Borderline Personality Disorder Why They Dont “Get Used to It ”

At the annual meeting of the American Psychiatric Association in New York this year, I learned about a new finding from one study with patients who exhibit borderline personality disorder (BPD). The same finding also applied, although to a lesser degree, to those with avoidant personality disorder (AVD), which is pretty much identical to the diagnosis of Social Phobia.  I suspect that the reasons for the similar findings may be different for the two disorders.

The finding involved a part of the brain called the Amygdala. This little doohickey is central to a lot of brain functions, but in particular, it is the center for the body’s “fight or flight” response. I always though it fascinating  that the amygdala also has specific cells which respond only to one’s own mother (or other primary female attachment figure) and nothing and nobody else, and other specific cells which respond onlyto one’s father (or other primary male attachment figure). 

Although one cannot prove such things, this fact suggests to me that primary attachment figures may be the most potent of all of the environmental triggers to fear-based flight or fight reactions. They are certainly more powerful that a therapist can ever be for doing so, for instance.

The finding may relate to one of the primary symptoms of BPD, which goes by a variety of names. In the actual DSM criteria, it is described as “affective instability, or 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.)” It is also called high reactivity, and lay people often label it hypersensistivity. In psychological tests, it is called neuroticism. Clearly, amygdala activation is intrinsic to this phenomenon.

Therapists have a tendency to think that patients with BPD over-react because they misperceive the behavior of others as being emotional slights, when the behavior is not at all meant as such. In fact, these therapists do not even know to what exactly the patient may be reacting to, or alternatively, that sometimes patients with BPD feign such reactions in order to provoke a specific response in others in order to recruit them to be enablers of the patients’ spoilerrole.

For example, one patient would go ballistic if anyone ever even implied that her mother might have been a loving parent. Of course, if one knew all the horrible things her mother had done to her, one could easily see why she would find such a comment annoying - to say the least!

The study I am discussing here is by Harold Koenigsberg and others (Journal of the American Psychiatric Association 171:82-90, January 2014). Study participants were asked to look at a series of pictures with either highly negative or neutral content, and the activation of the amygdala and another region of the brain called the dorsal anterior cingulate was measured using a specific type of brain scan. The subjects also subjectively rated their emotional responses to the pictures. 

Exposure to these pictures and these measurements were then repeated. Repeated only once, I’m afraid. The study would have been a lot more powerful if they had repeated the exposure several times.

The changes in emotional arousal and brain activation after a repeat viewing of the negative images was small but signficantly different between patients with BPD or AVD and the "normal" control subjects.  

The brains of the controls seemed to habituate, while those of the patients with BPD did not.  Habituation means that the controls got used to or became accustomed to the awful pictures, and their arousal levels decreased from what it had been after the initial viewing.

If anything, the emotional arousal of patients with BPD actually increased with the repeat viewing.

This finding, if it can be replicated, might seem to indicate that the brains of those with BPD are abnormal in this regard. However, as I have ranted in the past, a difference is not automatically indicative of an abnormality. In fact, it may be a conditioned response that is highly adaptive in particular environments.

In the case of patients with BPD in particular, they invariable grow up in chaotic family environments in which “getting used” to the chaos and not reacting to it when one needs to could be hazaradous to their and their family’s health, as described in my post on Error Management Theory.  If the chaos continues, such individuals need to pay even more attention to it, not less. 

This new research finding fits my ideas about that to a tee.

Treatment Resistant Depression and Borderline Personality Disorder

On October 18, 2013, John Gunderson, perhaps the most internationally recognized expert on borderline personality disorder (BPD), wrote a piece in the American Psychiatric Association’s newspaper, Psychiatric News. He opined that many if not the majority of cases of treatment resistant depression (TRD - depression that does not respond to antidepressant drugs) may in fact be undiagnosed cases of patients with BPD.  This opinion is totally consistent with my own clinical experience.

John Gunderson, M.D.

Of course, the psychiatric-industrial-Pharma complex immediately went on the offensive. On his Medscapeblog, Nassir Ghaemi - a fan of  bipolar m.a. - wrote a two part rebuttal. He expressed the opinion, asserted and not backed by any particular review of the literature, that the DSM criteria for BPD are invalid. In the past, he has also expressed the belief that the DSM duration criteria for manic and hypomanic episodes in bipolar disorder are far too restrictive, and seems to liberally substitute his own personal criteria for these disorders in his arguments

He goes on to assert that the “…bland, broad DSM definition allows Dr Gunderson and other borderline experts to diagnose the condition in a large chunk of persons with mood illness, not just bipolar illness but also simple depression, since depression entails relationship problems, is often associated with irritability and paranoia, frequently involves mood reactivity, often involves suicidal attempts, and can also entail nihilistic thoughts of feeling abandoned or empty.”

