Undesirable living situations and/or failures to achieve what you expect of yourself exacerbate and prolong depression.
Reorienting a Depressed Patient to Address Underlying BPD
John Gunderson, M.D.
October 08, 2013 DOI: 10.1176/appi.pn.2013.11a23
A 22-year-old African-American male named Morris was referred to me by Dr. Henri. Morris was diagnosed with borderline personality disorder (BPD) after a nonlethal overdose had led to an ER visit. This event occurred after several years in which his “treatment-resistant” depression had persisted despite many medication trials. Neatly dressed in black jeans and shirt, he seemed wary and perhaps, I thought, a bit frightened when he arrived. While we were in the waiting room, his worried overweight mother introduced herself and began to describe Morris’s “deep-seated pain.” Morris angrily interrupted her and quickly preceded me into my office. Slouching down in his chair, he said, “Dr. Henri gave up on me. I trusted him—that’s not easy for me—but he insisted I needed to see you.”
I asked whether he was OK with the new diagnosis of borderline personality disorder. “BPD you mean?,” he replied. Yes, he met the criteria, he said, but “I’m still depressed, and that’s still what I want help with. It’s my priority.” “That’s a reasonable goal,” I replied, “but what I will want….” He irritably interrupted, “I just need to know right off whether you can help me with my depression.”
Morris illustrates a common clinical problem. Many patients really have major depressive disorder (by DSM definition) and seek help, but if medications fail, they become fearful about whether to expect a recovery. Often they have not been introduced to the important role of psychosocial factors in creating or perpetuating their depressed mood. Moreover, as with Dr. Henri, many psychiatrists prefer by training, if not by orientation, to adhere to prescribing medications, and most psychiatrists avoid treating patients with BPD (Shanks et al. 2011). These facts are particularly relevant to cases like Morris, insofar as BPD represents the major source of chronic “treatment-resistant” depression (Skodol et al. 2011).