Question BPD outcomes

In Drs. Ali M. Hashmi and Dennis Vowell’s article “The manipulative self-harmer” (Cases That Test Your Skills, Current Psychiatry, June 2010, p. 44-48), the authors regard the patient’s outcome (“Recently she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated”) as characteristic of borderline personality disorder (BPD) (“Ms. L is no different from most axis II Cluster B disordered patients.”). In my view, this is the greatest risk of calling a patient borderline—it tends to justify poor outcomes by thinking that it is just characteristic of the illness. Instead, shouldn’t we worry that our treatment may be suboptimal? Maybe we are missing something?

For example, Ms. L may have some degree of bipolarity (see the Harvard Bipolarity Index as a characterization of that concept, incorporating but going beyond the DSM-IV-TR) that could account for their observation, “Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next.” Instead of concluding, “this stormy course is expected…” the authors should be wondering whether they might be contributing to it by restarting venlafaxine despite simultaneous carbamazepine initiation. Granted, the possibilities of bipolarity and antidepressant-induced rapid cycling are complex considerations, because we lack solid footing for differentiating BPD and bipolar disorder and for determining causality when a patient experiences rapid mood changes while taking an antidepressant. These are controversial issues, but why present the case as though it’s illustrative of accepted principles? I find it perfectly illustrative of how badly we’re floundering as a field.

Jim Phelps, MD
PsychEducation.org
Corvallis, OR

The authors respond

Dr. Phelps’ contention is that our observation that Ms. L’s “hostile and self-destructive behavior” makes her “no different from most axis II Cluster B disordered patients” somehow understates the extent of her illness, perhaps leading to poorer outcomes. Negative countertransference toward such patients is the norm and handling it empathically is an integral part of the treatment relationship. This is true even though the severity of Ms. L’s personality pathology, as evidenced by her placement in the “911 program,” may not be representative of all patients with BPD.

We agree that “the possibilities of…antidepressant-induced rapid cycling are complex considerations.” Even experts disagree on this. In fact, as we pointed out, Ms. L resisted medication tapers, at one point insisting that high doses of fluoxetine and venafaxine be used together for depression, a request we denied specifically for fear of worsening her mood lability. Fluoxetine was discontinued and venlafaxine restarted at a lower dose to treat her persistent depression as well as to help with her chronic back pain. Because by this time she was taking carbamazepine as well, we felt the risk was acceptable. Her positive long-term outcome has validated our approach.

We disagree that psychiatry is “floundering” as a field. In fact, exchanges like this are a core component of placing our specialty on a more solid, scientific basis to position it for future challenges.

Ali M. Hashmi, MD
Medical director
Mid-South Health Systems
Jonesboro, AR
Clinical instructor
Department of psychiatry
University of Arkansas for Medical Science
College of Medicine
Little Rock, AR

Dennis Vowell, PsyD
Clinical psychologist
Mid-South Health Systems
Paragould, AR

In Drs. Ali M. Hashmi and Dennis Vowell’s article “The manipulative self-harmer” (Cases That Test Your Skills, Current Psychiatry, June 2010, p. 44-48), the authors regard the patient’s outcome (“Recently she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated”) as characteristic of borderline personality disorder (BPD) (“Ms. L is no different from most axis II Cluster B disordered patients.”). In my view, this is the greatest risk of calling a patient borderline—it tends to justify poor outcomes by thinking that it is just characteristic of the illness. Instead, shouldn’t we worry that our treatment may be suboptimal? Maybe we are missing something?

For example, Ms. L may have some degree of bipolarity (see the Harvard Bipolarity Index as a characterization of that concept, incorporating but going beyond the DSM-IV-TR) that could account for their observation, “Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next.” Instead of concluding, “this stormy course is expected…” the authors should be wondering whether they might be contributing to it by restarting venlafaxine despite simultaneous carbamazepine initiation. Granted, the possibilities of bipolarity and antidepressant-induced rapid cycling are complex considerations, because we lack solid footing for differentiating BPD and bipolar disorder and for determining causality when a patient experiences rapid mood changes while taking an antidepressant. These are controversial issues, but why present the case as though it’s illustrative of accepted principles? I find it perfectly illustrative of how badly we’re floundering as a field.

