Borderline PD: a spurious condition unsupported by science that should be abandoned

[DynamicDidactic]

That's the title of the article, just came across my eyes recently:

https://journals.sagepub.com/doi/full/10.1177/01410768231164780

This articulates many of my thoughts about the disorder. I find very little of the diagnosis to be about personality (as opposed to state-based behaviors), the name is problematic, and the entire diagnosis as highly stigmatized. Unfortunately, too many people are making a name for themselves (or money) to want to change the status quo. But, that is just me.

Any thoughts/reactions?

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[cara susanna]

I mean, I think that a lot of those things are true, that these patients are over stigmatized and the personality label may not fit. At the same time, BPD is one of the better supported PD diagnoses in terms of empirical evidence. I don't think that the field treating these patients badly is a reason to abandon the diagnosis. As someone who works with these patients frequently, SOMETHING is going on that seems fairly consistent in terms of symptoms and behavioral patterns, and it's helpful to have some sort of label.

I also think that focusing only on the emotion dysregulation ignores the interpersonal aspects. In fact, that's why the switch to Axis I and "emotion dysregulation disorder" was abandoned--some BPD experts were concerned about that.

 

[Shiori]

I like using the mechanistic property cluster "kind" mindset for psychiatric disorders. I still use diagnoses, but I'm really more interested in how patterns of behaviors/symptoms are reinforced and maintained. There is a ton of overlap between PTSD, MDD, and GAD, and I regularly get clients who come in with all three. I'm thinking more in symptom networks rather than diagnoses when considering treatment approaches. I still definitely do a deeper dive to get symptom timelines, etc, but it often doesn't make a ton of difference to treatment. I want them to tolerate feeling whatever it is they're avoiding and go do stuff. Then once they're doing that, go repair relationships because they were probably crabby to loved ones. The magic happens with picking the EBP they're most likely to finish and making enough adjustments to keep them engaged.

I hope RDoC or something similar creates something more solid to hang out hats on. For now, it seems like a lot of the research is based on people we "know" have a diagnosis, collecting symptoms for EFA purposes, creating a list of symptoms to screen others by for CFA purposes, and yelling in auditoriums until a consensus is made for a diagnosis.

 

[clausewitz2]

I notice that one of the authors is Peter Tyrer, who among other things is a champion of reviving neurosis as a concept in mental health. Criticizing BPD as being a hazy concept is...odd.

 

[psycho1391]

"The new ICD-11 personality disorder classification takes a broader assessment far beyond that of ticking off a set of borderline operational criteria. The new dimensional classification – all of us are on a personality spectrum – leads to a more nuanced assessment of a patient’s psychopathology that extends far beyond borderline pathology. Clinicians begin by assessing the level of severity of personality dysfunction into four groups of severity that lead to the diagnosis and this is then qualified by the presence of one of five domains similar to the Big Five of normal personality variation. A ‘borderline pattern specifier’ has been added for those who feel they cannot yet dispense with the syndrome even though all the relevant pathology can be captured in ICD-11 without requiring its use.15 Most patients present acutely in emergency departments after self-harm, and similar crises are likely to have moderate personality disorder, as this is characterised by multiple areas of functioning and relationships, often associated with harm to self or others with significant impairment in most areas of life."


I mean the dimensional model does have a lot of great evidence. However, the word borderline is still going to come up even if a dimensional model is being used.

 

[Justanothergrad]

i thought this was also relevant here (re: diagnosis). popped up today for me.

https://journals.sagepub.com/doi/10.1177/17456916221079597

This seems horrible in my eyes. but hey, maybe I missed research on treatment mechanisms being known, etiological factors being discovered to differentiate diagnosis formation, or consistent inclusion of active control to assess relative efficacy.

