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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
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- 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
 Genetics in Borderline Personality Disorder I was reading an article called “Social cognition in borderline personality disorder: evidence for disturbed recognition of the emotions, thoughts, and intentions of others” and noticed a line in the article that said this: “Thus, in addition to high heritability of BPD (Torgersen et al., 2008), these results argue that environmental factors (e.g., trauma) contribute to disturbed social cognition in BPD. In summary, for the current study we expected PTSD to be a negative predictor of social cognition.” That intrigued me on two levels. One was the “high heritability” part, because often I see comments about BPD and how many people believe that it is mainly caused by childhood trauma (and/or invalidation). In WHINE I state this: As I said earlier, one of the causes of BPD is the “invalidating environment.” Now, it could be that it is not an actual “cause” (and that all the real causes of BPD are biological), but more a reinforcer of BPD. So, the second part of the article that intrigued me was the idea that “we expected PTSD to be a negative predictor of social cognition” – and the discussion and methodology of comorbid PTSD with BPD. What they found was that people with BPD (with or without comorbid PTSD) are less able to understand the intent, thoughts and motivations of social interactions in others – in other words, people with BPD can’t mentalize as well as controls. They also found that this lack of ability is more marked in people with BPD who also have comorbid PTSD. The fact that they mention comorbid PTSD at all is something of a revelation – or perhaps should be to us nons. Many people come to support lists and do research on the Internet and begin their “introduction” of their BPD person with a long list of childhood traumas that explains why the person has BPD. This current research would indicate that PTSD and BPD are clearly two separate disorders and that, while PTSD is a contributor to poorer functioning that BPD alone, BPD is in itself a highly inheritable disorder and biological in nature, yet “reinforced” or made more severe (especially in a social functioning sense) when PTSD is present.
Anyway, this research led me to another scientific study called “Familial Resemblance of Borderline Personality Disorder Features: Genetic or Cultural Transmission?” In which the researchers studied twins, siblings and parents of borderlines to determine the genetic underpinning of BPD or whether the environment and/or cultural influences could have more of an influence on the development of BPD. They found this: “In the present study an extended twin-family design was applied to self-report data of twins (N = 5,017) and their siblings (N = 1,266), parents (N = 3,064) and spouses (N = 939) from 4,015 families, to estimate the effects of additive and non-additive genetic and environmental factors, cultural transmission and non-random mating on individual differences in borderline personality features. Results showed that resemblance among biological relatives could completely be attributed to genetic effects.” and this: “There was no effect of cultural transmission from parents to offspring.”
Recently, in the ATSTP group, we have been discussing the idea that shame/honor-based cultures and whether that environment could be explanatory in some sense of the development of BPD. It appears (at least based on this 2009 study) that the development and transmission of BPD is NOT cultural. It is essentially genetic (mainly “additive”, meaning it is more than one gene involved) and the environment has an effect, yet cultural transmission was not apparent.
They do go on to say this: “Gene by environment interaction implies that genes determine the degree to which an individual is sensitive to an environment. In the presence of gene-environment interaction, individuals with a ‘sensitive’ genotype will be at greater risk of developing BPD if an undesirable environment is present, than individuals with an ‘insensitive’ genotype.” So, basically, although this interaction has not been fully studied, it appears that some sort of “sensitive” genotype is required to develop BPD.
A widely-used screening technique (the Mood Disorder Questionnaire) mistook borderline personality disorder for bipolar disorder.
http://esciencenews.com/articles/2010/03/25/is.it.really.bipolar.disorder
Is it really bipolar disorder?
Published: Thursday, March 25, 2010 – 13:00 in Health & Medicine
A study from Rhode Island Hospital has shown that a widely-used screening tool for bipolar disorder may incorrectly indicate borderline personality disorder rather than bipolar disorder. In the article that appears online ahead of print in the Journal of Clinical Psychiatry, the researchers question the effectiveness of the Mood Disorder Questionnaire (MDQ). The MDQ is the most widely-used and studied screening tool for bipolar disorder. It is a brief questionnaire that assesses whether a patient displays some of the characteristic behaviors of bipolar disorder. It can be administered by clinicians or taken by patients on their own to determine if they screen positively for bipolar disorder. For the purposes of this study, the MDQ was scored by researchers.
Bipolar and borderline personality disorders share some clinical features, including fluctuations in mood and impulsive actions. The treatments, however, will vary depending on the individual and the diagnosis. Principal investigator Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, conducted a study to test the accuracy of the MDQ.
