I wish Secretary Eric Shinseki, head of the Department of Veterans Affairs would read this comment but that will be close to impossible. I say so because for a long time I have been trying to capture the attention of the VA system to an angle of the problem discussed by doctors Goodman, Jeong and Triebwasser.
As a matter of fact, my stance is the complete opposite of the view postulated in their paper, in more than one way. As Dr. Hagop Akiskal1 and several others have argued, individuals labeled as "borderline" are bipolar patients on antidepressants. The authors see a beneficial effect of SSRIs on the irritability of "borderline" patients whereas my data shows that over a period of 3 years 100% of the bipolar patients arriving to the ER with suicidal attempts (in a general hospital) were taking antidepressants.2 Several of them were veterans with many years of treatment at several medical centers and clinics.
The use of SSRIs in the VA is more prevalent than in other setting because these medications are considered the first line of pharmacological treatment of PTSD. Unfortunately, many traumatized patients also have bipolar spectrum disorders and they never achieve acceptable levels of stability while on antidepressants.
Another compounding factor is substance abuse. Many veterans use alcohol, opiates and cannabis as tools of last resort to catch some sleep because the racings thoughts (exacerbated by antidepressants, nicotine and caffeine) drive them "crazy" at bed time. The VA expends vast amount of money in substance abuse treatments during which providers, either keep patient on antidepressants or expect they are going to stay "clean and sober" after a 30-days program, while the "sleep aid" is an anti-histaminic drug.
I started with a reference to General Shinseki because he strikes me as a sensitive and honest person, who would be distraught with the realization of the pain, loss in productivity and family suffering many veterans experience because of the myth of Borderline Personality Disorder (BPD) and the obfuscation with the treatment of bipolar disorder.
Dr. Gunderson deserved all the respect and admiration his brilliant career has earned but the veneration of an illustrious professor should not preclude the realization that numbers and tragic case reports do not lie. The Korean War veteran that was found by his wife with a construction block tied up to his neck and facing the bottom of his swimming pool had been released from a well-known teaching hospital a few weeks before his death. He also had been labeled "borderline" and bipolar and had a combination of 2 antidepressants and 3 mood stabilizers… so many medications and still he couldn't find a reason to be alive. Shouldn't this case be a wakeup call to re-think our approach to treatment of bipolar spectrum disorders and a revision of the validity of the so-called Borderline Personality Disorder?
The psychoanalytic establishment made great contribution to the advance of psychiatrist but they are also responsible for the birth of faulty diagnoses such as Oppositional-Defiant Disorder (ODD) and Conduct Disorder (CD). These two labels were incorporated into the psychiatric nomenclature because the psychoanalysts decided that children could not develop depression or "manic-depressive" illness. Consequently, the evaluators of youths exhibiting mood swings, unprovoked aggression, and defiance of authority had to put a name to those behaviors. Ironically, in medicine we don't consider abdominal pain a disease but when it comes to psychiatry the symptoms of "defiant and oppositional" become an entity with its own merits.
Wouldn't be a noble gesture if the psychoanalysts use their influence to dismantle those pseudo diagnoses that DSM-IV-TR calls ODD, CD and BPD?
Manuel Mota-Castillo, M.D.
Lake Mary, Florida
Akiskal, H.S.; Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum, Acta Psychiatr. Scand. 110 (2004), pp. 401–407. 2004
Mota-Castillo, M., Bipolar Disorder and the Case Against Antidepressants, Psychiatric Times, "From Our Readers", October 2008.