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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 →
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 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.
An article from the NY Times:
November 29, 2010
A Fate That Narcissists Will Hate: Being Ignored
By CHARLES ZANOR
Narcissists, much to the surprise of many experts, are in the process of becoming an endangered species.
Not that they face imminent extinction — it’s a fate much worse than that. They will still be around, but they will be ignored.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition.
Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.
Most nonprofessionals have a pretty good sense of what narcissism means, but the formal definition is more precise than the dictionary meaning of the term.
Our everyday picture of a narcissist is that of someone who is very self-involved — the conversation is always about them. While this characterization does apply to people with narcissistic personality disorder, it is too broad. There are many people who are completely self-absorbed who would not qualify for a diagnosis of N.P.D.
The central requirement for N.P.D. is a special kind of self-absorption: a grandiose sense of self, a serious miscalculation of one’s abilities and potential that is often accompanied by fantasies of greatness. It is the difference between two high school baseball players of moderate ability: one is absolutely convinced he’ll be a major-league player, the other is hoping for a college scholarship.
Of course, it would be premature to call the major-league hopeful a narcissist at such an early age, but imagine that same kind of unstoppable, unrealistic attitude 10 or 20 years later.
The second requirement for N.P.D.: since the narcissist is so convinced of his high station (most are men), he automatically expects that others will recognize his superior qualities and will tell him so. This is often referred to as “mirroring.” It’s not enough that he knows he’s great. Others must confirm it as well, and they must do so in the spirit of “vote early, and vote often.”
Finally, the narcissist, who longs for the approval and admiration of others, is often clueless about how things look from someone else’s perspective. Narcissists are very sensitive to being overlooked or slighted in the smallest fashion, but they often fail to recognize when they are doing it to others.
Most of us would agree that this is an easily recognizable profile, and it is a puzzle why the manual’s committee on personality disorders has decided to throw N.P.D. off the bus. Many experts in the field are not happy about it.
Actually, they aren’t happy about the elimination of the other four disorders either, and they’re not shy about saying so.
One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual.
Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how “unenlightened” the personality disorders committee is.
“They have little appreciation for the damage they could be doing.” He said the diagnosis is important in terms of organizing and planning treatment.
“It’s draconian,” he said of the decision, “and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”
He also blamed a so-called dimensional approach, which is a method of diagnosing personality disorders that is new to the DSM. It consists of making an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient.
This is in contrast to the prototype approach that has been used for the past 30 years: the narcissistic syndrome is defined by a cluster of related traits, and the clinician matches patients to that profile.
The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians.
It is one thing to call someone a neat and careful dresser. It is another to call that person a dandy, or a clotheshorse, or a boulevardier. Each of these terms has slightly different meanings and conjures up a type.
And clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.
Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: “Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”
Schism is probably not an overstatement. For 30 years the DSM has been the undisputed standard that clinicians consult when diagnosing mental disorders. When a new diagnosis is introduced, or an established diagnosis is substantially modified or deleted, it is not a small deal. As Dr. Gunderson said, it will affect the way professionals think about and treat patients.
Given the stakes, the blow-back from experts in personality disorders should come as no surprise.
Dr. Gunderson has written a letter co-signed by other clinical and research leaders to the trustees of the American Psychiatric Association and the task force that governs DSM-5. And Dr. Shedler and seven colleagues published an editorial in the September issue of The American Journal of Psychiatry. In the relatively small world of mental health diagnostics, this is most certainly a battle worth watching.
Right now, this much seems clear: It is way too early for the narcissists to give up their seat on the bus.
See my take on BPD vs. NPD.
 How much do feelings of emptiness matter in BPD? Recently Rajkumar Kalapatapu, et al., released a report in which they hosted an Internet-based survey to ask people with BPD what they wanted to see in the next version of the DSM with respect to BPD. As many of you know, scores of people find BPD (Borderline Personality Disorder) stigmatizing and confusing, since the term “borderline” was adopted to indicate “on the border between neurosis and psychosis” (although some indicate that it refers to “borderline schizophrenia” – although no correlation between BPD and schizophrenia exists as far as I am aware) and “personality” often connotes a “character-flaw” or something that is immutable and incurable. The only part of the name that seem to be in agreement is “disorder” – although even that can be called into question given a spectrum emotional regulation, impulsivity and other factors that play a role in BPD. I mean, NAAA and Bridget Grant published an epidemiological study that showed a 5.9% lifetime occurrence of BPD. Is that possible? Or is there something else afoot here?