The research team interviewed nearly 500 patients using the Structured Clinical Interview for Diagnostic Statistical Manual IV (DSM-IV) and the Structured Interview for DSM-IV for personality disorders. The patients were also asked to complete the MDQ. The research team then scored the questionnaires and found that patients with a positive indication for bipolar disorder using the MDQ were as likely to be diagnosed with borderline personality disorder as bipolar disorder when using the structured clinical interview. Further, their findings indicate that borderline personality disorder was four times more frequently diagnosed in the group who screened positive on the MDQ.
Zimmerman says that these findings raise caution for using the MDQ in clinical practice because of how differently the disorders are treated. “An incorrect diagnosis of bipolar disorder will usually lead to a treatment involving medications. If a patient truly has bipolar disorder, that treatment may work. However, at this time there are no approved medications to treat borderline personality disorder.
“Without an accurate diagnosis of borderline personality disorder, we may have many people in treatment who are taking medications that will not work to alleviate the characteristics of the condition from which they really suffer.” Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, continues, “In addition, patients with unrecognized borderline personality disorder will not be treated with one of the effective psychotherapies for this condition. It is therefore vital that we develop or identify a more accurate method to distinguish between these two conditions, and adopt it into clinical practice.”
Here is a chart comparing DSM-IV personality disorders to DSM-V personality types. Notice that NPD, Paranoid, Schizoid, and others have no DSM-V comparable disorder and are a combination of prominent personality traits.
DSM-5 Type and Trait Cross-Walk
| DSM-IV Personality Disorder |
DSM-5 Personality Disorder Type |
Prominent Personality Traits |
| Paranoid |
None |
Suspiciousness
Intimacy avoidance
Hostility
Unusual beliefs |
| Schizoid |
None |
Social withdrawal
Social detachment
Intimacy avoidance
Restricted affectivity
Anhedonia |
| Schizotypal |
Schizotypal (4 or 5) |
Eccentricity
Cognitive dysregulation
Unusual perceptions
Unusual beliefs
Social withdrawal
Restricted affectivity
Intimacy avoidance
Suspiciousness
Anxiousness |
| Antisocial |
Antisocial/Psychopathic
(4 or 5) |
Callousness
Aggression
Manipulativeness
Hostility
Deceitfulness
Narcissism
Irresponsibility
Recklessness
Impulsivity |
| Borderline |
Borderline (4 or 5) |
Emotional lability
Self-harm
Separation insecurity
Anxiousness
Low self-esteem
Depressivity
Hostility
Aggression
Impulsivity
Dissociation proneness |
| Histrionic |
None |
Emotional lability
Histrionism |
| Narcissistic |
None |
Narcissism
Manipulativeness
Histrionism
Callousness |
| Avoidant |
Avoidant (4 or 5) |
Anxiousness
Separation insecurity
Pessimism
Low self-esteem
Guilt/shame
Intimacy avoidance
Social withdrawal
Restricted affectivity
Anhedonia
Social detachment
Risk aversion |
| Dependent |
None |
Submissiveness
Anxiousness
Separation insecurity |
| Obsessive-Compulsive |
Obsessive-Compulsive
(4 or 5) |
Perfectionism
Rigidity
Orderliness
Perseveration
Anxiousness
Pessimism
Guilt/shame
Restricted affectivity
Oppositionality |
| Depressive |
None |
Pessimism
Anxiousness
Depressivity
Low self-esteem
Guilt/shame
Anhedonia |
| Passive-Aggressive |
None |
Oppositionality
Hostility
Guilt/shame |
Article from Science Daily about over-diagnosis of bipolar disorder:
If Bipolar Disorder Is Over-diagnosed, What Are The Actual Diagnoses?
ScienceDaily (July 29, 2009) — A year ago, a study by Rhode Island Hospital and Brown University researchers reported that fewer than half the patients previously diagnosed with bipolar disorder received an actual diagnosis of bipolar disorder after using a comprehensive, psychiatric diagnostic interview tool –the Structured Clinical Interview for DSM-IV (SCID). In this follow-up study, the researchers have determined the actual diagnoses of those patients.
Their study is published in the July 28 ahead of print online edition of The Journal of Clinical Psychiatry.
Under the direction of lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, the researchers’ findings indicate that patients who received a previous diagnosis of bipolar disorder that was not confirmed by a SCID, they were significantly more likely to be diagnosed with borderline personality disorder as well as impulse control disorders.
Their research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.
Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, “In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder.”
The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.
Zimmerman and colleagues note that “we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive.”
In their previously published study that concluded bipolar disorder was over-diagnosed, they studied 700 patients. Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. The authors state that the over-diagnosis of bipolar disorder can have serious consequences, because while bipolar disorder is treated with mood stabilizers, no medications have been approved for the treatment of borderline personality disorder. As a result, over-diagnosing bipolar disorder can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.
