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Borderline, Bipolar, and Overdiagnosis

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Experts in borderline personality disorder and bipolar disorder reach a consensus about the mercurial temperament that underlies borderline personality. The DSM Committee restores a diagnostic code to recognize those with a “clean bill of mental health,” and the word of the day goes psychedelic over the 5-HT2A receptor.

Published On: 9/5/2021

Duration: 19 minutes, 50 seconds

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“Anybody who goes to a psychiatrist ought to have their head examined,” as the old Samuel Goldwyn joke goes. But what do you do when you’ve examined their head, and you didn’t find anything wrong? 

Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of The Carlat Psychiatry Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

An important diagnosis got left behind in the transition from DSM IV to DSM 5. It was “no diagnosis”, or more specifically, “no diagnosis on axis I” and the closely related “no diagnosis on axis II.” When paired together, the two codes were the culmination of a difficult evaluation, because it’s not easy to conclude that a person who came to see you with psychiatric symptoms doesn’t actually have a mental illness. 

We don’t know how this critical category slipped through the cracks, but if you go to the APA website they have this update for us:

In May 2018 the DSM-5 steering committee approved the inclusion of the category “No diagnosis or condition,” and its corresponding ICD-10-CM code, Z03.89 is available for immediate use

Dr. Aiken: While I’m glad they put the “no diagnosis” category back in the book, there’s still a lot of biases against using it.  Makes me wonder if the omission was some kind of a Freudian slip

Kellie Newsome: There you go, diagnosing everything. Even the DSM committee can’t make an innocent mistake, it has to be a Freudian slip.

Dr. Aiken: And this bias in our culture goes back to Freud, whose bestselling book was The Psychopathology of Everyday Life – the title alone pushed forth the idea that everyone is a little mentally ill.

Kellie Newsome: I have to say it’s not like this in other medical specialties. Most neurologists are not looking to diagnose everyone with muscle spasms as being on the multiple sclerosis spectrum. And cardiologists have a whole system to rule out myocardial infarction – and when they do rule it out they don’t tell the patient that they might have had a touch of ischemia. No. They tell them they had benign musculoskeletal pain.

Dr. Aiken: This month we interviewed a psychiatrist who would like to see that change. Joel Paris has written a series of books that criticize the diagnostic fervor in psychiatry, and we would like to see us think more critically about what mental illness is so we can recognize what it’s not.

Dr. Paris: We are not doing it at all. The patient can always walk up with a diagnosis and that’s it, you know. It’s a problem, and the patients are disappointed if they don’t get one. People have often self-diagnosed themselves on Google before they even come to us, and they come with a differential diagnosis. And if I say, “Actually, you’re normal,” they’re gonna be deeply insulted and mad at me.

Dr. Aiken: In the interview, Dr. Paris talks about how to work with patients who are disappointed that they don’t have the diagnosis they think explains their problems. He lists the top 5 conditions that are overdiagnosed in psychiatry and the reasons we keep making those mistakes. An on his list was a surpise: Borderline Personality Disorder.

Dr. Paris: Now that we have DBT and other effective treatments for borderline personality disorder, it has become more popular and I’m having to tell people, “No, you actually you don’t have borderline personality disorder” and they’re disappointed. 

Kellie Newsome: Dr. Paris is a specialist in Borderline Personality Disorder. He even wrote a recent book about how borderline is increasingly misdiagnosed as bipolar II: Bipolar Spectrum: Diagnosis or Fad. Now, Dr. Aiken, you are a bipolar specialist, so what did you think of that book?

Dr. Aiken: Actually I started out by specializing in borderline personality disorder and drifted toward bipolar, so I have sympathies for both sides. When I read Dr. Paris’ book my reaction was that most of the misdiagnosis happens with cyclothymic disorder – which is not exactly the same as bipolar disorder. I’ve always thought of cyclothymic disorder as a personality disorder. It’s a strange thing in DSM. Both schizophrenia and the mood disorders have milder, spectrum disorders that occur at a temperamental level and are seen more often in the relatives of patients with the full disorder. In schizophrenia these spectrum concepts were put in the personality disorder section – schizoid, schizotypal, and paranoid personality. But the mood temperaments were placed in the mood disorders section, not the personality section – particularly dysthymic disorder, which is temperamental depression, and cyclothymic disorder, which is a temperamental version of bipolar.

Kellie Newsome: So your idea is that cyclothymic disorder belongs in the personality disorder section, but that doesn’t exactly make it borderline.

Dr. Aiken: Yes, but the two disorders have a lot of overlap – much more than bipolar and borderline which in their pure forms don’t really have much in common with each other. When you go back to the early drafts of DSM-III – this is when they were first sketching out the criteria that would become borderline personality in the 1970’s. In the early drafts they called it “cycloid personality,” and the criteria read a lot like cyclothymic disorder. The patients have “irregular energy levels” with “intense, variable moods,” where depression predominates but is interspersed by brief periods of “elation… dejection, anxiety, or impulsive anger.” In Marsha Linehan’s textbook on DBT she credits this early draft as informing her theory of borderline. She believed that patients with borderline personality had a unique temperament – she wrote “The theory I present is… in many ways similar to that of Cycloid Personality.”