 

[DynamicDidactic]

"The new ICD-11 personality disorder classification takes a broader assessment far beyond that of ticking off a set of borderline operational criteria. The new dimensional classification – all of us are on a personality spectrum – leads to a more nuanced assessment of a patient’s psychopathology that extends far beyond borderline pathology. Clinicians begin by assessing the level of severity of personality dysfunction into four groups of severity that lead to the diagnosis and this is then qualified by the presence of one of five domains similar to the Big Five of normal personality variation. A ‘borderline pattern specifier’ has been added for those who feel they cannot yet dispense with the syndrome even though all the relevant pathology can be captured in ICD-11 without requiring its use.15 Most patients present acutely in emergency departments after self-harm, and similar crises are likely to have moderate personality disorder, as this is characterised by multiple areas of functioning and relationships, often associated with harm to self or others with significant impairment in most areas of life."


I mean the dimensional model does have a lot of great evidence. However, the word borderline is still going to come up even if a dimensional model is being used.

this is better

 

[cara susanna]

I get that the dimensional model has good support and it makes sense, but I just don't think it's gonna be practical for everyday clinicians.

 

[Ollie123]

I actually think its our current model that is impractical for clinicians and a dimensional/RDoC/HiTOP style model at least offers some hope, but it is at least 20 years out from something that could conceivably drive daily clinical practice and probably more like 30-50.

The models do align more with how most people actually think as clinicians (or at least those I trained with). We pluck out a particular problematic behavior/tendency/etc. (e.g., avoidance) that may serve numerous forms of psychopathology and apply interventions targeting that interleaved with interventions targeting whatever other symptoms seem to predominate. We acknowledge that some avoidance is normal and not pathological, but attempt to shift them along a continuum back in the intended direction. At least to me, this makes vastly more sense than our current framework and at their core its really all RDoC/HiTOP are striving to achieve based on my reading of the relevant work.

So many people seem to think science needs to revolutionize clinical practice next week to be meaningful, but those are usually incremental advances that don't push boundaries and eventually get trapped in a local minima/maxima. The average gap between a discovery and a nobel prize is something like 20-30 years in physiology/medicine (and that's shorter than some other categories). Truly impactful science requires a long time horizon.

 

[cara susanna]

I actually think its our current model that is impractical for clinicians and a dimensional/RDoC/HiTOP style model at least offers some hope, but it is at least 20 years out from something that could conceivably drive daily clinical practice and probably more like 30-50.

The models do align more with how most people actually think as clinicians (or at least those I trained with). We pluck out a particular problematic behavior/tendency/etc. (e.g., avoidance) that may serve numerous forms of psychopathology and apply interventions targeting that interleaved with interventions targeting whatever other symptoms seem to predominate. We acknowledge that some avoidance is normal and not pathological, but attempt to shift them along a continuum back in the intended direction. At least to me, this makes vastly more sense than our current framework and at their core its really all RDoC/HiTOP are striving to achieve based on my reading of the relevant work.

So many people seem to think science needs to revolutionize clinical practice next week to be meaningful, but those are usually incremental advances that don't push boundaries and eventually get trapped in a local minima/maxima. The average gap between a discovery and a nobel prize is something like 20-30 years in physiology/medicine (and that's shorter than some other categories). Truly impactful science requires a long time horizon.

I agree that the model itself makes more sense in terms of conceptualization, but I'm not sure how it's gonna work for things like coding and billing.

 

[Ollie123]

Yeah, that's what pushes 20 years out to 30-50 Its going to require a shifts in the insurance model too.

I actually could see this working as we move to more of a value-based care model, which I think ultimately would be good for us if psychology got ahead of the game. We're similar to primary care in that the current reimbursement structure undervalues what we bring to the table given our patients are often sickest and psychologically healthy folks tend to have better outcomes for pretty much any medical procedure you can imagine. There are areas of medicine that operate more on a risk-continuum model (e.g., high blood pressure, diabetes) and could be adapted to an RDoC framework and current winds in the insurance world seem to be blowing in a direction that would make this even easier (albeit they seem to have been somewhat derailed by COVID so we'll see how this evolves). Either way, I think insurance will eventually adapt once the data is solid. Just not quickly.