Nassir Ghaemi, M.D.

As I shall discuss a little later, these symptoms, when all taken together as a group, are not typical for your average run-of-the-mill case of Major Depressive Disorder (MDD), but are extremely typical of depression in BPD.

Dr. Ghaemi's statement here is misleading, because, while any given patient with major depression and no BPD may indeed have any one or two of these characteristics, they usually do not have almost all of them together. Omitting mention of this pertinent fact is a tactic frequently employed in arguments from the everyone-who-is-moody-is-bipolar crowd.

As a reference for his assertion, Ghaemi cites a study by Angst, who is another bipolar disease monger whose circular pseudo-logic I dissected in a previous post.  

Ghaemi then goes on to focus on one of Gunderson’s statements in his article: Gunderson cited a study that showed that the presence of BPD was a major predictor of persistence of depression over time in a sample of persons who met MDD criteria.

I agree with Dr. Ghaemi that such a study does not prove, in isolation and by itself, that BPD is the most common cause of TRD, as there could very well be very many other even more common causes.

His impeccable logic: “It does not follow that if x makes y worse, then most cases of treatment resistant y are examples of x. Substance abuse makes the course of MDD worse; but it does not follow - it is scientifically incorrect and illogical - to then conclude that most cases of TRD are cases of substance abuse, end of story."

Of course, the fact that Gunderson cited this one particular study did not mean that he thought he was providing a complete literature review, but Ghaemi seems to be implying that Gunderson is saying that this one study is the onlyevidence he is relying upon - which he didn’t say. There are a host of studies, btw, that show that severe personality disorders are often predictive of a poor response to all sorts of psychiatric medications for all sorts of psychiatric disorders.

Ghaemi himself, on the basis of some highly questionable studies, opines that the most common cause of TRD is “unrecognized bipolarity.” He of course cites references produced by his fellow bipolar m.a. disease mongers in Hagop Akiskal’s incredibly biased Journal of Affective Disorders.

Their logic has always been a one or another version of the following:

Treatment resistant depression is often accompanied by symptoms such as racing thoughts or  hyperactivity

Racing thoughts, hyperactivity, and other such symptoms can look vaguely similar to symptoms of mania

Therefore, such patients must be bipolar

This is every bit as invalid as the logic that Ghaemi is attributing to Gunderson. In fact, anxiety disorders can and do produce, superficially, all of the symptoms that Ghaemi and his buddies attribute to an underlying “bipolarity.” When looked with a more discerning eye, of course, the symptoms of anxiety disorders and mania look very, very different.

A certain type of anxiety mixed with depression, is, as I shall discuss in a bit, one of the major qualitative factors that distinguish depression in BPD from other types of depression. I think the articles that Ghaemi is quoting are not only consistent with what Gunderson is arguing, but could have been used by him as clear evidence for his main thesis!

I have met Professor Gunderson. I think he is more than capable of telling the difference between BPD and bipolar disorder. 

It’s not subtle.

Dr. Ghaemi shows such limited understanding of BPD that I suspect that, in all likelihood, he has never or rarely sat down with such patients in long-term psychotherapy and painstakingly dissected the environmental and interpersonal context in which their depressive symptoms come and go.

Another person who, like myself, has done this with patients is my colleague, academic psychiatrist Ken Silk. He did a far more complete literature search [“The Quality of Depression in BPD and the Diagnostic Process.” Silk, K. Journal of Personality Disorders 24 (1), 2/2010] than was presented in the discussions by either Dr. Ghaemi or Dr. Gunderson.

Kenneth Silk, M.D.

He points out that, rather than restricting the diagnosis of MDD to those who clearly display a biologic depression - the cases that used to respond to tricyclic antidepressants back when they were the dominant drugs - the diagnosis has spread along with the assumption that most presentations of depression are some form of major depression and, even if not MDD, should respond to antidepressants. The term depression is now used in academic discussions to refer to a mood rather than an actual diagnostic construct.