Zimmerman concludes, “Because evidence continues to emerge establishing the efficacy of certain forms of psychotherapy for borderline personality disorder, over-diagnosing bipolar disorder in patients with borderline personality disorder can result in the failure to recommend the most appropriate forms of treatment.”
Along with Zimmerman, other researchers involved in the study include Camile Ruggero, PhD; Iwona Chelminski, PhD and Diane Young, PhD, all of Rhode Island Hospital and Brown University.
I reopened the diagnosis poll now that I am getting more traffic. I have noticed in my email list and in general that BP’s go through at least 8 therapists before they start being real with someone. My wife has been through at least 10 therapists before she admitted to the suicidal ideation and the self-injury. She immediately dropped a therapist who diagnosed her with BPD. Is that you guy’s experience as well?
Here’s an article about the DSM…
Wednesday, Mar. 11, 2009
Redefining Crazy: Researchers Revise the DSM
By John Cloud
If you wanted to make a list of important books you should read, what would you choose? Anna Karenina, maybe? The Bible? How about the Diagnostic and Statistical Manual of Mental Disorders?
It may not be at the top of your list, but the DSM, as it’s usually called, is one of the most important books in the world. It attempts to categorize, describe and give a code number to literally every problem that can occur in your mind, from schizophrenia to borderline personality disorder to something called mathematics disorder, which is essentially being so bad at math that it amounts to a mental problem.
The DSM is important not only because it is wildly ambitious but also because mental-health professionals around the world have adopted its classification system. In the U.S., it is virtually impossible to get reimbursed by an insurance company for treatment unless a mental-health professional identifies your condition by a DSM code number. (The number for mathematics disorder, if you were wondering, is 315.1. The code for Tourette’s syndrome is 307.23; the code for sexual sadism is 302.84. As I said, the DSM tries to cover everything.) (See the top 10 medical breakthroughs of 2008.)
The American Psychiatric Association (APA), which owns the DSM, is in the process of rewriting the book, which was first published in 1952. The DSM-V, as the fifth edition will be called, is set to be published in 2012. But the process of researching it began way back in 1999 — five years after the publication of the last major revision, the DSM-IV — meaning the new book’s production will take 13 years overall. (Read about how we get labeled by the DSM.)
Why so long? Last week, a research organization called the American Psychopathological Association (which goes by the acronym APPA, to distinguish it from the APA) brought many of the key players in the development of the DSM-V to a conference in New York City to discuss some of the reasons the writing of the book is so complicated.
One obvious reason is that so many people have a stake in what the world defines as crazy and what it calls normal. Famously, homosexuality was listed as a DSM condition until a 1974 vote among APA members removed it. Other groups of mental-health professionals and patients want certain disorders to be added (and covered by insurance): sexual compulsivity, for instance, is not in the DSM, even though “sexual aversion disorder” (302.79) — the persistent and distressing avoidance of genital contact not explained by another disorder like depression — is included. (Read an interview with an author who has bipolar disorder.)
Debates about what should and shouldn’t be in the DSM are fascinating and often bitter, and as I have pointed out before, the book makes at least one fundamental error in the way it conceives of mental problems: it ignores causes almost entirely. If you feel sad and tired for a couple of months, have trouble sleeping and making decisions, and gain weight, you can be given a DSM diagnosis of depression (296.31 or 296.32, mild or moderate, recurrent) and prescribed drugs for it — even if the reason for your funk is that you just lost your job. Such physiological responses as insomnia are evolutionarily natural (and sometimes helpful, in a jump-starting sort of way) when you suffer a trauma like losing your job. But according to the DSM, only perfect is considered normal. Another basic problem with the DSM: it tries to reduce the vastly complex experiences of your mind to a single number.
At last week’s conference, there were tantalizing hints that the DSM-V might fix some of these problems. Dr. Steven Hyman, provost of Harvard, a former psychiatry professor at its medical school and a former director of the National Institute of Mental Health, agitated at the meeting for a new DSM framework that would stop trying to divide mental problems into discrete all-or-nothing categories. That method is appropriate for some medical problems — you either have leukemia or you don’t — but depression, for instance, doesn’t work like that. (Read “Why Do the Mentally Ill Die Younger?”)
Rather, Hyman argued that many mental illnesses are problems that lie along a continuum from normal and functioning to disordered and tragic. To the annoyance of some old-fashioned DSM defenders, he made the case that the DSM should regard mental illness as “continuous with normal”: less like leukemia and more like hypertension. You don’t get diagnosed with hypertension until you meet a cutoff point for high blood pressure that takes into account other extenuating factors: your age, for instance, or the conditions under which the blood-pressure reading is taken. Depression should be the same: if you are sad because you just got divorced, the DSM shouldn’t necessarily consider you to have an illness.
