http://www.mcmanweb.com/borderline.htm

In 2005, I joined the board as an officer in a state mood disorder patients group. There, I came across behavior I could not ascribe to bipolar disorder – extremely abusive verbal attacks, explosive meltdowns, public outbursts, poison pen emails, delusional self-centeredness, love and light one minute-on their **** list the next.

Yes, bipolars can behave badly, but this was different. It was like being back in high school again, only worse.

It got so I started to believe that the B in the acronym for our organization stood for something other than bipolar. For my own self-preservation, I got out of this toxic environment and cut off all ties with the state organization. I literally wound up hating these individuals and their illness. But I also recognized how lonely life must be for these individuals. None of them was married or in a loving relationship. None of them had children. None of them was employed. All of them engaged in frightening behavior. All were serious accidents waiting to happen.

The illness is called borderline personality disorder. On the surface, the emotional volatility, impulsivity, depressions, mood swings, high drama, and destructive behavior of individuals with this diagnosis resembles bipolar disorder. The suicide rate is in the bipolar ballpark, about ten percent, and the pain and suffering individuals with this illness experience is similar.

No wonder they are drawn to depression and bipolar support groups, I realized. We have a lot in common. Unfortunately, there is only so much we can do to help them. Only one of the individuals I encountered openly acknowledged the diagnosis. The others, I assumed, had not been diagnosed. Yes, they may have had bipolar disorder, but something else was going on here, and they were not being treated for it. Their psychiatrists were sending them out into the world with mood stabilizers and false hope.

My curiosity was aroused, particularly when I started connecting the dots to other individuals I had encountered in my life. I needed to find out more. The 2006 American Psychiatric Association annual meeting was approaching, and I made it a point attend the few sessions they had on personality disorders.

Is Borderline Real?

Unexpectedly, the first borderline discussion there occurred during question time at a packed luncheon symposium on bipolar II. One of the presenters, Terence Ketter MD of Stanford, happened to say that as opposed to bipolar disorder, which is about MOOD lability (volatility), borderline personality disorder is about EMOTIONAL lability. As soon as they develop an emotion stabilizer (analogous to a mood stabilizer), he said, borderline personality disorder will become an Axis I disorder rather than Axis II.

Axis I disorders, as categorized by the DSM-IV, include bipolar disorder, depression, anxiety, schizophrenia, and other illnesses regarded as biologically-based and treatable with medications. Axis II disorders tend to get a lot less respect. As well as borderline personality disorder, these include antisocial personality disorder, narcissistic personality disorder, and a host of behaviors that impede personal and social function.

During the same round of questions, S Nassir Ghaemi MD of Emory University said that he thought borderline personality disorder was a "clinical condition" rather than a disease. As such, the condition is more appropriate for psychotherapy rather than medications treatment. Hagop Akiskal MD of the University of California, San Diego, was decidedly less accommodating: "I don’t have any use for the borderline diagnosis," he asserted.

Dr Akiskal, the leading proponent of the mood spectrum, has been badmouthing borderline for decades. A 1985 article he co-authored had this title: "Borderline: An Adjective in Search of a Noun." Dr Akiskal has made a study of personality, but in the context of temperaments distributed along a continuum ranging from benign to affective illness.

A 2005 study by Dr Akiskal (with his frequent collaborator Franco Benazzi MD from Ravenna) found that 37 percent of unmedicated patients with unipolar depression and 60 percent of those with bipolar II depression displayed irritability. Two-thirds of those who were irritable had had at least three hypomanic symptoms – what the two authors call a depressive mixed state – vs just 14 percent among those not irritable.

Concluded Drs Akiskal and Benazzi: "Major depressive disorder with irritability may lie along a continuum linking bipolar II and nonirritable major depressive disorder."

But don’t expect the DSM-IV to enlighten and inform. In their same article, Akiskal and Benazzi observed that whereas hostility and anger do not even rate as a subtype of depression, they are cardinal features of borderline personality disorder. No wonder Dr Akiskal disses this diagnosis. Clinicians who fail to appreciate the irritable behavior characteristics of mixed depressions wind up ignoring the biological causes and instead blame the poor patient for their illness or even the parents of the patient.

Axis II Grind

Joel Paris MD of McGill University is one of the leading authorities on borderline and other personality disorders. In 2006, he was one of a handful of APA honorees delivering an award lecture at the annual meeting. Ironically, Dr Akiskal delivered an award lecture a year earlier. But unlike Dr Akiskal from the year before and the bipolar II symposium, Dr Paris’s lecture was far from packed. The name of his talk said it all: "Personality Disorders: Psychiatry’s Stepchildren Come of Age."

