QA: Borderline personality that goes away and lamotrigine deficiency syndrome

by | Jan 9, 2023 | Curbside Consults

Question: In one of the last lectures I attended, our lecturer expressed his views, that borderline personality disorder to him, isn’t really a personality disorder.. and that he prefers the psychodynamic view of the condition, in that.. it’s more like a state of functioning, that is in between neurotic and psychotic states. His evidence behind that view was that BPD patients often respond greatly to dialectical behavior therapy (DBT), and that’s why it’s unlikely to be a personality disorder if it can be resolved to such a great extent.

Answer: The origin of the concept of “borderline” personality was that it was on the “borderline” between neurosis and psychosis. So that description is historically accurate. Neurosis and psychosis were terms psychoanalytically in the mid 20th century. If someone had “neurosis”, it meant that they had any of a range of mental symptoms, usually anxiety or depressive or obsessive, but not delusions or hallucinations. The latter terms were labeled “psychosis”. Further, the person with neurosis was functional, treated in the office setting, while the person with psychosis was not functional, and was seen mainly in the hospital setting. Psychoanalysis was the main treatment given in the office setting for patients with “neurosis.” Sometimes, these apparently neurotic persons would lie down on the psychoanalytic couch, and, after free association for an hour every day, five days per week, for months or years, they would have a hallucination or develop a brief delusion. They had started psychoanalytic treatment “neurotic”, and they had become “psychotic.” The phrase “pseudoneurotic schizophrenia” was used: they seemed neurotic, but they really weren’t; with the lack of structure of psychoanalytic sessions, they showed their underlying psychosis. (The term “schizophrenia” was used as a synonym for “psychosis” by most psychoanalysts). They were on the “borderline” between neurosis and psychosis because in normal life circumstances, they were mainly neurotic (with anxiety, depression, obsessionality), but under stress (like a psychoanalytic session), they became psychotic. The psychosis was brief, however, and once the stress was over, they became neurotic again. (This is why brief psychotic episodes has been a DSM criterion for borderline personality). The term “borderline personality organization” was given by the psychoanalyst Otto Kernberg for these same patients, and the term “disorder” was inserted instead by John Gunderson as head of the DSM-III committee on personality disorders, when the concept was first formalized in 1980.

Of course DSM is mostly false, and the definition of borderline personality disorder (BPD) in DSM is mostly false scientifically. It includes criteria that are not at all specific to borderline personality (mood swings, suicidality, unstable interpersonal relationships) and happen as frequently or more so in other conditions, such as mood illness. It excludes criteria that are much more common in BPD, like sexual trauma, than in other conditions. It totally ignores genetics as a predictor of having or not having BPD. This all is discussed in this review paper. Thus, many people with apparent DSM-based BPD improve with treatments, including medications or DBT or other interventions, because they don’t have BPD. And they don’t have BPD because the DSM definition of BPS is scientifically false. That would be my conclusion. Your lecturer assumes that DSM is true and draws conclusions from response to DBT that the person doesn’t have a “personality disorder” whereas the whole DSM concept of “personality disorder” is scientifically weak. (Most DSM personality disorders have been proven to be invalid, and the DSM-5 personality task force wanted to remove them, but the APA leadership refused).

Besides the scientific weakness of the DSM criteria for BPD, the DSM falsehood of “comorbidity” leads to similar confusion. DSM refuses to exclude a diagnosis if another is present. A person meets BPD criteria during a manic episode, or during a depressive episode, and does not meet those criteria when those episodes resolve. Yet DSM still diagnoses the BPD. There are many studies that show that patients with supposed BPD are cured by antidepressants, and their “personality disorder” is resolved in a year. Such persons never had BPD; they just had a depressive state, which was interpreted in the lens of “personality disorder” as meeting criteria for BPD, without any attention to what was causing what. The same observation happens with mood stabilizers in persons with bipolar illness, frequently with mixed states, who are misdiagnosed as having BPD. Hagop Akiskal observed such “cure” with treatments like lamotrigine, and he used to joke that people with supposed borderline personality appeared to suffer from “lamotrigine deficiency syndrome.”