Sunday, May 18, 2008

Over The Border Line



A podcast listener asked us to talk about managing patients with Borderline Personality Disorder. Ugh. I don't want to talk about it.

Instead, I'm going to talk about why I hate the term, why I rarely place it in writing, why I wish it would go away.

Okay, the diagnosis of Borderline Personality Disorder is probably a perfectly valid diagnosis. If you read Roy's post about the differential diagnosis of Chloe O'Brians Personality Disorder (from 24), you'll see the following diagnostic criteria:

BORDERLINE PERSONALITY DISORDER
A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, with many of the following features:
1. Frantic efforts to avoid real or imagined abandonment such as lying, stealing, temper tantrums, etc.. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, substance abuse, reckless driving, overspending, stealing, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness, worthlessness.
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights, getting mad over something small).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

I mean, okay, these symptoms cluster in some people, so why don't I like them?
Here goes, with no particular rhyme or reason:

  • The diagnosis (unlike, say, Trichotillomania or Major Depression) is pejorative.
  • Clinicians are sloppy with the diagnosis and it's not uncommon for a doc to refer to a patient as "a borderline" as a defense--- the patient is difficult to deal with, he's angry or demanding--it's gotta be him, not the doc.
  • It's what clinicians label patients they don't like.
  • Actually, men are almost never called "borderline"....they get to be narcissistic or antisocial.
  • Treatment-wise, many docs avoid these patients and hope runs dry quickly. The prognostic implications are generally not great, these patient don't have rapid and dramatic improvements.
  • The diagnosis ends up being it's own endpoint, it doesn't leave room for alternate explanations and sometimes patients with Bipolar Disorder look a lot like patients with borderline personality disorder. Oh, while I'm there, patients with Borderline Personality Disorder often have co-morbid Bipolar Disorder (and hey, how about some substance abuse issues thrown in) and if the clinician can get focused on treating the Mood Disorder, sometimes the other noise fades into the background.
  • It doesn't seem to me that every patient who has these symptoms has them forever in an inflexible way. They come, they go, they change, they get better, they get worse.
Okay, so there are those people who tend to live life feeling victimized, who see things in black and white, who cut themselves to ease their pain, who can't maintain relationships, who create drama wherever they go.... I guess we're left to call them Borderlines.