Shirah Vollmer MD

The Musings of Dr. Vollmer

Borderline Rant

Posted by Dr. Vollmer on September 26, 2013

 

 

http://en.wikipedia.org/wiki/Borderline_personality_disorder

 

23 years in practice and I still struggle with this diagnosis of a borderline personality disorder. I tell my students that I have never seen one, meaning that what they see, I do not. Brianna, twenty-five, has had multiple suicide attempts. She is the product of an Italian immigrant father and an African-American mother. She complains that she cannot fit in anywhere, because of her mixed heritage, and as a result, she often feels like killing herself. My students, who have seen Brianna, say she is borderline or Asperger’s. I propose that she is lost, searching for meaning in her life. Once again, I find myself using lay terminology to express the desperate feelings that lead to self-injurious thoughts and behaviors, in preference to the jargon in psychiatry, which I find to be unhelpful in terms of thinking about how to help patients like Brianna. Once again, I feel the laziness of using diagnoses like Bipolar, Asperger’s (now Autistic Spectrum), or Borderline, as a way of NOT thinking about the struggles of living in this world. Psychiatric diagnosis, sometimes, skims over the complexity of mental existence, leading to yet another irony, where on the one hand, in the neurobiological world, the brain is seen as complex, but in the clinical world, there is a push towards simplicity. Self-injurious thoughts do not necessarily imply a DSM 5 mental illness, but often implies, psychological pain, which is not an illness, but a symptom of a deeper problem of struggling to latch on to the beauty of the world, and the  beauty of oneself. All of this dispute, my plea to get away from jargon, makes me scared that psychiatry will bury itself. Brianna, and so many people like her, need understanding and listening; they do not need a label. Other mental health professionals (non-MDs), and clergy, understand this, but psychiatry, at least a large part of psychiatry, pushes away from the value of embracing the complexity involved in finding meaning in life. Labeling patients Borderline often embodies this issue. It is as if the label stops the psychiatrist from probing deeper into the personal struggles of Brianna. She is Borderline, implying that she needs medication to control her impulses. I do not have an issue with giving Brianna medication to control her impulses, but I do have a problem if the intervention stops there. Controlling her impulses allows Brianna to become more contemplative, and hence more reflective on what is important to her. Medication in this light, opens the door to an internal journey which is messy and complicated, but ultimately helpful to Brianna becoming an authentic, and hence beautiful human being. I repeat. She is not Borderline. She is lost . So is psychiatry.

16 Responses to “Borderline Rant”

  1. Jon said

    I have probably quoted the mathematician George Polya before in this blog. If so, it is time to quote him again, “Pedantry and mastery are opposite attitudes toward rules. To apply a rule to the letter, rigidly, unquestioningly, in cases where it fits and in cases where it does not fit, is pedantry… To apply a rule with natural ease, with judgment, noticing the cases where it fits, and without ever letting the words of the rule obscure the purpose of the action or the opportunities of the situation, is mastery.”

    Sadly, there is much pedantry in modern psychiatry – the discussion of borderline personality disorder as a fine example. The understanding that some souls are lost (and some professions are as well is a good step towards mastery.

  2. Ashana M said

    I don’t think our current set of diagnostic categories are very helpful, but I do think that there are elements about them that might have value–especially when some portion of the symptoms is about atypical processes in the brain, which I think in some cases they are. For someone with bipolar, it isn’t just how to deal with life, but how do you deal with having a brain that periodically makes you feel grandiose and somewhat delusional or even paranoid? It’s an atypical process, which means our ordinary ways of coping with life don’t prepare you for it. Mine, for example, although it’s done a lot of unpleasant things, has never done that. I can’t even really imagine it. I certainly don’t need to learn how to manage that. Similarly, with borderline there seems to be a core problem of emotion regulation, and the intense emotions distort cognition in predictable but difficult to control ways–impulsiveness is part of this. This results in skills deficits that impact navigating all kinds of relationships and also results in a discontinous image of the self, so the question here–among many others–is how do you live with those kinds of very intense emotions, how do you manage them, and how do you make up for lost time and learn how to maintain relationships? I’m very cynical about avoiding labels, because labels are simply a derogatory term for a noun, and we need nouns with definitions we agree on in order to understand one another and to find solutions. Language is our best hope for understanding.

