Saturday, May 13, 2006


Midnight, and Sarah, overtired and not one hundred percent well, is asleep in the next room under a geological stratum of blankets. I have fed cats, washed dishes with ninja-like stealth and and devoured any and all leftovers.

So - the promised writing on borderline personality disorder - or BPD, as it is known to its very few friends.

I've been thinking about some of my patients, and trying to understand what's going on with them, what happens to the eighteen year old on heroin to turn them into the forty year old on the methadone programme.

How they change, how things gradually shift inside their heads, settle, calm down - or don't.

I've been trying to work out what's going on in their heads, and what's gone on in mine, and try to understand a bit more of both.

This DSM IV I keep talking about, the Diagnostic and Statistical Manual of Mental Illnesses. It's one of the two or three books that has basically changed medicine. It's fundamental to psychiatry, and I know of nothing comparable that exists for, say, emergency medicine, or renal. Nobody would think to publish a psychiatry paper, or run a trial, or even write up a patient without referring to the criteria in the DSM IV. Medical students and psych interns learn it by rote, and consult our good book as frequently and as diligently as any other priest or friar or exorcist.

But there are problems with... if not the DSM IV, then the DSM IV how it is used, psychiatry 'as she is spoke' by the (usually) junior (probably) undertrained (generally) overworked med reg or emerge intern or psych RMO. These are the people who have the greatest amount of contact with the unwell patient.

(If you suddenly realise what is going on, and the pivotal part the crab people of Venus have in recent events at the highest level, these are the doctors who will be seeing you, signing the forms for the security guards to restrain you and sticking the needle of haloperidol into one anterior thigh and the clonazepam into the other).

One of my problems with the use of the DSM IV as far as I can see, is that it is a book of definitions: the definition of schiozophrenia is this, the definition of autistic disorder is this.

This necessarily involves a series of inclusions or exclusions, binary decisions. Someone either 'suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her', or they do not.

There is no room in the DSM IV for "well, sometimes, kinda, maybe". You're either in or you're out. Fulfill the criteria or don't. Sick or healthy.

(Again, the parallels with the Pentateuch are eerie. A house afflicted with mildew either has or has not been cleansed, a clay pot into which a snake has fallen is not clean, but is unclean, and must be shattered).

See, the problem is, that kind of stuff, the basic medical school stuff, is practically useless in the methadone clinic. At the clinic you get to see that whole slow change a lot of them go through, the alteration over twenty years that you can see. The gradual unravelling of a tightly wound spring, the scouring smooth of a rock in a river, that kind of thing. Fixed diagnostic criteria are of limited use.

I think what I'm trying to say is I know people are more complicated than that, and I've had to change some of my ideas. I've realised that either my understanding of psychiatry is actually pretty close to nothing... or I've realised I've been using a lot of the stuff I was taught in medical school in a stupid and lazy way.

Anyway. Examples.

In DSM IV borderline and bipolar are two completely different diseases.

Bipolar is an Axis I disease - thought of by non-psychiatrists as the real mental illnesses. It responds gratifyingly to medications. It makes people spectacularly unwell - psychosis frequenly appears at either end of the spectrum, as I know well.

Bipolar is up there with heavyweights like schizophrenia and major depressive disorder. It has kudos, mana, a bit of cred. There is a glamour attached to it.

Borderline, on the other hand, is an Axis II disease, lumped in in the DSM IV with the psychopaths, the drama queens (histrionic personality disorder), the weirdoes (schizotypal) and so on (and, for some unexplained reason, mental retardation and autism). These are the disorders seen as milder, less obviously disabling than the full-blown psychoses.

There is an air of therapist helplessness about the axis II disorders - an aura of nihilism, a feeling of things that can't be fixed. Medications, at least until recently, were seen as useless. Psychological therapies involved much effort for little success, and were associated with high levels of doctor burnout.

Psych patients in the ED, if they are lucky, are seen either real psych cases (axis I) or as manipulative and malevolent trespassers (axis II). Real patients get admitted, fake ones get sent back home. Distressingly, both classes kill themselves at unacceptably high rates, but no system is perfect.

