Is Borderline Personality Disorder a Real Syndrome or a Cluster of Symptoms?
To the Editor of The Journal Of Bipolar Disorders:
Borderline personality disorder (BPD) has been the preferred label given to those overemotional patients like one adolescent who shocked me with this answer: "What do you mean? ... I don't go by feelings, if I go by feelings I kill myself." Such a display of anger was her response to my greeting: "Good morning, how do you feel today?"
That encounter happened long before Dr. Akiskal wrote a well-thought-out challenge to the BPD diagnosis. 1 Had I known then what I know today about the negative impact antidepressants (ADs) have on bipolar spectrum disorders, that patient's hospitalization could had been shortened from 4 weeks long to probably 4 or 5 days.
For the psychosocial treatments of BPD, so far, the most successful has been the dialectical behavioral therapy (DBT) created by Marsha Linehan, PhD. I had the opportunity to observe its outcomes at Massachusetts Mental Health Center, but, in retrospect, I realize that what I witnessed in Boston was the covering of a wound with a bandage, without a suture, and it became obvious to me why relapses (bleeding upon removing the bandage) happen.
That also explains why my "borderline" patients in Phoenix, Arizona, never achieved complete recovery and why my Floridian patients who come to my office with such a diagnosis either get well in a matter of weeks or return home with a prescription to treat a mood disorder. My practice covers the most frequent psychiatric settings, i.e., residential treatment center, hospital, and private outpatient office. For 2 years I combined these milieus with community psychiatry in Daytona Beach, Florida.
From my Floridian experience I can present the following findings.
Sixteen patients (13 females and 3 males) either had a diagnosis of BPD or displayed symptoms that met the DSM-IV-TR criteria for such diagnosis. I must admit that I did not apply the BPD diagnosis because every case qualified for a primary diagnosis that explained the presenting symptoms. For example, in 2003 I diagnosed a 9-year-old girl with post-traumatic stress disorder and sexual abuse of a child. At the age of 2, she had a sexually transmitted disease when she was found wandering around the streets while her mother was doing drugs at home. At 5 years old she was raped by an older foster brother and tortured by the foster parents until she came to the care of a nice family that adopted her.
I think of patients like this girl and names such as Otto Kernberg, Glenn Gabbard, Michael Stone, John Gunderson, and Robert Waldinger, and it becomes challenging to ask these lighthouses of psychiatry to "Show me the money." This intellectual conflict reminds me of the famous phrase that Galileo mumbled under his breath, while leaving the Inquisition Tribunal where he was interrogated for having said that the Earth rotates around the sun: "and nonetheless it does move."
This is not to imply that what Kernberg, Gabbard, Gunderson, Stone, and Waldinger teach about so-called BPD is not effective or wellfounded, but that treating the root of the symptoms that form the clinical picture known as BPD is a faster and more durable way of "suturing the wound" instead of placing a bandage. Besides, we tend to focus only on the patient and forget about the genetic linkage: The abused girl not only has the emotional scars from the abuse but also the genes from her abusive parents.
It is relevant to mention that worsening of "borderline symptoms" after treatment with ADs was reported before the selective serotonin reuptake inhibitor era. In 1986, a study showed "a paradoxical increase in suicide threats, paranoid ideation, and demanding and assaultive behavior occurred among 15 borderline inpatients receiving amitriptyline in a double-blind study. This pattern differed significantly from that of 14 nonresponding patients receiving placebo." 3
I wish somebody could prove me wrong because I hate the idea of arguing against real masters of psychiatry, but I can't remain silent at the cost of prolonging the suffering of mood-impaired individuals misdiagnosed as having a personality disorder.
To that effect I want to reproduce a few lines from Dr. Akiskal's paper mentioned above:
Of perhaps greater concern is that the operational construct of BPD may not coincide with what an authority of the stature of Kernberg means by borderline personality organization. The latter denotes a vulnerable psychic structure, rather than a formal nosologic entity. As such, it refers to patients with certain specific defensive operations which place their functioning at a "stably unstable" level between the classic neuroses and the psychoses.
This "predictable volatility," noticed in children previously diagnosed with BPD, is frequently a trait that persists after the mood is stable, but none of my 16 patients with ''borderline personality organization" has shown self-harming behavior or explosive and unprovoked rage when ADs were stopped and a mood stabilizer plus cognitive-behavioral therapy was used. My experience with "borderline" youths is that a preceding reputation of "never getting better" was secondary to the mood-disrupting effect brought on by the ADs and that their borderline organization is a trait that should be treated with the therapies validated for the cluster of symptoms that we have overrated to a diagnostic category.
Manuel Mota-Castillo, MD
Lake Mary, Florida
Akiskal H. Acta Psychiatr Scand 2004;110:401--407.
Linehan MM. Cognitive-Behavioral Treatment of Borderline Personalir.y Disorder. New York: Guilford Press; 1993.
Soloff PH, et al. Am ] Psychiatry 1986; 14 3:1603-1605.