 

[R. Matey]

The models do align more with how most people actually think as clinicians (or at least those I trained with). We pluck out a particular problematic behavior/tendency/etc. (e.g., avoidance) that may serve numerous forms of psychopathology and apply interventions targeting that interleaved with interventions targeting whatever other symptoms seem to predominate. We acknowledge that some avoidance is normal and not pathological, but attempt to shift them along a continuum back in the intended direction. At least to me, this makes vastly more sense than our current framework and at their core its really all RDoC/HiTOP are striving to achieve based on my reading of the relevant work.

Wouldn't you say that some ideas are better than others? I'm not sure p is more useful than a GAF score.

 

[ClinicalABA]

Haven't done any therapy or otherwise with individuals with an actual BPD diagnosis in quite some time, but I can say that the term "borderline" has been coopted to the point of not carrying the diagnostic specificity it one did. I think some of this is in part to over-pathologizing personality types, as well as skill deficits. When every client/person who is a bit selfish, unorganized, indecisive, missing sessions, swapping therapist, has poorly developed or inconsistent social skills, or just plain drives you crazy- whatever the reasons- is labeled "borderline" the term and the concept in general just gets too watered down. When the research definition strays to far from the colloquial usage, problems ensue.

As an aside, back when I was marginally involved in adult therapy services, It would always drive me crazy when another clinician who read a magazine article, attended a crappy 3-hour DBT "training" at the local La Quinta, etc., would speak on the topic of BPD and seemingly start every sentence with "Marsha says..." or "according to Marsha..." You never met her or even read any of her primary sources, and even if you did don't use just her first name! It would be like me talking about reinforcement learning and saying "Fred says..." or- even more egregious- "according to Burrhus..."

 

[Ollie123]

Wouldn't you say that some ideas are better than others? I'm not sure p is more useful than a GAF score.

100% yes. That's a great example actually as p is sort of a mishmash that makes interpretation difficult. It may have greater predictive validity than GAF (TBD) but would almost certainly need to be used differently. Not that GAF is really used either in most settings.

To be clear, I'm not saying that "The current instance of RDoC/HiTOP/etc. is sooooooo much better than what we have now." I'm saying the vision for where this could lead has the potential to be soooooo much better than what we have now. It could reshape how we conceptualize and treat psychopathology in a way that is more effective than our current system.

To be blunt, right now we're pretty good at treating phobias and a handful of other things when we can get people to actually engage in the treatment (a big issue) but mediocre-to-terrible at treating the overwhelming majority of things in the DSM. That doesn't mean we don't have effective treatments. We have effective treatments for pancreatic cancer too, but we still acknowledge it has a terrible prognosis. We don't think in those terms because misery isn't as discrete an outcome as death, but I think failure to do so holds us back.

Without something LIKE RDoC, I think we continue to develop new psychotherapies that are philosophically interesting and yield complete remission in 34% of individuals instead of 32% (made-up numbers). Without a new paradigm, I doubt we ever get to 50%, let alone 90%. The latter requires a paradigm shift. RDoC has the potential to be that. It probably won't be because that's how science works, but I like to see people trying.

 

[clausewitz2]

Haven't done any therapy or otherwise with individuals with an actual BPD diagnosis in quite some time, but I can say that the term "borderline" has been coopted to the point of not carrying the diagnostic specificity it one did. I think some of this is in part to over-pathologizing personality types, as well as skill deficits. When every client/person who is a bit selfish, unorganized, indecisive, missing sessions, swapping therapist, has poorly developed or inconsistent social skills, or just plain drives you crazy- whatever the reasons- is labeled "borderline" the term and the concept in general just gets too watered down. When the research definition strays to far from the colloquial usage, problems ensue.