He lists the qualitative difference between the symptoms of MDD and those of depressed BPD’s. Besides the fact that the BPD patients meet criteria for BPD, not to mention that they also exhibit the family dynamics typical of those with the disorder, the quality of their depression is characterized by the following [My comments in italics]:

1.      A“mad-bad” depression closely tied to anger and hostile behavior.

2.      Mood symptoms that are very sensitive to interpersonal situations in which the patient feels abandoned, lonely, or empty in the absense [or in the presence for that matter] of a longed-for important other.

3.      Depressed moods can come on quickly and disappear quickly [the opposite of true MDD] depending on the reactions of an attachment figure.

 

4.      The depression is at times more closely related to chronic self-criticism and a feeling of intrinsic “badness” than in MDD without BPD.

 

5.      It is associated with chronic self destructive behavior [including self-injurious behavior like cutting].

 

6.      It is associated with a loss of gratification and frustration.

 

7.      Recovery from BPD facilitates recovery from MDD when it is co-occurring, rather than the other way around.

 

8.      The depression often comes from exhaustion and demoralization from repeated unsuccessful battles with chronic and overwhelming anxiety. [BPD often is accompanied by panic disorder].

9.      Patients with BPD often exhibit impulsive aggression (a hair trigger leading to rage). [Patients with true major depression, especially of the melancholic variety, tend not to show this characteristic at all. They are usually extremely passive because they do not have the energy to strike out].

Important questions glossed over by Dr. Ghaemi include: in what contextdo symptoms appear? How attached is the low mood to specific interpersonal events? Is affective dysregulation (high reactivity to interpersonal problems) prominent? 

An important additional point is that these qualitative differences in depression  that Dr. Silk lists are not measured clearly by any of the standard symptom rating scales used in the vast majority of psychiatric studies. Therefore, citing any studies which employ these instruments in this debate is sort of irrelevant to the basic question. 

A few final caveats.  People with BPD can still have depression that does respond to an antidepressant. And even when the depression in BPD does not improve with SSRI antidepressants directly, other symptoms such as panic attacks can improve dramatically with these drugs (especially if the SSRI is combined with certain benzodiazepines).  SSRI’s can also decrease reactivity by raising the bar, so to speak, so that it takes somewhat more extreme behavior by an attachment figure to create a severe emotional reaction. 

In patients in which either or both of these two things happen, their depression may improve indirectly because of the effects of the drug on the other symptoms, as opposed to in MDD, in which the decrease in low mood is a direct effect of the drugs.

Finally, patients can also have both BPD and true bipolar disorder. In fact, patients with bipolar disorder, when not in the midst of a manic or a depressive episode (when they are euthymic), can have just about any psychological or psychiatric reaction or personality issue in addition to bipolar disorder.  That is because, when they are euthymic, they are basically just like anyone else! 

Writers in the Journal of Affective Disorders just love to merely assume that any emotional reaction a patient with bipolar disorder has simply must be due to the underlying bipolar disorder.  What hogwash.

Dr Allen Discusses Borderline Personality Disorder The Earth Needs Rebels Show on Orion Talk Radio

Dr. Allen discussed his ideas about borderline personality disorder in detail (this time it's just him and the host) on The Earth Needs Rebels Show broadcast on Orion Talk Radio http://oriontalkradio.com from Tonawanda, New York, 1650am and global on the internet, with additional feeds like Tunein Radio (http://tunein.com for more information on tunein radio and free software).

Here is the link to the downloaded broadcast: http://oriontalkradio.com/archives.htm.  Click on "down" and not on "listen."  The date and times posted for the broadcast: Tuesday, August 13, at 1:05 and 2:05 PM.

Parts 2 will be on live September 10 from 12-2 PM U.S. Central Time.

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder Part II

At the end of Part I of this post of September 12, 2012, I mentioned that doing psychotherapy outcome studies is diabolically difficult, and promised to discuss the reasons why in this post. In fact, because of the literally infinite numbers of uncontrolled variables in studies of human beings both individually and in relationship to other human beings, psychotherapy outcome research can never be the only standard by which the "science" of human behavior-change technology should be measured.  In fact, it's not even the gold standard.  

In order to better understand ourselves and what leads us to change our behavior, we must use ALL available sources of information. We have to look at the widespread clinical experience of psychotherapists who use a variety of techniques and theories with a variety of clinical populations. We have to look for potential biases in both clinical studies and within an individual therapist's anecdotes and the conclusions that we draw from them. In forming conclusions about both anecdotal and controlled-trials data, we have to look at a wide variety of possible explanations, as well as for any information and experiences that would seem to contradict those explanations.