If psych patients in the ED are unlucky, they're all lumped together as psych and ranked slightly below the anal pains and the vomit-crusted alcoholics in terms of anticipated doctor satisfaction, and they wait in the waiting room for hours and hours and hours, while the crab people from Venus whispter in their ears.

Anyway, I've worked out lately that my earlier way of looking at things was crap. I've been returning more to the biopsychosocial model we learnt in first year. This sees mental (and other) illnesses as the product of biological, psychological and social factors or stressors.

The diseases wax and wane with the advancing and retreating of those stressors. They change over time, they change with what's going on in your life, how you think, what else is going on in your body.

This means, for a start, that constellations of symptoms which may simplistically be explained away as a disorder (major depressive disorder, brief psychotic episode) can be looked at as products of what's going on in your mind and your life, as much as your biochemistry. That if you're not eating and not sleeping and you've made a noose in the garage, then maybe there's a reson why.

Lately what I'm thinking is happening is that certain personalities, under certain pressures, produce certain mental illnesses.

People with anxious temperaments may develop anxiety disorders.

People who were always a bit odd - rigid, guarded, a bit stand-offish - may develop the schizotypal illnesses.

And borderline - the personality disorder that a lot of my patients have been saddled with? What do they get, what do they tend to grade into?

Here, paraphrased, is what DSM IV says.

People with borderline personality disorder, which usually manifests in early adulthood, have intense, unstable relationships, often marked by self-sabotage.

They may alternately idealise or completely devalue the same person.

They have extreme, often startlingly rapid mood swings.

They make frantic efforts to avoid real or imagined abandonment... sometimes to the extent of self harm.

They may damage themselves or put themselves at risk of harm (this can range from inappropriate spending through promiscuous sex to bingeing on crystal meth).

They have an unstable "sense of self" - they may morph from a helpless cripple in need of rescue to an avenging angel setting right past wrongs in a few minutes.

They feel, all the time, empty.

Now that's not me. I don't have the intense, unstable relationships. I don't cut myself. I avoid putting myself at risk of harm - I wear a seatbelt at the dinner table and am a coward from a long and successful line of cowards*.

But when things are bad, this stuff comes out.

I have a paralysing fear of abandonment, a disabling terror that I can't really explain in a way that will get the intensity of feeling across. When I 'am abandoned', when a relationship breaks up, there is always that part of me that will do anything, anything, to show how I can't do without the person who is leaving me. Lacerate myself so they have to bind my wounds, show them how their leaving makes me feel. I do it with words, instead of razor blades, so in that sense I don't 'act' on it, but it's there.

I have, at times, that rapidly fluctuating sense of self. There is some anxiety, some unsteadyness and formlessness inside me that has only recently stabilised.

The thing about the emptiness - that explains a lot about what I do. The noise and light of the ED, the emotional turmoil of psych and drugs and alcohol. Even at home at night, I fill the silence and the dark with writing.

I am not saying I have borderline personality disorder. I don't, and in this fact the DSM IV reassures me. I do not fit inside the circle it draws around the various types of unwell. But like a lot of people I have a personality that becomes disordered under pressure, that for a moment or a month may fall inside the criteria. For me, it's borderline. For others I know, it's anxious, or antisocial, or dependent.

The DSM IV separates clean from unclean, sinners from sinless, but all have sinned, all have fallen short of the Glory of God.

Romans 3:23. Always found that passage very easy to believe.

Personality's a complex thing, a dynamic, almost creative thing, something that changes over time. People move from disorder to order, health to wellness, as time and tide change them.

You see some twenty year old kid, on speed and smack, and they're living out of the Good Salvos and in and out of prison.

And then the next client is thirty years older and has a housing trust house and three grandchildren.

You see someone cutting herself up and starting to steal things from shops, then six months later, when her husband is back in prison, she's doing okay. Not wonderful, but okay.

Anyway, there was a point to this when I started typing, but this one's been a hard one to articulate, and I don't reckon I've got it through at all. And anyway - one AM and Sara, who suffers from "Won't Tell Anyone She's Sick Until She's Quite Unwell Disorder", needs her brow felt.