Clearly, Axis II is not psychiatry’s favorite child.

Significantly, Dr Paris was not about to let Dr Akiskal go unanswered. Referring to Dr Akiskal’s long-standing views concerning borderline personality disorder, Dr Paris let it be known, "I would say that is wrong."

In true Axis I depression, Dr Paris explained, when patients come out of a depression, they are nice people again. Individuals with personality disorders, by contrast, can come out of a depression and still have problems with life. Unfortunately, clinicians prefer not to want to hear about personality. It means trouble. They would rather throw more meds at the problem.

The world is complicated, Dr Paris noted, but we want it simple, and therein lies the challenge: In the bipolar II symposium, the presenters were discussing difficult-to-treat depressions. The depressions they were talking about were those that acted suspiciously like bipolar, which strongly implies using mood stabilizers instead of antidepressants.

Dr Paris was also talking about difficult-to-treat depressions, but the ones he described pointed to personality issues and a long course in talking therapy. These patients are not going to get better fast, he warned. Clinicians have to plan for chronicity. Moreover, in a true personality disorder, the course of the illness is different. These individuals are not going to become bipolar over time.

Here’s Where You Come In

So here you are. Your first antidepressant has either failed you or has achieved only a partial result. Your psychiatrist now has three broad, and not necessarily mutually exclusive, options:

1. Assume for the time being your depression is unipolar, and try a second antidepressant or augment that antidepressant with another medication.
2. Probe for evidence of bipolar disorder or for bipolar characteristics in unipolar depression (such as mixed states and cycling), and consider trying a mood stabilizer.
3. Investigate for personality features that may have an impact on outcome, and consider referral to a talking therapist or combined meds-talking therapy.

Just to illustrate how far psychiatry has to go, the APA’s 2000 "Practice Guideline for the Treatment of Patients with Major Depressive Disorder," in its Failure to Respond section, only considers the first option. There are scattered references throughout the Guideline to bipolar disorder (such as looking for a family history of the illness), and a single paragraph concerning "comorbid personality disorders."

A number of articles on this website devote considerable space to the possibility of option two. What about the third option? Can we turn to the personality disorders experts for some guidance? Unfortunately, it’s not as easy as rolling down the window and asking for directions …

Diagnostic and Statistical Muck

A point that everyone seems to agree on is there is not much to like about the way the DSM defines and classifies personality disorders. In all likelihood, Axis II will receive a major overhaul in the next DSM. The situation is outlined in a 2002 APA publication, A Research Agenda for DSM-V: Summary of the DSM-V Preplanning White Papers. According to the "Research Agenda," 56 percent of psychiatrists and psychologists in a survey considered personality disorders "problematic" and 35 percent regarded personality disorders as "most in need of revision."

Love the personality, hate the axis. What’s wrong is that it is virtually impossible to establish clear boundaries between the various personality disorders (not to mention between Axis I and Axis II), much less arrive at some kind of consensus on diagnostic thresholds. A sign of failure is the NOS (not otherwise specified) diagnosis, which, according to the "Research Agenda," is "often the single most frequently used personality disorder diagnosis in clinical practice." As an alternative to the DSM’s "categorical" approach to personality disorders, the "Research Agenda" discusses a "dimensional" approach that assumes that personality traits are fairly universal. What distinguishes worry-free from worrisome is severity.

The dimensional schema most likely to make it into the next DSM, Dr Paris advised in his lecture, is the five-factor model, which measures for openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Neuroticism breaks down into anxiety, hostility, depression, self-consciousness, impulsiveness, and vulnerability.

The five-factor model would probably complement newer versions of the current categories, resulting in a mixed diagnostic system.

Back to Depression

We turn this part of the proceedings over to Michael Bagby MD of the University of Toronto, who spoke at an even smaller venue at the 2006 APA annual meeting. Dr Bagby has investigated depressed patients using the five-factor model. In a 2002 study, he and his colleagues examined 58 patients with major depression who had responded to treatment. Twenty-six were identified as having underlying chronic minor depression. This group, after the major depression had resolved, still had higher hostility scores and lower agreeableness scores than those without the underlying minor chronic depression.