We also have to look at the experience of marketers who have been able to induce a large numbers of people to buy a product or vote for a politician (many of whose very powerful techniques have been discussed in previous posts on this blog). We have to look at the social psychology literature, which shows that people behave very differently when interacting with different groups of people and with different individuals than they might do in a therapist's office. 

We have to look at historical and sociological trends. We have to look at new knowledge from the neurosciences that might account for findings that are difficult to explain or reconcile with other beliefs.  We must look at evolutionary biology. We must examine our own beliefs for logical inconsistencies. We have to be honest about thinking about ourselves what makes us tick personally.

What follows is a list of some of the difficulties psychotherapy outcome researchers encounter, as well as the reasons they may overstate their results.  A fuller discussion of each of them can be found in my book, How Dysfunctional Families Spur Mental Disorders.

1.  The Problem of the “False Self”

People do not act the same way in all social contexts.  They do not act or speak the same way around a boss that they do when they are alone with a lover. A man’s behavior in a strip club is very different than his behavior when he is playing with his children. We have different “faces” or masks which we apply to ourselves in different environments.  Not infrequently, these masks are meant to manipulate others to get them to do what we want them to do. 

I never cease to be amazed at how mental health professionals and researchers seem to believe that they really know what is going on in a patient’s or a research subject’s life based solely on the self report of the patient, or solely on the reports of the patient’s intimates, or even on the reports of people like teachers who observe the behavior of children in only one context that includes thirty other distracting students. If these professionals were asked if they believe that people often act differently in public than they do behind closed doors, they would of course say yes, but they seem to develop amnesia for this fact in discussions and in studies. 

A patient’s family members may be just as motivated to give a distorted view of a patient as is a patient.  Parents, for example, may prefer to believe that their child has some sort of mental defect, so as not to experience as much of their own covert guilt about their parenting skills. Conversely, some may actually prefer to blame the child’s behavior completely on themselves, in order to let their “perfect” child off the hook. Most mental health practitioners do not make home visits to watch patients and family members interact in their natural environment. Even if they did, unless they had a camera operating twenty four hours a day as in the movie The Truman Show, they could still be easily deceived.

2.       Double Blinding

When it comes to psychotherapy treatment outcome studies, we cannot do double blind placebo controlled comparisons of two different types of psychotherapy treatments. This is true because, in a sense, the therapist – or more correctly the relationship between the patient and the therapist – is the treatment. If the study were to meet the criteria for being double blind, that would mean that the therapists who administer the treatment would have to not know what they were doing. 

Of course, they cannot administer psychotherapy without being aware of what techniques they are using. If they could, that would mean that they were incompetent.  Not a fair test of a treatment!  The fact that the therapy relationship is one of the basic aspects of the treatment also makes placebo or “sham” treatments difficult, because any relationship has some effect on an individual. Does this mean we should give up on evaluating psychotherapy treatment scientifically and rely exclusively on clinical anecdotes?  Of course not.  Studies are still important.  We just have to understand their limitations.  

3.       Randomized Clinical Psychotherapy Trials 

One strategy used in therapy studies is to compare the outcomes of two different, presumably active types of psychotherapy treatment techniques with each other, rather than with placebo, on similar groups of patients, without the benefit of double blinding.   These studies are referred to as randomized clinical trials, or RCT’s. 

A large number of different schools of psychotherapy have different approaches to the understanding of and methodology for changing a patient’s repetitive dysfunctional habits.  Most of these therapy schools were designed by charismatic and creative individuals who based their ideas on clinical anecdotes. These innovators are highly invested emotionally in their own personal theories, and want them to look good in comparative psychotherapy outcome studies.

This leads to a so-called allegiance effect in RCT’s. The preferred psychotherapy school of the researcher is likely to be delivered more enthusiastically and with more rigor to subjects in the study than is the competing therapy treatment. One survey study examined 29 RCT outcome studies that compared one type of therapy to another and found a correlation of .85 between researchers’ therapy allegiance and outcome. That is, the researcher’s preferred treatment came out ahead 85% of the time. Just as in sponsored drug studies, this number is too way high to discount the presence of a significant bias in the studies.

When differences are found between two therapies, they are often statistically but not clinically significant. They show that one therapy is slightly more advantageous than the other, but that the actual improvement of the subjects was so minimal as to be inconsequential. 

