Borderline Personality Disorder - The New England Journal of Medicine

[acd]

The New England Journal of Medicine is the most highly regarded medical journal; each week there is a state-of-the-art review of a major illness.  These articles are often considered the "definitive" summary and are read by many thousands of physicians who practice in other specialties in order to stay current on diseases beyond their own specialty.  This week, BPD "made it" to the Journal, and this article will undoubtedly affect the concepts that clinicians have about this disorder.  It is striking to me that this review presents only the classic, "low functioning" BPD side of the disease, and virtually ignores that many BPs are "high functioning" - as a result, physicians may recognize the "woman" with feigned suicide attempts, but may miss the diagnosis in the professional, in the non-suicidal, in short, in the BPs that are often discussed on this board. What do you think of this "scholarly" (and very brief) review?  Here is the link:

www.nejm.org/doi/full/10.1056/NEJMcp1007358

Does this article reflect your experience with the diagnosis?  Will it mislead clinicians into thinking that the suicidal woman in the vignette is the "typical" BPD patient? That only these extreme cases merit consideration of the diagnosis?  Should the article at least have mentioned that many patients with BPD are executives, entertainers, professionals, even physicians themselves?

"This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 26-year-old woman is brought to the emergency room by an anxious-looking man who explains that she became angry and suicidal, stating that her “life had no value” and that she would “like to end it all” after he criticized her. Her history includes five previous emergency room visits (twice involving self-inflicted cuts that required sutures) and two psychiatric hospitalizations after overdoses. Adolescent adjustment reaction and major depressive disorder have been diagnosed in the past, and she has been treated with sertraline, alprazolam, and aripiprazole. How should she be evaluated and treated?"[/color]

[an0ught]

Well the author is Gunderson (one of the world top experts on BPD) so I suspect he a) knows what he is talking about and b) knows what message he conveys. We lack the full text and there is no deliberate abstract so I'm inclined not to comment on the whole article further.

Case vignettes are deliberately chosen or possibly even designed to highlight key features. And to get attention. Without attention you can not deliver any message. This one here is imho. suitable as it mentions a lot of stuff:

by an anxious-looking man who explains - he brings the partner into the picture. This is great!

became angry and suicidal, stating that her “life had no value” and that she would “like to end it all” after he criticized her  - this is a situational dynamic and a key feature of BPD allowing it to distinguish from other candidates. I would suspect he focuses on this later.

Her history includes five previous emergency room visits - good. Emergency room visits whether caused by suicide or medical emergencies of unclear origin - they are a sign of drama common with BPD and worth to focus on.

Depression indidcation. But several medications, some anti-depressant, some anxiety, some anti-psychotic antidepressant... .- anxiety is a big factor in BPD. And possibly someone has decided that some anti-psychotic medication may be in order.


It is easy to get hung up on the suicidal bit in the story but he has crafted this carefully and put a lot more into it than may be visible on first sight.

[swampped]

As a recently retired pediatrician, I was delighted to see this well-written article, by a noted authority on the subject, appear in NEJM.  The exposure it will receive will validate BPD as an entity in the minds of many who have undoubtedly seen it in practice, but have not recognized it.  And the fact that this is a description of a "low-functioning" pwBPD is probably a better illustration of a clinical situation that is often mislabeled.  If it starts someone thinking about a patient, a family member, a colleague, whoever---it will get BPD out there, which is badly needed.  The distinction between high and low functioning aspects of the condition will be clear once the health provider recognizes the entity, and is motivated to read about it.  I trained in the 1970's, and only heard about BPD sometime in the '80's, after I was in practice, and with the understanding that it was an uncommon, and basically untreatable disorder.  When our son married a woman with bizarre behavior patterns, the term "borderline personality" ran through my mind, and a google search led to an exact description of her behavior.  Bingo!  Her own family had struggled for years with her difficulties, but had never been aware that there was a clinical reason for the cutting, suicide attempts, rages, broken relationships, etc, etc, etc.  If I had known then what I have learned from this Board, maybe something would be different.  Or not.  But understanding that this is a form of mental illness makes all the difference, as you all know.  At any rate, I applaud the editors of NEJM for publishing this paper, and believe that they have done a great service to patients and families with BPD, in getting the term---and the knowledge that it is not a hopeless diagnosis---out to physicians all over the world.      Swampped