Dr Bagby and his study co-authors cited the pioneering diagnostician Emil Kraepelin in support of the proposition that, historically, minor depression was thought to exist on a spectrum with personality. They also speculated that these individuals "may define a group who are pessimistic, disaffected, and frustrated, perhaps because they see their illness as an intractable and enduring part of their selves."

So forget the antidepressant and go with psychotherapy, right? Not so fast, said Drs Bagby and Paris in their talks. For one, it is often difficult to form a therapeutic alliance with an angry or hostile individual. Moreover, SSRIs decrease anger and hostility while mood stabilizers work for impulsivity. Dr Bagby suggests first going with meds for a patient who scores high on neuroticism, then talking therapy.

Is There a Relationship Between Bipolar and Borderline?

John Gunderson MD of Harvard, is author of "Borderline Personality Disorder: A Clinical Guide," and his body of work is cited everywhere. In an article in the July 2006 American Journal of Psychiatry Dr Gunderson and his co-authors delivered a direct broadside to Dr Akiskal:

"Advocates for an expanded bipolar disorder construct (ie a ‘bipolar spectrum’) believe that the affective lability and impulsive behaviors characteristic of patients with borderline personality disorder derive from shared genes and that borderline personality disorder should be reconceptualized and reclassified as a part of the bipolar spectrum."

Very quickly, the authors added: "Of this research, very little supports the thesis of a spectrum relationship between the two disorders."

Gunderson et al tracked 196 patients with borderline personality disorder and 433 patients with other non-related personality disorders (such as avoidant personality disorder) over four years, and found that the borderline patients had a higher co-occurrence of bipolar disorder (19.4 percent) than patients with other personality disorders.

In other words, four in five patients with borderline did not have bipolar.

Bipolar I was more common than bipolar II in this group. Eight percent of the borderline patients entering the study without bipolar had new onsets of bipolar, mostly following highly stressful events, significantly higher than those with other personality disorders.

Said the authors of the study: "These findings support the concept of a modest association between borderline personality disorder and bipolar disorder," though this association "is not yet conclusive."

The authors note that although co-occurrence between the two disorders is not widespread, "it has become unusual for patients with borderline personality disorder not to have been diagnosed with bipolar disorder, usually bipolar II disorder."

In making a diagnostic assessment, periods of depression and irritability are rarely instructive, say the authors. Sustained periods of elation, mood swings without evident stressors, or true mania point to bipolar, and indicate ruling out borderline or making it secondary. Repeated angry outbursts, on the other hand, suicide attempts, or acts of deliberate self-harm that are reactive to interpersonal stress "are axiomatic" of borderline. The presence of these symptoms suggest ruling out bipolar or making it secondary.

The authors caution that misdiagnosing a borderline patient as bipolar may have the damaging effect of encouraging patients and their families to have unrealistic expectations about what medications can do. Patients get diverted from useful psychosocial interventions. Instead, more meds are piled on, with predictability discouraging results.

Short Al and Amy Dala

Daniel Weinberger MD is chief of the Clinical Brain Disorders Branch at the NIMH. In 2003, Science magazine singled out his work (with others) into the genetics of mental illness as the number two "scientific breakthrough of the year." The big bang got top billing, and who is going to argue with that?

Genes do not encode for personality, Dr Weinberger said in two different symposia at the 2006 APA annual meeting. Genes are about the molecular biology of cells. Cells are about systems in the brain, from which emerge mood and personality and cognitive function, displayed as distinct but overlapping phenomena.

Temperament, said Dr Weinberger, is "a lifelong personality style of responding to environmental stimuli." Examples may include novelty-seeking and harm avoidance that may be associated with psychiatric disorders, but may also be part and parcel, he said, of personality, validated by various personality dimensional scales.

Exhibit A concerns Dr Weinberg’s 2002 breakthrough study (with Ahmad Hariri PhD of the University of Pittsburgh as lead author) that linked a heightened response in the amygdala, which mediates fear, to a variation (known as the short allele) in the serotonin transporter gene. A year later, another set of investigators (Caspi et al) found that a New Zealand cohort with this same short allele were prone to stress-induced depression while those with the long allele demonstrated considerable resilience.

As Dr Weinberger explained, the serotonin transporter genotype "impacts on how threatening the environment feels." The study implies that the short allele has something to do with anxiety and depression, but Dr Weinberger's slide also listed neuroticism.