As an aside, back when I was marginally involved in adult therapy services, It would always drive me crazy when another clinician who read a magazine article, attending a crappy 3-hour DBT "training" at the local La Quinta, etc., would speak on the topic of BPD and seemingly start every sentence with "Marsha says..." or "according to Marsha..." You never met her or even read any of her primary sources, and even if you did don't use just her first name! It would be like me talking about reinforcement learning and saying "Fred says..." or- even more egregious- "according to Burfhus..."

Relevant:

The Last Psychiatrist: The Diagnosis of Borderline Personality Disorder: What Does It Really Mean?

thelastpsychiatrist.com

 

[ClinicalABA]

Relevant:

The Last Psychiatrist: The Diagnosis of Borderline Personality Disorder: What Does It Really Mean?

thelastpsychiatrist.com

That's perfect. Thanks.

 

[cara susanna]

Yeah, in the VA especially that diagnosis seems to get attached to "woman with sexual trauma history who sometimes gets angry at her providers."

There is a study showing though that providers don't diagnose BPD enough, and that clinics may want to consider routine screening.

 

[Ollie123]

There is a study showing though that providers don't diagnose BPD enough, and that clinics may want to consider routine screening.

Don't diagnose or just label it as bipolar disorder despite the complete absence of anything even hinting at a manic episode beyond irritability?

I always assumed it was just because that way they could justify throwing mood stabilizers at someone and shoving them out the door, but the last psychiatrist article makes it sound like there was actually a deliberate push within psychiatry to misdiagnose people because bipolar disorder would be less stigmatizing?

 

[annoyedpsychiatrist]

I think BPD conceptualizes a significant number of patients and puts their symptoms into proper context. I would say its one of the more consistent personality disorders. The history, symptoms, etc.

 

[smalltownpsych]

I treat these patients a lot. For about half of them we do talk about the label at some point during the course of treatment and I try to help them understand how broad and unhelpful it is in understanding themselves. I prefer to talk about the distress they experience and how they respond to it in maladaptive ways and help them practice more adaptive ways of responding. It’s really the essence of DBT and it really isn’t that hard to make significant progress unless they are also addicted to substances. I don’t think the label is as much of a problem as stupid people in the field, but since we can’t stop people from being stupid, we’ll change the label and the same people will misunderstand and misuse that one.

 

[cara susanna]

I treat these patients a lot. For about half of them we do talk about the label at some point during the course of treatment and I try to help them understand how broad and unhelpful it is in understanding themselves. I prefer to talk about the distress they experience and how they respond to it in maladaptive ways and help them practice more adaptive ways of responding. It’s really the essence of DBT and it really isn’t that hard to make significant progress unless they are also addicted to substances. I don’t think the label is as much of a problem as stupid people in the field, but since we can’t stop people from being stupid, we’ll change the label and the same people will misunderstand and misuse that one.

Yup, I always talk to my patients about the label and how "personality disorder" isn't the nicest term. Actually, back on internship I developed a reputation on our inpatient unit for being really good at giving BPD patients diagnostic feedback (basically, I just used the biosocial model from DBT).

 

[futureapppsy2]

Yup, I always talk to my patients about the label and how "personality disorder" isn't the nicest term. Actually, back on internship I developed a reputation on our inpatient unit for being really good at giving BPD patients diagnostic feedback (basically, I just used the biosocial model from DBT).

What specific things do you say in feedback that seem particularly helpful?

 

[futureapppsy2]

Yeah, in the VA especially that diagnosis seems to get attached to "woman with sexual trauma history who sometimes gets angry at her providers."

There is a study showing though that providers don't diagnose BPD enough, and that clinics may want to consider routine screening.

In the VA, patients (and some providers) can also be really resistant to any diagnosis other than PTSD, especially for men. Female vets sometimes get diagnosed with BPD (not always accurately) instead.

 

[cara susanna]

What specific things do you say in feedback that seem particularly helpful?

Highlighting the strengths as well as the weaknesses associated with BPD. Also, like I said, basically just talking about the biosocial model and how DBT conceptualizes BPD.