In the Internet survey/study, the researchers asked self-identified people with BPD their ideas on a name and criteria change for BPD. I was forwarded a copy of the study findings because ATSTP hosted a link to the study and encouraged our readers with BPD to fill it out. The most-mentioned alternative names for BPD included were (not surprisingly since the DBT community has been advocating some change like this for years) “emotion” (or emotional) and “regulation” (or dysregulation) with Emotional Regulation Disorder (or similar form) mentioned in 21.4% of the cases. Again, not surprising considering the idea has been in the DBT community for years. A total of 53.3% of accepted responses indicated that a name change is desired.
There were a couple of things that I noticed in this survey data that actually piqued my interest. One was the most common symptom (based on the current DSM criteria) mentioned was emptiness (92.9%), not emotional instability. While unstable relationships was very high on the list, even higher was the “self image” aspects of BPD – emptiness and questions of identity. Personally, as someone who has for several years paid devotion to the “altar” of DBT, those aspects are not as noted within the clinical framework that is DBT. In fact, the idea of “systems-level” issues (emotional system, impulse control system) seems to be the most common way of approaching BPD, once you get out of the psychoanalytic backwater and into the CBT/DBT state of the art. Yet, these self-reporting people with BPD report emptiness and questions of identity as the most common symptoms (at 92.9% and 91.8% respectively) and relationship-based issues (fear of abandonment, unstable relationships) in a close second (each at 91.8%). I guess I am wondering then if a name change to “emotional regulation disorder”, while it is certain much less stigmatizing than BPD, would actually capture the crux of the issue? And what would instead? Frankly, I don’t really think the name matters all that much (if the stigma was expunged).
What further got me interested in this data was the biographical data. Of 646 included responses (1,186 were excluded), 88.5% of the population was female, 88.7% was Caucasian, the mean age was 36 (the median 35) and 45.2% of the respondents were single/never been married (with over 18% in the divorced or separated category). So what we have here is a group of white, 30-something women who are generally not married or not attached to another person – and almost half have NEVER been so attached, even though their biological clock is ticking (at 36). Plus, they feel empty and have unstable relationships and fear people will leave them. Granted, I am making assumptions based on this data and I am generalizing and “averaging the averages” at some level, but if this is the picture of a borderline person, it makes sense as to why she would be angry and fearful and shameful.
Recently, I started working with several men who want to get their BPD girlfriends back. And the picture of a thirty-something, white, never-before-married woman with BPD has arisen in several of these cases. That got me thinking about this person with BPD and how she must feel about her life. Here she is: empty, sad, distrusting, childless (when her friends probably have kids), unmarried (no one will truly love her), with a history of broken relationships thrown aside (if it doesn’t work out I’ll feel horrible, best to end it now). I rarely see a non-BPD man in a relationship with such a woman who actually thinks about how it must feel to be in her shoes. I think it would be quite beneficial to the men in the lives of these women with BPD to consider how it feels to be in that situation – empty, unmarried, childless, in your mid-30s, etc. I think if one were really to ponder and meditate on what that must feel like, the behavior might become less confusing and more compassion could flow into the relationship.
On the director’s blog at the NIMH (National Institute of Mental Health), Director Dr. Thomas Insel discusses the name of borderline personality disorder:
Director’s Blog
April 19, 2010
What’s in a Name? — The Outlook for Borderline Personality Disorder
Thomas Insel
In Shakespeare’s “Romeo and Juliet,” the question is posed to illustrate that a name doesn’t define a person’s feelings or intent. In psychiatry, the same may be said of that which we call borderline personality disorder. Noted primarily for symptoms such as impaired mood regulation, unstable relationships with others, and self-harming behaviors, the name “borderline personality disorder,” fails to capture the essence of this serious mental illness.
As currently defined, borderline personality disorder is considered a reflection of an essential aspect of a person’s character that influences his or her way of seeing and being seen in the world. Recent research, however, has shown that symptoms of the disorder aren’t constant and may not always be as enduring as some researchers and clinicians may think. Yet fluctuating moods and behavior also happen to define another mental illness, bipolar disorder, with which borderline personality disorder may be confused….
He concludes with this:
…Whatever the outcome of reclassification efforts, however, we must keep in mind the essence of the question — that “borderline personality disorder” by any other name would still be as real, as disabling, and as necessary to treat, as other serious mental illnesses.
Read the whole post here.
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 |
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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