ABQJOURNAL HEALTH: Hope on the Horizon

Monday, October 26, 2009

Hope on the Horizon

By Shari Roan
Los Angeles Times
          They have the thinnest skin, the shortest fuses and take the hardest knocks. In psychiatrists' offices, they have long been viewed as among the most challenging patients to treat.
        They are the kind of people who drive a friend away for interfering and subsequently berate that friend for abandonment.
        But almost 20 years after the designation of borderline personality disorder as a recognized mental health condition, some understanding and hope have surfaced for people with the condition and their families.
        Borderline personality disorder was center stage this spring at the annual meeting of the American Psychiatric Association — with multiple sessions and speakers devoted to the topic. And the message from the meeting was clear: After years during which they threw up their hands, leaders in psychiatry now want to convey a more positive message about the condition and what can be done to help those who have it.
        "Borderline personality disorder is considered a pejorative term," says Dr. Richard G. Hersh, a psychiatrist at Columbia University's College of Physicians and Surgeons. "But there are new treatments and new data that give reason for optimism."
        That is especially significant given results of a survey of more than 24,000 adults, conducted by the federal government and released last year, that found a lifetime prevalence of borderline personality disorder to be almost 6 percent — more than double previous estimates.
        "The public and patients want to learn more about this condition, and more doctors want to treat it," says Valerie Porr, founder of a national advocacy group called TARA, Association for Personality Disorders.
        People with the disorder make a mess of their relationships — and no wonder, given the hallmark symptoms: mood instability, fear of abandonment, impulsive behavior, anger and suicidal or self-injurious acts. People with the disorder may misperceive the actions — even the facial expressions — of others.
        "You can't regulate your emotions despite your best efforts," says Marsha Linehan, a University of Washington psychologist and leading expert on the disorder.
        Borderline personality disorder occurs equally in men and women and sufferers often also have other mental illnesses or substance abuse problems. The composite of an angry, unstable, clingy substance abuser is not a pretty one, and people with the disorder suffer greatly because they drive away even the people who love them most, experts say.
        "Having a relative with BPD can be hell," says Perry D. Hoffman, president of the National Education Alliance for BPD. "But our message to families is to please stay the course with your relative because it's crucial to their well being."
        One of the most significant developments for those affected by the disorder has been the emergence of a strong family and patient advocacy movement pressing for more research and establishing support networks and treatment referral services. Porr started TARA in 1995; Hoffman launched her organization in 2001. In 2007, the National Alliance on Mental Illness, a patient advocacy group, put borderline personality disorder on its list of "priority populations" for public policy efforts.
        The National Institute of Mental Health, along with the nonprofit advocacy groups and major medical institutions such as the University of California, Los Angeles and the Mount Sinai School of Medicine in New York have convened national and regional conferences on the disorder.
        The flurry of research on borderline personality disorder is casting the condition in a new light. Originally, the behavior was blamed on abuse, trauma or neglect in childhood. But newer research suggests that people with the disorder are born with the predisposition to be emotionally sensitive. Abuse puts a person at higher risk for borderline personality disorder but not everyone who develops it is abused or neglected.
        "Parents commonly say, my kid has not been normal since he or she was born," says Dr. Marianne Goodman, a psychiatrist at Mount Sinai School of Medicine in New York.
        In a study presented at the American Psychiatric Association meeting, Goodman found signs of emotional sensitivity in young children who were later diagnosed with borderline personality disorder.
        Research on the brains of people with the disorder suggest there is a biological predisposition to the core symptoms of emotional sensitivity and misperceiving the actions and feelings of others.
        For example, a study published in 2008 in Science showed different patterns of brain activity in people with the disorder: The scans showed abnormal responses in a brain region called the bilateral anterior insula when borderline personality patients played a game with other people that tested their sense of fairness and social norms.
        Through such studies, experts say, it is becoming clearer that the condition may simply be a type of personality that some people enter the world with. Some describe that mind state as a "pervasive emotional dysregulation" — a brain that is primed to overreact.
        Future progress in helping people with borderline personality disorder may rest on the willingness of therapists to recognize it and apply therapies that are specific to the condition. The correct diagnosis is key because specific behavior-change therapies seem to work best.
        There are several helpful therapies, experts say, notably dialectical behavioral therapy, and all share common elements. The bond between the patient and therapist is strong — important for a long-term, therapeutic relationship. And the therapy focuses on the present rather than the past, on changing one's behavior patterns now regardless of how patients feel about the past or if they see themselves as victims.

    Borderline personality disorder traits
    Borderline personality disorder often can be difficult to distinguish from bipolar disorder, depression and anxiety. But the essential feature of BPD is a pattern of unstable personal relationships, self-image and emotions and impulsivity.
    Traits (at least five of which must be present for a diagnosis) include:
    Efforts to avoid abandonment
    Unstable, intense interpersonal relationships
    Identity disturbance
    Impulsivity
    Suicidality
    Mood instability
    Chronic emptiness
    Inappropriate, intense anger
    Paranoid ideation or dissociation
    Source: Diagnostic and Statistical Manual, American Psychiatric Association

You also can send comments via our comment form