psychiatric disorders. Personality disorders have bedeviled the clinician’s practice. Rarely have these two been rearranged in a meaningful clinical dialogue. Using the largest psychiatric epidemiologic survey ever, the National Epidemiologic Survey on Alcoholism and Related Conditions, and among the few to venture into axis II disorders, Skodol et al. (1), in this issue of the Journal, give a community-based national view of a common clinical question: What is the effect of specific personality disorder comorbidity on the course of major depression?
The original sample included over 40,000 adults, and 2,422 met criteria for DSM-IV current major depressive disorder. Three years later, 1,996 of the original currently depressed subjects were available for reinterviewing, which makes both a respectable sample size and response rate for generalizability. However, some caution is needed, since the sample was over-represented with Caucasian, college-educated, and married respondents. Fifteen percent of participants had persistent major depressive disorder, and 7.3% of those who remitted had a recurrence over the follow-up period. These figures are within the range of longitudinal studies of patients with major depressive disorder (2). While the presence of any personality disorder elevated the risk for persistence of major depressive disorder, when all axis I and II disorders, age of onset of major depressive disorder, number of previous episodes, family history, treatment, and duration of illness were controlled, borderline personality disorder remained the most robust predictor of major depressive disorder persistence. Neither personality disorders nor other clinical variables predicted recurrence of major depressive disorder. Thus, an epidemiologic survey yielded a practical jewel. The finding, undoubtedly, does not surprise the clinician but is now confirmed nationally. As the authors conclude, borderline personality disorder should be assessed in all depressed patients and considered in prognosis and addressed in treatment.
One can raise a number of methodologic issues about this study, including the use of lay interviewers or the instrument for assessing axis II disorders. The diagnostic interview, the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (3), was developed for this survey. The personality disorders included were adapted from items in the Structured Clinical Interview for DSM-IV Personality Disorders. The test-retest and internal consistency results reported for all personality disorders are fair to good, not great. However, the agreement with clinician interviews for borderline personality disorder (kappa=0.71) is about as good as it gets (4). The only other national survey to venture into assessing all axis II disorders was the National Comorbidity Survey Replication (5), which used the International Personality Disorder Examination. The investigators carried out a clinical reappraisal in a sample of 214 subjects using clinically trained interviewers to follow up screened, positive subjects and reported excellent predictions of classification. They also noted that the International Personality Disorder Examination is commonly regarded as a conservative diagnostic assessment of axis II disorders. The community rate they generated for any personality disorder in the United States was 11%, and in the World Health Organization World Mental Health Surveys (6), involving 13 countries, the rate was 6.1%. These rates seem to be lower than those reported in the National Epidemiologic Survey on Alcoholism and Related Conditions, but different presentations make it difficult to directly compare rates between studies. No articles from the National Epidemiologic Survey on Alcoholism and Related Conditions reporting overall rates of axis II disorders could be found. Unfortunately, given the findings in the Skodol et al. article, not all personality disorders were included in the first wave of the survey, and borderline personality disorder was added in the second wave. Both of these landmark studies used state-of-the-art measures. While they are imperfect, these are the best available. It is too bad they could not share the same methods.
The major issue now is not a debate about the methods of personality disorder assessment but about the future of personality disorders. The DSM-5 committee is working on the next version of psychiatric classification (7). In parallel, the National Institute of Mental Health is working on moving diagnosis away from clinical presentations to understanding of syndromes based on pathophysiology in a new project called Research Domain Criteria (8). These efforts will certainly effect how personality disorders are described, classified, or reimbursed in the future.
DSM-5 raises issues about the categorical conceptualization of personality disorders because of the high concurrence among disorders, both within and across axes, and the difficulty in differentiating normal from pathological. How dimensions will solve the problem of a lack of understanding of the pathophysiology underlying the disorders is unclear. Some cutoff along the dimension will need to be established for clinical practice.
The Skodol et al. study, based on an epidemiologic survey, may add light to the issue or, at least, generate a hypothesis about diagnosis that can be translated into a more experimental approach. Borderline personality disorder, defined categorically, and not the other axis II disorders explained the persistence of major depressive disorder over 3 years. Other axis I disorders may map out to different axis II disorders. The National Epidemiologic Survey on Alcoholism and Related Conditions, because of its large sample, could be mined for these clues about the relationship between specific axis I and II disorders.
The Research Domain Criteria project, in the long run, may offer more enlightenment for personality disorders if its goals can be achieved. The primary focus is on neural circuitry, with levels of analysis progressing from measures of circuitry function to clinically relevant variation or downward to the genetic and molecular cellular function (8). In the final analysis, the new molecular and neurobiological parameters will need to predict prognosis or treatment response. They will need to do as well as borderline personality disorder in predicting major depressive disorder persistence. If the Research Domain Criteria approach is successful, more than prediction of prognosis might be achieved, including a deeper understanding of the biological mechanism underlying the joined symptoms.