Kellie Newsome: But Dr. Paris did not exactly agree with you.

Dr. Paris: Well I don’t think it’s a good term.

Dr. Aiken: You mean cyclothymic temperament?

Dr. Paris: Cycloid. What we’re talking about is emotional instability, affective dysregulation. I think that’s a much better term.

Kellie Newsome:  So Dr. Paris agrees that borderline personality disorder arises out of a unique temperament, but he doesn’t see that temperament as cyclothymic disorder. Instead he calls it emotional instability, and this is how he describes it

Dr. Paris: So I would say what you see in the patients when they describe it to you and they’ll say to you: “I get upset and I blow sky high. It takes me hours to calm down.” And this is not anything like hypomania in bipolar II you know because I take a lot of trouble and sometimes I’m not sure if the patient has bipolar or not. So I go to a lot of trouble to say, “Did you ever have a period of 4 days where you were high consistently or more?” Well if they do then I start wondering well maybe this is one of Hagop Akiskal’s cases. But the vast majority of them do not describe that; they describe that it goes on for a few hours and then they sleep it off and the next day something else happens.

Kellie Newsome: Dr. Paris emphasized is that this “emotional instability” becomes particularly charged at moments of stress or conflict in close relationships. Lois Choi Kain used the term “interpersonal hypersensitivity” in our 2020 interview to describe the same phenomenon, which she saw as the core problem in borderline personality disorder. Here she describes how to work with this symptom in treatment:

Dr. Choi-Kain: So this model of BPD as a problem of interpersonal hypersensitivity – when people with BPD are feeling really connected and secure in their relationship with somebody else, they tend to be very collaborative and appreciative of that person. But also sensitive to looking out for threats or signs of rejection or disapproval. (39.51)

Kellie Newsome: Dr. Aiken did this interview change your mind?

Dr. Aiken: Yes – we’re getting closer to a consensus here. I think Dr. Paris’s view is more scientifically pure, because he’s isolating a more specific component – emotional instability – rather than a broader concept like cyclothymic disorder. And there is still overlap there – because patients with cyclothymic disorder usually have this emotionally reactive, unstable trait, but he’s focusing on that instead of the fluctuations of energy and sleep that also characterize cyclothymic disorder. So he’s looking for the core, and I respect that. It’s a lot like the new RDOC approach to diagnoses that the NIMH is promoting – instead of looking at broad diagnostic concepts like cyclothymic disorder or major depression, they want researchers to look at isolated symptoms or traits that stretch across diagnoses, like avoidance, disinhibition, or – in this case – emotional instability. 

Traits like emotional instability are considered trans-diagnostic because we see them in many different disorders. There are many paths to emotional instability, and while Dr. Paris nixed cyclothymic disorder as the central pathway, he also clarified that trauma is not the royal road to borderline personality disorder either:

Dr. Paris: It is not trauma. This is one of the great myths about BPD that it’s due to trauma. That’s why I’m against complex PTSD which is because trauma is common in BPD, patients but it’s actually less than half the cases that have a significant history of trauma.

Kellie Newsome: What? I’m thinking. I mean how many patient’s with borderline personality disorder have I seen who trace their problems back to childhood trauma?!? Dr. Paris isn’t exactly disagreeing with that, he’s just being more specific. In his view, it’s not so much the trauma as the invalidating environment that often goes along with those traumatic childhoods that creates borderline personality

Dr. Paris: And also we have a good etiological theory of borderline personality disorder unlike many mental disorders. Marsha Linehan’s theory was one of her greatest contributions: emotional dysregulation is a heritable trait which is then amplified by an invalidating environment. I mean there’s more to it than that, but I think the essence of borderline personality disorder is in that conceptualization. And the treatments are in fact based on that conceptualization because we are all doing some version of Linehan’s therapy.

TCPR: Can you put that in concrete terms? What is an invalidating environment?

(25 mins)

Dr. Paris: Invalidating environment usually means is that you grow up in a situation where your family isn’t interested in your emotions. It has sometimes been called emotional neglect as well and in fact Gordon Parker studied that as well. 

So the idea is that if you are unusually sensitive – you know Belsky has called this “differential sensitivity to the environment.” Some people just have very thin skins: they have high neuroticism; everything bothers them; everything upsets them; they can’t calm down. And that is a highly heritable trait. But if you are in an environment where there’s somebody around you who says, “I understand how you feel. You have every right to feel that way. Let’s figure out how you can get past this. You know calm down and think of a way to solve the problem.” And we’ve all done this as parents with our kids. And then it’s not so bad.

But what the patients describe to me almost universally is “Nobody was interested in my feelings. I was told to buck up; get over it; not make a big deal out of it.”