When both groups of therapists who are providing the treatment in the study are equally committed to the paradigms they are delivering, comparative psychotherapy outcome studies almost always result in a tie. In psychotherapy research circles, it is known as the “dodo bird verdict.”  This refers to a character from Alice in Wonderland, the dodo bird, who in one passage said “Everybody has won, and all must have prizes.”

4.       Treatment as Usual 

Lately, many researchers engaged in psychotherapy RCT’s have employed a control group called treatment as usual (TAU), which really stacks the deck in favor of their pet psychotherapy school. Lining up practitioners of a different school from the researcher’s to act as therapists for a comparison group is often difficult.  Additionally, if the researcher were able to do so, the study might not show his or her therapy to be superior to another type. For these reasons, the use of TAU control groups has become almost epidemic in psychotherapy RCT’s. 

Subjects randomly assigned to the TAU condition, which serves as a comparison group to the group of subjects receiving the researcher’s therapy model, are simply released back into the community to get whatever other treatments are already out there. Some may see practitioners from other therapy schools, some may get medications, some may get both, and many others may get neither.  Both the TAU group and the experimental group are followed up at equal time intervals and given all the same outcome measures.  The psychotherapy methodology that serves as the investigated treatment always seems to beat TAU.

The reader should understand that within any widely-practiced therapy model, both good therapists and bad therapists can be found, just as practicing physicians can be either good or bad psychopharmacologists. For the subjects in the TAU condition who receive treatment, the results of the good clinicians in the community are probably cancelled out by those of the bad ones. TAU subjects may also be seen less frequently. Some, as I mentioned, are getting no treatment at all. Meanwhile, the experimenter’s group is usually getting a lot more individualized attention by therapists who are highly committed to the particular treatment model. These factors may be the real reasons their patients do better than those receiving TAU. 

The experimenter’s therapy is provided by uniformly well-trained and enthusiastic therapists under very well controlled conditions. The psychotherapy that is provided is applied with rigor and consistency, and is scrutinized by other observers through the use of videotapes of the sessions. Therapists who make errors are supervised almost immediately.  On top of this, research therapists often have caseloads that are very much smaller than those of folks out in practice, allowing them to spend more time deciding how to approach the clinical issues they face.  I cannot recall a single instance of a study in which TAU beat another therapy delivered in such a manner. If it did, I would have to wonder how the experimenter could have possibly accomplished such an unlikely feat.

5.       The Choice of Outcome Measures 

Another huge controversy in psychotherapy RCT’s is the question of which outcome measures should be used, because the different psychotherapy schools target different aspects of the patient's problems. What should we measure, exactly?  Symptom relief?  Whether or not the patient continues to meet criteria for a specific DSM disorder?  Whether they stop engaging in chronic repetitive dysfunctional behavior?  Whether they experience fewer conflicted emotions?  Whether they have improved and more satisfying relationships? Whether they can hold a good job?

In their November 1995 issue, Consumer Reports published a large survey on the public’s experience with psychotherapy. In response to the survey, satisfaction with their experience was reported widely by those who had been in therapy. Furthermore, longer term therapy was rated higher than therapy limited in duration by managed care, and satisfaction with psychotherapy was rated about equally by those who had therapy alone and those who were given a combination of therapy and medication.

In surveys of this sort, the question of selection bias arises - whether or not the sample of people polled is representative of the general therapy population. The respondents in this case were almost all middle class and educated, so we have to limit our conclusions to that population rather than the population of the United States as a whole.  Nonetheless, the study was the most extensive study of its type on record. Should opinions expressed by patients evaluating psychotherapy outcomes for themselves count as science?  Many in the field would say no.  

But one must consider, however, that psychotherapy target's a patient’s subjective sense of personal well being. That is, we want to know whether patients feel better mentally about their lives. By this measure, assuming that the survey respondents were being somewhat honest with their answers, we would have to say it should count.  A paradox about the “science” of psychotherapy is that we are attempting to be objective about subjectivity, two concepts which are usually defined as antonyms.

6.       Funding Issues

Another big issue for the field concerns which psychotherapy treatment outcome research studies get funded.  If a scientist cannot get money for a project, it will rarely get off the ground, because these types of studies are very expensive to mount. Most successful psychotherapy RCT’s have employed CBT because of the predominance of this model in professional psychology training programs, and because most CBT treatments aim primarily for symptom reduction, which is relatively easy to measure, rather than personality change, which is not. 