  3. Ellen said

    A borderline diagnosis can be like an insult, a doctor saying there is nothing to be done but medicate. I enjoyed your rant.

    • YES! Thanks.

      • Ashana M said

        I’m afraid I disagree there. Narratives are one way of communicating, and they have their purpose. But there are other forms of communicating that are equally important. None of them,however, are very effective if we stick to vague vocabulary that often has a different meaning to the speaker than to the listener or reader–which vague vocabulary usually does. This gives us the felt sense of understanding without actually communicating anything.

        • Ashana M said

          Incidentally, this comment is under the wrong thread of comments. But I would add that there are effective treatment protocols for borderline that don’t involve medication, so there’s no real reason to see it as a diagnosis that means there is no hope aside from drugs.

  4. Shelly said

    It is interesting that you have never, in your career, seen a borderline patient. What if you took video footage of a patient diagnosed by your predecessors and put it side-by-side with Brianna. Would you find similarities? Differences? I realize that a person is far more than the sum total of their diagnoses, however you, as the professor, do have a responsibility to your students to show them examples of all sorts of possible patients they will meet in their professional careers. Do thoughts of suicide imply a borderline personality? I think not. However the borderline personality disorder imply a constellation of symptoms that Brianna may or may not display. By showing the video your students may see the difference.

    • I find the Borderline diagnosis unhelpful, as I would rather characterize the individual’s struggles with his world, as opposed to clumping them together with other folks who only share the common thread of emotional lability. Thanks.

  5. savemefrombpd said

    Hi,

    I very much appreciate and respect this blog post.

    After three years of being filled full of psychiatric medications, sometimes on 8 medications at one time, anti-depressants, mood stabilisers, anti-epilepsy meds, anti-psychotics, sleep medications, anti-anxiety medications, then being put on a trial medication that was an opiate, then getting ECT at the hospital I was in — My eyes opened up and I realised that after three years of being very sick, I needed ‘help’ beyond what I was being given. I released myself from hospital and they wrote on my discharge letter that I am ‘treatment resistant’. I was appalled. That is just not true. It only means that what they tried to do with me (medications and ECT) was the wrong treatment that I needed, so OK, I was therefore treatment resistant to what they tried to give me. But that label ‘treatment resistant’ is not true and is a very negative thing to state. From what I understand, many people with BPD are also told the same thing. It’s a very bad stigma that reinforces the illness even more so.

    Now I am focussing on other things as I realised over time that I need to be out of hospital, find the specific therapy that I need (DBT) and ‘sort my life out’. Because NO medication or zapping of my brain is going to make me happier or sort my life out for me – Obviously! So it’s no surprise that I went downhill week by week by being in hospital.

    Therapy is key. Relationships. Group meetings that I go to in order to make friends and like-minded people. Behavioural therapy. Hobbies. Keeping busy. Eating and sleeping well. Much more.

    The attitude has to change towards BPD, because like you wrote about, people with BPD are just labelled as ‘one of those’ and the hopeless and helplessness is truly awful when the nitty gritty of your problems are not worked through and instead you’re just labelled as having x y and z symptoms because the DSM says so! So not true. We are not all the same. By far. We are not all the same.

    Keep up the good work.

    • Dear Savemefrombpd,
      Thank you for chiming in. Your experience is so important, because, as you clearly state, psychiatrists can harm patients by being too quick to label, and too slow to really listen and understand. As you say, and I agree, “therapy is key”. Yes, the attitudes have to change, and I am hopeful that the internet can be a means to that end. Thanks again. SV

    • Ashana M said

      DBT is indicated as an effective treatment for BPD, so it’s teresting that this wasn’t pursued as a front-line treatment for someone with your diagnosis.

      • savemefrombpd said

        True. My psychiatrist said here that it’s a big problem. Literally one course has been done in the country to train therapists in giving DBT. Another one is starting soon but it’s a 2 year course so this problem won’t solve overnight. Adding on that if you do get someone that has been trained in this course, I’m not taking away from their knowledge, however, you are a bit of a lab rat! It would obviously be nice to have someone with experience too. I’ll go sleep for a few years and come back then I think! No, it’s not funny. It’s a real shame. But I’ve got to work with what’s available.

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