Intriguingly, in a seminal article published at almost the same time as the 2006 APA meeting, Dr Akiskal attributed fear as one of the two underlying traits responsible for mood and personality dysregulation (the other was anger). Intriguingly again, Dr Akiskal's article cited Dr Weinberg's study.

The point is that personality disorders may one day be validated by brain science. By the time this occurs, psychiatry is likely to have a whole new system for classifying and diagnosing personality disorders, including borderline. Finally, psychiatric thinking on personality disorders is outgrowing its Freudian legacy. In his APA lecture, Dr Paris related how his daughter had asked him where personality disorder comes from. Confided Dr Paris in his audience: "I wish I could wake up in one hundred years and find out the answer."

So What Have We Got?

Clearly, something is going on. But can clinicians pick it up? Psychiatrists and therapists tend to base their assessments on what their patients tell them. Typically, the patient says he or she is depressed, and depression is the first diagnosis. When treatment fails the patient is deemed either treatment-resistant or is reclassified as bipolar. End of story for the clinician, unfortunately, in many cases, not for the patient.

Family members and associates of these individuals, however, may encounter a far different reality. They have a lot more to go on than the patient's word. My quick answer to Dr Akiskal is if you don't think borderline is real then hang around with some of the people I had to hang around with.

Dr Akiskal may well be right. Where he is absolutely dead on is in his point that clinicians who are at a loss to explain irritability in their patients may be too quick to brand them as borderlines, with all the horrific stigma that implies.

The DSM has a lot of catching up to accurately portray the reality of both mood disorders and personality disorders. It is particularly important to note that with both mood and personality the DSM has an all-or-nothing approach. When viewed as a spectrum, however, we are looking at shades of an illness. In other words, it may not be a question of whether you have bipolar disorder or whether you have borderline personality disorder. The more appropriate questions to ask may be, "How much bipolar do you have? How much borderline do you have?"

A little bit of bipolar may warrant putting a depressed patient on a mood stabilizer (and a program of very careful mood monitoring) rather than an antidepressant. A little bit of borderline may suggest adding certain types of talking therapy designed to pick up useful coping skills (such as dialectical behavior therapy). It should not be regarded as shameful to admit to your psychiatrist that you have personality issues. Your psychiatrist probably has more of them than you do.

However you want to slice and dice borderline - part of the shmutz that goes with your mood disorder, a set of personality issues, or a full-blown diagnosis - it is important to recognize that people can change their behavior. AA is proof of that. People can also modify their biology. The way we think can change our response to stress. Brain studies show two-way traffic between the developed parts of the brain and the primitive limbic system (where the amygdala is located).

Thinking your way into recovery may not be the easiest task in the world, but it is not a hopeless one, either.

Final Word

By the time most of us begin to suspect someone we know may have borderline personality disorder, our dealings with this individual have usually passed the point of no return. They're the ones who may have burned their bridges, but we're the ones still smarting from the burns. It's one of those terrible facts of life - to know them is to hate them.

But if we experience burns, their flesh is smoking from the flaming hot branding iron that psychiatry stamps into their already tender psyches. (I use the terms "we" and "they" very advisedly). The B word is the cruelest label ever devised to describe an individual, way worse than the N word or Q word, way more humiliating than any scarlet A Hester Prynne was forced to wear.

These individuals already have enough difficulties with personal relationships without putting the rest of the world on notice that they should be shunned and ridiculed. Yes, I was still licking my wounds from my earlier bad encounters, but I needed to hear actual patients speak, for them to tell their stories in their own words, in a place where they felt safe to talk.

That opportunity was offered at the 2006 NAMI national convention. A few weeks before, NAMI had expanded its list of "priority populations" to include those with borderline personality disorder. As a result, the convention had on offer an ask the doctors session devoted to this illness.

On the panel was a patient – we’ll call her Anne – who presented a human face to the condition. She is 36, very smart, very articulate, very personable, with a degree in creative writing. Unfortunately, the best job she can get is answering phones, and she feels herself lucky. Her illness cannot take the demands of something more challenging, more stressful, that would place her in pressure cooker situations amongst people. When she loses it, she admits, you don't really want to be around her.

Those who live with individuals with borderline describe the experience as akin to walking on eggs. By contrast, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, and the ground beneath her could collapse any second.

"It’s like demons possess me," she related. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.

She emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"). Anne concluded with reference to her favorite bumper sticker, "Don’t believe everything you think."

I immediately approached Anne after the session ended. I may have made a new friend.

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July 14, 2006