Jim Phelps, MD
PsychEducation.org
Corvallis, OR

The authors respond

Dr. Phelps’ contention is that our observation that Ms. L’s “hostile and self-destructive behavior” makes her “no different from most axis II Cluster B disordered patients” somehow understates the extent of her illness, perhaps leading to poorer outcomes. Negative countertransference toward such patients is the norm and handling it empathically is an integral part of the treatment relationship. This is true even though the severity of Ms. L’s personality pathology, as evidenced by her placement in the “911 program,” may not be representative of all patients with BPD.

We agree that “the possibilities of…antidepressant-induced rapid cycling are complex considerations.” Even experts disagree on this. In fact, as we pointed out, Ms. L resisted medication tapers, at one point insisting that high doses of fluoxetine and venafaxine be used together for depression, a request we denied specifically for fear of worsening her mood lability. Fluoxetine was discontinued and venlafaxine restarted at a lower dose to treat her persistent depression as well as to help with her chronic back pain. Because by this time she was taking carbamazepine as well, we felt the risk was acceptable. Her positive long-term outcome has validated our approach.

We disagree that psychiatry is “floundering” as a field. In fact, exchanges like this are a core component of placing our specialty on a more solid, scientific basis to position it for future challenges.

Ali M. Hashmi, MD
Medical director
Mid-South Health Systems
Jonesboro, AR
Clinical instructor
Department of psychiatry
University of Arkansas for Medical Science
College of Medicine
Little Rock, AR

Dennis Vowell, PsyD
Clinical psychologist
Mid-South Health Systems
Paragould, AR

In Drs. Ali M. Hashmi and Dennis Vowell’s article “The manipulative self-harmer” (Cases That Test Your Skills, Current Psychiatry, June 2010, p. 44-48), the authors regard the patient’s outcome (“Recently she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated”) as characteristic of borderline personality disorder (BPD) (“Ms. L is no different from most axis II Cluster B disordered patients.”). In my view, this is the greatest risk of calling a patient borderline—it tends to justify poor outcomes by thinking that it is just characteristic of the illness. Instead, shouldn’t we worry that our treatment may be suboptimal? Maybe we are missing something?

For example, Ms. L may have some degree of bipolarity (see the Harvard Bipolarity Index as a characterization of that concept, incorporating but going beyond the DSM-IV-TR) that could account for their observation, “Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next.” Instead of concluding, “this stormy course is expected…” the authors should be wondering whether they might be contributing to it by restarting venlafaxine despite simultaneous carbamazepine initiation. Granted, the possibilities of bipolarity and antidepressant-induced rapid cycling are complex considerations, because we lack solid footing for differentiating BPD and bipolar disorder and for determining causality when a patient experiences rapid mood changes while taking an antidepressant. These are controversial issues, but why present the case as though it’s illustrative of accepted principles? I find it perfectly illustrative of how badly we’re floundering as a field.

Jim Phelps, MD
PsychEducation.org
Corvallis, OR

The authors respond

Dr. Phelps’ contention is that our observation that Ms. L’s “hostile and self-destructive behavior” makes her “no different from most axis II Cluster B disordered patients” somehow understates the extent of her illness, perhaps leading to poorer outcomes. Negative countertransference toward such patients is the norm and handling it empathically is an integral part of the treatment relationship. This is true even though the severity of Ms. L’s personality pathology, as evidenced by her placement in the “911 program,” may not be representative of all patients with BPD.

We agree that “the possibilities of…antidepressant-induced rapid cycling are complex considerations.” Even experts disagree on this. In fact, as we pointed out, Ms. L resisted medication tapers, at one point insisting that high doses of fluoxetine and venafaxine be used together for depression, a request we denied specifically for fear of worsening her mood lability. Fluoxetine was discontinued and venlafaxine restarted at a lower dose to treat her persistent depression as well as to help with her chronic back pain. Because by this time she was taking carbamazepine as well, we felt the risk was acceptable. Her positive long-term outcome has validated our approach.

We disagree that psychiatry is “floundering” as a field. In fact, exchanges like this are a core component of placing our specialty on a more solid, scientific basis to position it for future challenges.

Ali M. Hashmi, MD
Medical director
Mid-South Health Systems
Jonesboro, AR
Clinical instructor
Department of psychiatry
University of Arkansas for Medical Science
College of Medicine
Little Rock, AR

Dennis Vowell, PsyD
Clinical psychologist
Mid-South Health Systems
Paragould, AR