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Choi-Kain Lois W. - Borderline personality and mood disorders : comorbidity and controversy

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Borderline personality and mood disorders : comorbidity and controversy
Author:
ChoiKain Lois W / Gunderson John G
Publisher:
Springer New York, New York, NY
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Books / Home and family
Year:
2014
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Borderline personality and mood disorders : comorbidity and controversy: summary, description and annotation

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In Borderline Personality and Mood Disorders: Comorbidity and Controversy, a panel of distinguished experts reviews the last two decades of progress in scientific inquiry about the relationship between mood and personality disorders and the influence of this empirical data on our ways of conceptualizing and treating them. This comprehensive title opens with an introduction defining general trends both influencing the expansion of the mood disorder spectrum and undermining clinical recognition and focus on personality disorders. The overlaps and differences between MDD and BPD in phenomenology and biological markers are then reviewed, followed by a review of the overlaps and distinctions between more atypical mood disorder variants. Further chapters review the current state of thinking on the distinctions between bipolar disorder and BPD, with attention to problems of misdiagnosis and use of clinical vignettes to illustrate important distinguishing features. Two models explaining the relationship between mood, temperament, and personality are offered, followed by a review of the literature on risk factors and early signs of BPD and mood disorders in childhood through young adulthood as well as a review of the longitudinal studies on BPD and mood disorders. The last segment of the book includes three chapters on treatment. The book closes with a conclusion with a synthesis of the current status of thinking on the relationship between mood and borderline personality disorder.

An invaluable contribution to the literature, Borderline Personality and Mood Disorders: Comorbidity and Controversy insightfully addresses the mood and personality disorders realms of psychiatry and outlines that it has moved away from contentious debate and toward the possibility of synthesis, providing increasing clarity on the relationship between mood and personality to inform improvements in clinical management of the convergence of these psychiatric domains in common practice.

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Part I
Introduction

Springer Science+Business Media New York 2015

Lois W. Choi-Kain and John G. Gunderson (eds.) Borderline Personality and Mood Disorders 10.1007/978-1-4939-1314-5_1

1. Mood Disorders and Personality Disorders: Simplicity and Complexity

Joel Paris 1

(1)

Department of Psychiatry, Institute of Community and Family Psychiatry, McGill University, 4333 cote Ste. Catherine, Montreal, QC, H3T 1E4, Canada

Joel Paris

Email:

Mood and Personality

Mood is a relatively straightforward concept. For the most part, mood varies as to whether it is high, low, or unstable. In contrast, personality is a very complex construct. It describes traits that affect behavior, thought, and emotion. Since personality describes normal variations, as opposed to abnormal states of mind, it is difficult to separate personality disorder (PD), which only some people have, from personality, which everyone has. Another difference is that while depressed or manic mood states can be scaled by clinicians, personality is often measured by self-report systems derived from factor analysis, such as the five-factor model []. Finally, mood disorders are often treated with drugs, while personality disorders usually require psychotherapy. For all these reasons, the construct of a mood disorder more readily appeals to clinicians who are looking for targets for treatment, while a personality disorder is seen as a murky and problematic idea.

Why the Mood Disorder Spectrum Has Expanded

Diagnostic constructs in psychiatry often reflect currently popular treatment options. Fifty years ago, a wide variety of clinical syndromes, most particularly somatic symptoms, were seen as reflections of abnormal mood or masked depression []. Physicians naturally favor making diagnoses that lead to a prescription. Even then diagnoses that were indications for psychotherapy, an option that has always been expensive and not readily available, were less popular.

Theoretical ideas about mood disorders have also supported expansion of their scope. Forty years ago, Akiskal and McKinney [].

Depression and Personality Disorder

While research on depression has been active from the 1950s, systematic empirical studies of personality disorders began to appear only in the 1980s []. Yet pharmacological treatment for these patients, not to speak of all psychiatric patients, became ubiquitous. To understand this shift in practice, we need to examine changes in the ideology of psychiatry as a medical specialty.