The epidemiologic finding that borderline personality disorder contributes to poor prognosis of major depressive disorder might be viewed as a hypothesis that can be translated into methods in the neurosciences to understand the mechanism behind this association. The features of borderline personality disorder, particularly the pervasive instability of the regulation of emotions and impulse control, would seem ripe for the Research Domain Criteria approach. When these symptoms occur in conjunction with major depressive disorder, a different syndrome may be present. Further experimental work may test how the symptoms of borderline personality disorder contribute to the prognosis of major depressive disorder. But what about the persistence of borderline personality disorder without major depressive disorder? Can the epidemiologic data provide any clues? In the meantime, the clinician treating major depressive disorder would be wise to assess for borderline personality disorder, even as currently defined.
Here is an article about bipolar depression that mentions BPD. The mention says:
Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’
… which in combination with this finding: People with Borderline Personality Disorder over diagnosed with Bipolar Disorder …could have some interesting ramifications for the medical community.
The text of the article:
Bipolar depression unrecognised in primary care
03 Mar 11
By Christian Duffin
Up to a fifth of primary care patients with depression may have an undiagnosed bipolar disorder, a UK study suggests.
The researchers argue that their findings have important implications for GP diagnosis and assessment, because prescribing antidepressants as monotherapy for patients with bipolar disorder may result in mania and frequent mood swings.
The researchers believe that their study is the first to investigate the extent to which bipolar disorder is misdiagnosed as major depressive disorder among UK primary care patients.
The study involved a two-phase sampling technique to produce three estimates of unrecognised bipolar disorder.
The researchers initially collected diagnostic, clinical, psychosocial functioning and quality of life data from 11 GP practices in south Wales for patients with a diagnosis of unipolar depression.
576 of the 3,117 patients contacted sent back completed Hypomania Checklist (HCL-32) and Bipolar Spectrum Diagnostic Scale (BSDS) screening tool questionnaires, both used to test for bipolar disorder.
Of these, 154 were then given a comprehensive diagnostic and clinical assessment. 29 met the diagnostic criteria for bipolar disorder.
The researchers calculated three estimates of the prevalence of previously undiagnosed bipolar disorder, ranging from 3.3% up to 21.6%.
The estimates were based on different assumptions. The most conservative estimate assumed that all individuals who dropped out of the study did not have bipolar disorder.
Assuming that all of those who were invited to interview but did not attend did not have bipolar disorder resulted in a prevalence of 9.6%, while assuming all who were invited and attended had bipolar disorder resulted in a prevalence of 21.6%.
Lead researcher Dr Daniel Smith, a clinical senior lecturer in psychiatry at Cardiff University, said: ‘Although challenging, these are findings with potentially considerable implications for they way in which GPs approach the diagnosis and treatment of their patients with depression, especially when we consider how commonly antidepressants are prescribed in primary care and the potential for harm when antidepressants are used as monotherapy for bipolar disorder.’
He added: ‘It will be important that GPs are supported in developing strategies to ensure that their patients with depression receive the correct diagnosis with regard to the possibility of a primary bipolar illness.’
Dr Thomas Shackleton, a GP from Bottisham, near Cambridge with an interest in depression, said the research should serve as a reminder to GPs that they should screen for manic symptoms when they make they make a diagnosis for depression and during the follow-up at 5-12 weeks.
Dr Shackleton, also an advisor to NICE for its guidelines on depression, added: ‘This is a big issue because the majority of first presentations are depressive, and if you prescribe antidepressants you can induce a manic episode in someone who has bipolar disorder.
‘It can be difficult for GPs because if patients have impulsive or risky behaviour, such as risky sex or gambling, they tend you hide it from GPs. But GPs can explore patients’ histories and ask them if their family have had any concerns about them.’
Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’
NICE GUIDELINES ON BIPOLAR DISORDER
-
- GPs should fully involve patients in decisions about their treatment and care, and determine treatment plans in collaboration with the patient’s preference.
- GPs should discuss contraception and the risks of pregnancy with all women of child-bearing potential, regardless of whether they are planning a pregnancy.
- People experiencing a manic episode, or severe depressive symptoms, should normally be seen again within a week of their first assessment, and then regularly at appropriate intervals, for example, every 2–4 weeks in the first 3 months and less often after that, if response is good.
- The treatment of bipolar disorder is based primarily on psychotropic medication, but side effects and potential harms will determine the choice of drug. A range of psychological and psychosocial interventions can also have a significant impact.
CG38 Bipolar disorder: NICE guideline, October 2006
|
Loading ...