Such a diagnostic model wouldn’t be simple, though, which is one reason the DSM is taking 13 years to rewrite. And in the meantime, the book still has to be useful to everyday clinicians seeing patients who need a code number for insurance companies. “It’s like wondering how you repair the airport while the planes are still flying,” Hyman said at the conference.
Hyman noted that medical problems, whether in the mind or in the body or both, are usually caused by some combination of genes, environment, behavior and chance. Despite the comforting modern notion that severe psychological illnesses are simply due to an unfortunate genetic inheritance, it is the exceedingly rare mental condition that is caused only by genes. (Rett syndrome is one example.) Rather, if you take something like generalized anxiety disorder (300.02), there may be a variety of causes that set it off: genes that cause excessive activity in the fear-producing part of the brain called the amygdala, a stressful job that stimulates that activity, engaging in dumb behavior like having an affair that exacerbates your anxiety, then randomly getting into an anxiety-heightening situation like a car accident. The DSM has to try to account for all of that complexity — causes, effects, unintended consequences — and still be definitive.
Hyman said in an interview that one way the DSM currently handles this complexity is to have what he described as a “wastebasket” diagnosis — called “not otherwise specified” (NOS) — that captures just about anything that doesn’t easily fit the categorical model. One major problem with the NOS diagnosis: pretty much anyone can qualify for a diagnosis that, by definition, is not specified. A 2005 American Journal of Psychiatry paper found that nearly half of a group of 859 people who sought psychological help in Rhode Island could be considered to have a DSM personality disorder if diagnosticians were allowed to include the NOS option. Another problem: how do you adequately treat patients whose illness is unspecified?
A continuum model like the one Hyman proposes could help solve this problem by recognizing that people aren’t always one thing or another. They’re sometimes just a little depressed or a little anxious. To avoid medicalizing normal stress, the DSM-V would set a cutoff point within the spectrum. Of course, determining the right cutoff point for the DSM’s 350 illnesses would take an enormous research effort, one that has begun for some disorders like depression but probably hasn’t even been thought about for rare problems like sexual sadism.
Other attendees at the APPA conference indicated that the new DSM will almost certainly adopt a continuum model for mental illnesses. But don’t be surprised if the book doesn’t come out as scheduled in 2012. If the three-day conference came to any solid conclusion, it was that toting up all the ways our minds can fail is a lot harder than, say, explaining why your appendix might burst.
Read “Tallying Mental Illness’s Costs.”
Read “I’m O.K. You’re O.K. We’re Not O.K.”
 When I was reading the Time article on BPD – which is cited below and provides a nice new overview of BPD – I was struck by this quotation:
A 2008 study of nearly 35,000 adults in the Journal of Clinical Psychiatry found that 5.9%–which would translate into 18 million Americans–had been given a BPD diagnosis. As recently as 2000, the American Psychiatric Association believed that only 2% had BPD. (In contrast, clinicians diagnose bipolar disorder and schizophrenia in about 1% of the population.) BPD has long been regarded as an illness disproportionately affecting women, but the latest research shows no difference in prevalence rates for men and women. Regardless of gender, people in their 20s are at higher risk for BPD than those older or younger.
Because generally, it has been acknowledged that BPD occurs in about 2% of the population (which is already equal to the level of bipolar and schizophrenia combined, yet the condition gets much less attention or funding); however, this article states that research has shown that BPD is more than twice as prevalent than previously thought (at 5.9%, which would be almost three times as much as bipolar and schizophrenia combined). Also, the article states that, against the previously published data, there is no difference in prevalence rates between men and women. Typically, the research has shown that BPD patients are 75% female. So, I decided to track down this study and did so. Here is an abstract of the study:
Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.
Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ.
Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD 20892-9304, USA. bgrant@willco.niaaa.nih.gov
OBJECTIVES: To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of borderline personality disorder (BPD) among men and women. METHOD: Face-to-face interviews were conducted with 34,653 adults participating in the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Personality disorder diagnoses were made using the Wave 2 Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS: Prevalence of lifetime BPD was 5.9% (99% CI = 5.4 to 6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI = 5.0 to 6.2) and women (6.2%, 99% CI = 5.6 to 6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education and was less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled for, associations with bipolar disorder and schizotypal and narcissistic personality disorders remained strong and significant (odds ratios > or = 4.3). Associations of BPD with other specific disorders were no longer significant or were considerably weakened. CONCLUSIONS: BPD is much more prevalent in the general population than previously recognized, is equally prevalent among men and women, and is associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD, and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical, and genetically informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of BPD and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.
I suppose that the idea that BPD “is associated with considerable mental and physical disability, especially among women” points to the fact that more women seek treatment for the disorder because of the “disability” aspect of its presentation among women. Perhaps that can explain the previously acknowledged statistics of 75% occurrence in women.
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