Will try to be less wordy next post.

Thanks for listening,


*On the losing side of every war we've been in for the last hundred years. Beaten by the Bolsheviks in Russian, the Russians in Latvia, the English in Ireland, the Allies in Germany (twice)... If I had any patriotism I'd go overseas and enroll in an enemy army.


Anonymous Camilla said...

I've realised that either my understanding of psychiatry is actually pretty close to nothing... or I've realised I've been using a lot of the stuff I was taught in medical school in a stupid and lazy way.

I think a lot of people working in the helping professions come to this realisation. Or rather, I hope they do, because in my opinion, it's one of the realisations that leads to someone being a more effective practitioner. Knowing what you don't know is, IMO, more important than knowing what you do know. Sometimes.

Great article! Please, feel free not to become less wordy on my account. I would like more of your words, not less :)

4:37 PM  
Blogger Benedict 16th said...

1) " and I've been returning more to the biopsychosocial model we learnt in first year."
Shit, I thought you were asleep through that bit!

2) That was a great post... I hope you realise I am going to print it out for all my FITH* syndrome patients!
And it is too late, I have already copied it. I think it should be mandatory that all psych registrars are made to read it.
The number of times one of my specials have been stuff up by a psych registrar taking a literal reading
into the holy book (of DSM) ....

3) As for the losing side thing, no wonder you are a Freo supporter!

4) Yes, when I am under stress I think I react in much the same sort of way, and do AXIS II stuff....

Thanks for the post - it was really gud!


* FITH syndrome = "Fucked in the head", it has about the same negative connotation
as calling someone "Borderline" and I think it is a little bit more honest...
Maybe it should be ITYA FITH (I think you are or we thing you are????
What do ya reckon?

Word Verification = Huchar, an Eschar from a rabbit bite? Tache Bunny instead of Tache Noir?

5:53 PM  
Blogger kaal boishakhi said...

i must say i like the idea of a personality that is disordered when youre under pressure.
thats me to the hilt. It took years to diagnose me as borderline (im bipolar 1 as well) on account of...well...lack of ambivalence in terms of identity (im quite the opp) and intense unstable relationships (im artfully diplomatic and tend to not get too close in the first place thus avoiding tumultous emotions)...
the rest..
i have no idea why im posting this.
i suppose theres a certain amount of disdain at this new diagnosis. bipolarity i could handle. less personal. take your meds and you wont think youre a prophet or want to kill yourself...
its just the effin accountability really.
and then things still dont get better. and i self sabotage and self destruct and while relatively happy that little emotional vaccum doesnt go away.
nonetheless... i spent my life putting up a cold detached front and negated the turbulence within instead of dealing with it.
the diagnosis fits well enough...
im young though, and most of my behaviours i am working on or have already worked through so woot me!
enough ranting...i apologize for this. its late and i need to sleep.

3:45 PM  
Blogger Bronze John said...

I remember us being given a talk in med school by a tiny Sri Lankan man with an inpenetrable accent and a delight in wordplay and caustic humour - most of which was lost on many of my colleagues because of said accent. But what he was talking about was actually quite good.

He said doctors (and any other group) can be divided into not only those who know and those who don't know, but furhtr into those who don't know they don't don't know, don't know they do know, etc.

Of these the most dangerous was theose who knew bugger all, and didn't even know that they knew bugger all.

It is chilling to realise how recently I have moved from that group to the group who at least grasp the fact they know bugger all.


6:58 PM  
Blogger Bronze John said...

I read in one of our city's new newspapers that His Holiness wears Prada sneakers and carries an ipod. Good to see that Macintosh have ecclesiastical approval.

Glad you liked the post. And you - Axis II behaviour? I remember being told by a psych reg that "borderlines never think they're borderlines". Another Golden Rule that turned out to be a lot of FeS2.


7:05 PM  
Blogger Bronze John said...

Thanks for the comment - interesting comment and interesting site. If you get a young creative person with atypical symptoms that could be interpreted as either borderline or bipolar, and you ask three different psychaitrists what that person has, you will get eight different diagnoses.

Good luck,

7:07 PM  

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