Psychotherapy and Psychopharmacology

Psychiatry used to be closely identified with psychotherapy. (Even today, the image of a bearded analyst behind a couch continues in New Yorker cartoons.) But beginning in the 1970s, the specialty underwent a paradigm shift []. Psychopathology would now be understood as a problem in neurochemistry or neurocircuitry and treated accordingly, largely with pharmacological interventions.

These conclusions were strongly supported by the pharmaceutical industry and by key opinion leaders drawn from academic psychiatry, who are often supported by the industry []. One cannot deny that in choosing interventions for psychiatric patients, money talks. One never sees advertisements in journals supporting psychotherapy. In contrast, each of the latest antidepressants is heavily marketed, even if they differ by only a few atoms from those that have been used for years.

This trend led to the theoretical dominance of neurobiology and a decline in the provision of psychotherapy in psychiatry []. It supported diagnoses of mood disorders, which are widely understood to derive from abnormalities of neurotransmission that can be corrected by pharmacotherapy. It undermined interest in personality disorders, seen as poorly defined concepts treated with psychotherapies of doubtful value.

Moreover, patients themselves often prefer to be diagnosed with mood disorders. They may see depression (or bipolarity) as validatinga chemical imbalance for which they are not responsible. For some, personality disorder is seen as stigmatizing, implying they have a bad personality. It is possible to explain to patients what a personality disorder is and to reassure them that their condition is less chronic than many mood disorders, since research shows that most patients can be expected to get better with time []. But while some appreciate this feedback, particularly when antidepressants have not helped, others prefer a diagnosis of mood disorder and request more medication cocktails, showing little interest in talking therapy.

All these factors help to explain why the mood disorder model remains dominant, and some psychiatrists never diagnose a personality disorder. As shown by Zimmerman et al. [] in a large clinical sample, PDs are highly prevalent but often missed. Of course it is also possible to misdiagnose a mood disorder as a PD, but that is less of an issue in the climate of contemporary psychiatry. Historically, the DSM system tried to encourage clinicians to think about personality by introducing multiaxial diagnosis. But Axis II was a failure, and it only succeeded in marginalizing the concept. In clinical reports, one often sees a statement that Axis II is deferred, i.e., to be ignored. In contemporary psychiatry, the roots of psychopathology in personality are downplayed, while many aspects of life are medicalized and understood as epiphenomena of an abnormal mood.

It is often said that PDs cannot be diagnosed in the presence of depression, since abnormal mood distorts personality, and PD features can disappear once mood goes back to normal. While this is sometimes true, when patients are followed over several months, most personality disorder symptoms remain stable even when mood returns to baseline []. Yet this idea continues to be taught to students, discouraging them from taking the careful life history required for making a PD diagnosis. It serves as another rationale for ignoring personality disorders, given that patients usually come for treatment when mood is low.

Bipolarity and Personality Disorder

The introduction of lithium for the treatment of bipolar disorder was a heroic chapter in the history of psychiatry. But lithium is a powerful drug that should only be prescribed when definitely required. The introduction of anticonvulsant mood stabilizers, however, made it more possible to consider treating outpatients with milder problems as suffering from variants of bipolar disorder.

The expansion of the bipolar diagnosis has been one of the most influential developments in modern psychiatry [] continues to see BPD as fictional but now views it as a form of bipolarity rather than depression. Needless to say, Akiskal views psychotherapy as misguided and favors pharmacological treatment for almost all these patients.

Other advocates of the spectrum have expanded the boundaries of classic bipolar disorders into all forms of mood instability, sometimes called soft bipolarity [].

The trajectory of this expansion could eliminate the diagnosis of BPD as well as most other PDs. These ideas have also been very influential. It is rare to see a patient with the classical features of BPD who has not been given a bipolar diagnosis by someone. The idea that mood swings, even when brief, are a sign of bipolarity has also gained currency among primary care physicians. Yet expansion of the spectrum has not been supported by controlled trials showing that patients with soft bipolar symptoms benefit from mood stabilizing medication [].

Reductionism and Medicalization

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