Dr. Aiken: So it’s emotional hypersensitivity and an invalidating environment – not trauma and cyclothymia – that sow the seeds of borderline personality disorder. It just happens that a lot of patients with cyclothymic disorder are emotionally hypersensitive, and a lot of patients with trauma histories grew up in invalidating environments. In fact, if we go back to Emile Kraeplin – who was one of the first to describe cyclothymic temperament – he also wrote about a more specific temperament that is probably closer to our idea of borderline today. He called it “excitable personality”:

“The patients display from youth up, extraordinarily great fluctuations in emotional equilibrium […] they fall into outbursts of boundless fury […] the colouring of mood is subject to frequent change […] they shed tears without cause, give expression to thoughts of suicide, and bring forward hypochondriac complaints […] In consequence of their irritability and their changing mood, their conduct of life is subject to the most multifarious incidents.”

Kellie Newsome: Borderline personality disorder inspires a lot of controversy – whether it’s splitting in a treatment team or debates about the origins of this mercurial disorder. In some ways that controversy is baked into the word itself. The Hungarian-American psychoanalyst Adolph Stern first used it in 1938 to describe a patients who were on the border of neurosis and psychosis. Psychoanalysis was a treatment for patients with neurotic-level disorders – for example, conditions that we know of today as generalized anxiety, somatization, panic and major depression. Patients who functioned at a psychotic level – such as schizophrenia – were considered too out of touch with reality to tolerate the open-ended structure of psychoanalysis, which required patients to lay on a couch, stare at the ceiling, and unlock the gates to their repressed unconscious by freely associating over any thought that enters their mind. The patients that Dr. Stern was seeing appeared neurotic – with intact reality testing – on their first interview, but when they were put on the couch they got worse. Their lives unraveled and they became self-destructive as they were unable to grapple with the intense emotions that psychoanalysis brought up. Laying on the couch, unable to see the face of their psychoanalyst didn’t bring freedom – it brought paranoia. 

Dr. Aiken: 20 years later, Otto Kernberg picked up on that observation and modified the psychoanalytic technique to treat borderline personality. He put more structure into the therapy and swapped the couch for a chair so he could conduct the sessions face to face. This reduced the risk of unworkable psychotic transference. Fast forward to 2021 and we hear that same idea echoed by Lois Choi-Kain as she described how to work with the intense emotions that come up with borderline clinets. 

Dr. Choi-Kain: When there is a real or perceived threat to that relationship and feeling so connected, that’s when they become more hot, so to speak. They feel threatened in their stability because they need that other person, so they become more angry, devalued and self-harming at that point in time. And that is where we would suggest leaning into being more involved. That may be anti-intuitive, but do it in a way that shows concern and investment in the stability of the relationship, rather than one that is equally hot or disrregulated or emotionally driven. What can happen is when the patient becomes more angry and threatened and threatening, this can cause people to naturally withdraw. It’s when the patient is more alone and hard to reach that very little can be done in a definitive mode of treatment meaning that the outpatient psychotherapy will have a very difficult time engaging with the patient in effectively management their symptoms, knowing what’s real and what’s not real, what rationale and whats irrational and that’s when they become more at risk for actual suicide attempts. And this is where unilateral action has to be taken where the person has to be hospitalized or the person has to (41:26) take some action of doing something more serious and more self-damaging.

Kellie Newsome: From Dr. Stein to Dr. Paris, we are getting closer to a clarity around this mercurial disorder, but we are a long way from fully understanding it.

Dr. Paris: Well, I went into psychiatry in part because it was so mysterious and hard to understand mental illness and it still is 50 years later. But you know it’s an awful lot of fun. If I was working in a field where everything was cut and dry I think I’d be bored. I only am sorry I won’t live to see the answers to the big questions. But let’s be honest with ourselves that we don’t have those answers and we’re just beginning.

Lois Choi-Kain is Director of the Gunderson Personality Disorders Institute at McLean Hospital, Belmont, MA. Her 2019 APA textbook describes a practical approach to borderline personality disorder called Good Psychiatric Management.

Joel Paris is a Professor Emeritus at McGill University and Senior Psychiatrist and Research Associate at Sir Mortimer B. Davis-Jewish General Hospital. He is the author of over 20 books including 2020’s Overdiagnosis in Psychiatry.

And now for the word of the day…. 5-HT2A

Let’s get this straight. 5-hydroxytryptamine is the scientific name for serotonin, and 5-HT is shorthand for 5-hydroxytryptamine. So when you see 5HT, think serotonin. There are seven families of serotonin receptors, from 5HT 1 to 5 HT 7, and each family has a bunch of members labeled A, B, C, etc.  You don’t need to know them all, but you do need to know this one: 5-HT2A.  This receptors does two things in psychiatry – activating can cause psychosis, dissociation, and out of body experiences, which is why some antipsychotics like Lumateperone, olanzapine, and clozapine block 5HT2A. But there’s another side to 5HT2A agonism – it can also raise empathy, openness, improve emotional processing, and possibly treat depression. Join us next week to learn about psilocybin, a 5HT2A agonist that is undergoing phase-III trials for FDA approval in depression. 


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