7.       Problems with Generalizability of Study Results

Another big problem with all psychotherapy RCT’s is that most studies require that the subject population be homogeneous, meaning that the subjects in the study must be very similar in the nature of the disorder they exhibit, and in how severe it is. This requirement means that patients who have more than one DSM disorder or psychological problem are often excluded from studies.  In contrast, most patients seen in practice, at least by psychiatrists, have more than one disorder (co-morbidity). This fact alone limits what is termed the generalizabilityof the study’s finding. We do not know from a study using patients who have only one disorder if the treatment employed in the study would work as well with patients who have multiple problems.

Because studies need subjects who will stick with the treatment until the end of the research project, some subjects who have certain characteristics that are common in clinical practice tend to be excluded. This problem further limits the generalizability of the study.  For instance, most studies of treatments for depression exclude patients who are suicidal!  Another problem with RCT’s is that many subjects drop out of a study or are removed from a study as it proceeds because they do not completely cooperate with the treatment in some way. CBT studies, as do many others, tend to have a fairly high dropout rate. The subjects who end up completing the study are usually the most motivated to change, and would therefore be expected to do better than those who lack this motivation. This all makes the treatment method look much better than it would be if it were employed in a typical clinical practice setting. 

8.       Treatment Manuals

Another big issue in psychotherapy outcome studies is that, in comparing different treatments for different behavioral problems, researchers need to have some way of knowing that all the therapists employed in the study are doing mostly the same things. In early psychotherapy studies, the methods section of a journal report might say that such and such number of patients was “given psychoanalytic therapy,” with no description of what the therapists actually did. This was clearly unacceptable.

The solution to this problem that has been employed most frequently is the use of treatment manuals, as well as manuals that measure the study therapists’ competence in and their adherence to the treatment paradigm.  Treatment and adherence manuals specify exactly what the therapist should be doing under a variety of circumstances. Tapes of psychotherapy sessions of patients in the studies are reviewed to make sure that the therapists are employing the same interventions. A “rater” will count the times the therapist did the right thing and the times the therapist strayed from the procedures specified in the manual. This process assures that all patients are getting approximately the same treatment. 

Unfortunately, a good therapist has to be flexible and employ a variety of different strategies in ways that are tailored to the proclivities and sensitivities of the patient in front of them. Generic interventions may not only fail to work, they may backfire and make matters worse. Verbal interventions must often be phrased differently to different patients in order to reduce the patient’s defensiveness. Treatment and adherence manuals take away a lot of this flexibility, so that the therapy as performed in an RCT is not always similar to the way that clinicians out in the field practice it. Creating treatment manuals can itself be a daunting task. I heard a respected researcher tell a group of other researchers that his team was having trouble designing such a manual because the founder of the treatment they wanted to study was observed to perform psychotherapy completely differently than his own wife, who supposedly was a practitioner of the same model of therapy.

The Extremely Quick and Dirty on Personality Disorders

What do you guys know about personality disorders? My guess: not a whole lot. And not because you're not a well-informed bunch of people, because of course you are! It's just ... I think there's a lot of confusion out there about them.

First, let me explain something. When we diagnose (using the DSM-IV, which is not the only diagnostic system, but is the most commonly used among American mental health professionals), we do so on five "axes". I'll explain the whole system in a future post, but basically:

• Axis I disorders are considered "clinical" disorders, that is, in need of clinical attention. Things like anxiety, depression, schizophrenia, and bipolar disorder are Axis I disorders.
• Axis II disorders are of two types: mental retardation and personality disorders.

Personality disorders signal that a person is showing a relatively inflexible pattern of behaviors, thoughts, and emotions across most of his/her environments, and that inflexible pattern is almost certainly causing the person some trouble in terms of occupational, personal, and relational functioning.

There are three "clusters" of personality disorders outlined in the DSM-IV (and a few more identified in other diagnostic systems, but I won't get in to those today). Below is a tiny snippet about each--keep in mind that, to be diagnosed with a personality disorder, the behavior has to cause impairment, AND it has to be out of the norm for one's culture and society.

Cluster A (the odd or eccentric patterns):

• Paranoid Personality Disorder--irrational suspicions and extreme distrust of others
• Schizoid Personality Disorder--extreme lack of interest in other people and relationships
• Schizotypal Personality Disorder--odd behavior and thinking

Cluster B (the dramatic, emotional, or erratic patterns):

• Antisocial Personality Disorder--pervasive disregard for the law and rights of others
• Histrionic Personality Disorder--pervasive attention-seeking behavior (i.e., inappropriate sexual seductiveness and shallow, exaggerated emotions)
• Borderline Personality Disorder--instability in self-image, relationships, and identity often resulting in impulsivity and self-harm (I'll bet nearly all of y'all have heard of this one)
• Narcissistic Personality Disorder--grandiosity, need for admiration, lack of empathy

Cluster C (the anxious or fearful patterns):

• Avoidant Personality Disorder--social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation
• Obsessive-Compulsive Personality Disorder--precoccupation with orderliness and interpersonal control at the expense of flexibility, openness, and efficiency
• Dependent Personality Disorder--extreme psychological dependence on other people

These disorders really shouldn't be diagnosed until late adolescence or adulthood. The prognosis depends on the disorder. Most people with these disorders don't seek treatment until their behaviors have caused them some real suffering and turmoil in their lives. Studies show that adolescents with personality disorders are twice as likely to develop an Axis I disorder (like depression or anxiety) in adulthood when compared to their non-personality-disordered peers.

In other words, personality disorders make a person more vulnerable to other bad stuff. And also harder to treat.

I'll be doing posts on nearly every one of these personality disorders at some point. Although these disorders are not pleasant in real life, they could really make for some powerful, interesting characters in a novel, and you'll see an example of this Wednesday, when I will post about Obsessive-Compulsive Personality Disorder.

So ... are you familiar with the term "personality disorder"? Were you aware it was actually numerous disorders? Which ones have you heard of, and which ones are new to you? Are there any in particular you'd like to know more about sooner rather than later? Have you ever written a character with a personality disorder (either intentionally or unintentionally)?

Today's Monday, so remember to visit Lydia to read her Medical Monday post, and Laura for her Mental Health Monday post.

Double Standards for Brand Named vs Generic Drugs in Literature Reviews Use of Medication in Borderline Personality Disorder

In the free psychiatric "journal" Psychiatric Annals (Psychiatric Anals?) of August 15, 2015 - no doubt financed by PhARMA - one article correctly points out that studies on medications used for symptoms of Borderline Personality Disorder have been very small, extremely infrequent, very short-term, poorly controlled, and of limited usefulness. (And done without ANY consideration for comorbid disorders like panic disorder, which is seen in about 40% of subjects, I might add).

It also points out, again correctly, that there are no medications for the disorder itself, and that psychotherapy is the treatment of choice for that. Nonetheless, most of these patients do take medications for certain symptoms of the disorder: most usually the mood instability, irritability, and impulsivity that lead to such other problems such as self-injurious behaviors like cutting.

The review of the studies that have been done is fairly complete, although I notice that they left out an extremely important articleon the use of Prozac for the symptom of "impulsive aggression" by Coccaro and Kavoussi from 1997.

During its rather limited review of studies of the use of antidepressants in the disorder, it says things like, "The authors found a reduction in anger among the fluoxetine (Prozac) recipients," "Fluvoxamine (Luvox) improved rapid mood shifts," "Sertraline (Zoloft) was more effective in decreasing symptoms of depression, hypersensitivity in interpersonal relationships, and obsession," and "superior efficacy for phenelzine (Nardil, and MAO inhibitor) on measures of depression, borderline psychopathologic symptoms, and anxiety."

In the summary of this part of the review, it nonetheless says, "No statistically significant effects were observed for the selective serotonin reuptake inhibitors (SSRIs) or phenelzine." So what on earth were those that they had just listed?

Yet, after discussing similar weak data for mood stabilizers, it makes the following summary: "RCT's (randomized controlled studies) involving the mood stabilizers were limited by low statistical power. Divalproex sodium (Depakote) shows an effect for anger and interpersonal sensitivity. Topiramate (Topamax) and lamotrigine (Lamictal) were found to have an effect on anger."

And for atypical antipsychotics, after reviewing even weaker evidence, the summary says: "Olanzapine (Zyprexa) has the most supporting data of the antipsychotics; studies have shown its use can lead to reductions in anger, paranoia, anxiety, and interpersonal sensitivity. Effects were found for aripiprazole (Abilify) on impulsivity, anger, anxiety, psychosis, and interpersonal problems."

Misleading double standard for summarizing the effect of brand-named versus drugs available as generics, ya think?