The Impact Of Erlier And More Concrete Diagnosis Of Borderline Personality Disorder
Borderline personality disorder is a mental illness in which an individual can show a variety of behaviour, from depressive episodes to mania; anxiety, a distorted sense of self, emotional stress, emptiness, abandonment and delusional behaviour. The cause of this disorder is not known, but around 40,000 Australians currently suffer from this illness and an estimated 1 in 50 of 24-64 year olds have dealt with this condition in their lifetime. Medications do exist to calm this disorder but there is no cure, and it has not only a significant personal impact, but a major impact on society and healthcare costs. Over 340 million dollars were spent last year to help those with BPD in Australia. The current diagnosis method involves a GP at the first step and then a specialist in mental health who is able to prescribe medication; however, it is estimated that an average of 10,000 people go undiagnosed every year in Australia and this is problematic because their symptoms can continue to worsen and they can become a danger to themselves in many cases. The methods of diagnosing BPD need to improve so that more people can be treated. The key findings in this report are based on analysis of a wide range of sources including primary journals, reports, and online articles to determine how BPD can be better diagnosed so that more people can live better lives or be treated entirely.
How is BPD currently diagnosed?
BPD is currently diagnosed during a person’s early childhood or teenage years, only some individuals are diagnosed in adulthood. However, a person may show the signs of BPD, but not fully develop the disease until years later and this is because the current methods of diagnosis used by the Australian Psychiatric medical practitioner board considers a variety of factors when diagnosing a person with BPD considers the self-reported experiences of the symptomatic individual, abnormal behavior reported by family members, friends or co-workers, observable signs of illness as assessed by a clinician, and often a medical work-up to rule-out medical causes.
There are currently three well-known methods of diagnosis, the APA and the DSM 5 and the IC10 which is made by the world health organisation. All methods look for signs such as depression, anxiety, extreme mood swings, schizophrenia, and borderline personality disorder. This report looks at the WHO method of diagnosis as it is used in Australia. BPD is mostly diagnosed through patient questionnaires and interviews with doctors where they attempt to determine their mental health condition through discussion.
Other signs which can help doctors to diagnose BPD include brain abnormalities within the hippocampus, amygdala, prefrontal cortex and the HPA. Essentially, a person with BPD should have a less active prefrontal cortex, but a lot of activity in the HPA and the amygdala as chemical imbalances in the brain can cause a person to experience a great deal of stress and emotional imbalances. Furthermore, people who have undergone any type of trauma in their childhood are 40% more likely to have BPD and this can either be due to damage in the brain to the aforementioned parts (due to hunger, violence, sleep deprivation and sedation) or prolonged emotional abuse.
What are the issues with the methods of current diagnoses and how can they be changed?
A major issue is that misdiagnosis (true or false) is extremely common with BPD as it shares a similar pattern of behavioural issues and categories with bipolar disorder, unipolar depression and anxiety, Post traumatic stress disorder, and Attention deficient disorder (ADD). This makes it very hard to exactly diagnose this condition as a number of the signs fit into other diseases as well. A study conducted by the national Psychiatric board of Australia highlighted that GP’s have often misdiagnosed BPD with a generalised mood disorder as the symptoms have not been there for a long time2. All patients with this condition can show different signs and symptoms to one another and as some experts have called for categories to be established which would make diagnoses easier for doctors and other mental health professionals. A key researcher and expert in this area, Theodore Millon, proposed the four subtypes of BPD in 2007. He proposed that someone with BPD could be placed into 1 or more the categories below;
- Discouraged Borderline – people who exhibit signs of helplessness, depression, powerless and feelings of constant jeopardy.
- Petulant borderline – people who show signs of pessimism, disillusionment, impatience, and stubbornness to perform actions or tasks even if it is beneficial for them.
- Impulsive borderline - Captivating, capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, the individual becomes agitated; gloomy and irritable; and potentially suicidal.
- Self distructive borderline - Inward-turning, intropunitive (self-punishing), angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.
What else can be done?
According to Dr Aviram, a medical researcher in Harvard, USA the key might be to use genetic testing along with brain imaging and neurological patterns to make a more accurate diagnosis which can be separated from conditions such as bipolar disorder and depression. There are several studies conducted in the United Kingdom and Australia which show that there is a major genetic link in BPD in that children of a parent are 50% more likely to have the condition as a young teenager or in early 20’s. This is not to say that a person’s environment, and broad family conditions have no impact, it's just that genetics is the best predictor of the disease to date. The main gene which of issue is the dopamine receptor D4 on the 11th chromosome which can have abnormalities leading to a person being more likely to develop BPD. The issue in this area currently seems to be that whilst genetic testing can indicate a greater likelihood of having BPD, it is expensive to do especially in places where the funding for mental health has been lowered. Furthermore, the other issue seems to be that just because someone has the matching gene, does not mean they will develop the condition. Finally, the final obstacle in gene testing with BPD diagnosis is that research has still not shown us which particular symptoms of BPD (as different people may experience different symptoms but still have the same broad disease/condition) are linked to which gene. The D4 gene on chromosome 11 is a generalised gene for BPD but it cannot tell us anymore. Further research in this area will enable us to determine at a very early stage which types of symptoms a person is more likely to show and hence they could be treated much faster.
Brain imaging
Whilst brain imaging is used in some cases of suspected BPD (where the person is suspected to have had trauma), there is some research which suggests that brain imaging can be more broadly used to identify BPD in people who show symptoms. This is because as mentioned above, some parts of the brain are less active and some parts of the brain are more active when a person has BPD. However, Dr Brady raises concerns over the impact of brain imaging as whilst it can show signs of BPD, it still has a decent likelihood of a false positive result and the fact that there is some radiation exposure involved in medical imaging so we cannot use it too many times on a patient.
Hormonal testing
Whilst hormonal testing is done by most doctors, it is still not widely adopted as 23% of GP’s did not use it when trying to diagnose BPD. This needs to be more widely adopted as differences between the levels of hormones such as oestrogen (in women) and dopamine in men can show the signs of BPD. Hormonal testing is relatively cheap and inexpensive so it is surprising to see why it is not more widely used. A potential drawback is that it can only give yes or no answers, but not give detailed information about the person’s particular issue.
It should be noted that the methods described above have the potential to be used together meaning that brain imaging can be done alongside genetic and hormonal testing to see whether a person has BPD or another related mental illness. We must always remember that the goal is to break a person’s condition down in a specific manner so that they can receive a targeted treatment which can help them live better lives.
How will an earlier or more concrete diagnosis of BPD impact a person’s life?
It is evident that the longer a person lives with BPD without it being diagnosed and properly treated, the more likely they are to commit self-harm and lose control of their lives as they become less functional. This can result in the loss of relationships, employment, eating disorders and a host of other personal issues which can leave the individual in a helpless state. BPD is mostly treated by psychotherapy, cognitive behaviour therapy – where a person undergoes various interviews with a doctor, and medications to help with some symptoms. Research in the United Kingdom which looked at over 25000 over a period of 15 years found that a person is much more likely to recover from BPD if it is diagnosed early, specifically if diagnosed within a one year period – the person is 31% less likely to have suicidal thoughts and other associated symptoms.
Conclusion
Overall, it is evident that BPD has a major personal toll on a person as they can experience a variety of stressful symptoms like body image issues, harmful tendencies, eating disorders, emptiness and depression. The current methods of BPD diagnosis have been effective to a good degree, however, more work is needed in this research area so that we are more accurately able to diagnose a person with BPD (or see if they fit into another mental health issue such as bipolar or unipolar depression). A misdiagnosis can hurt a person as if they are wrongly diagnosed they could receive the wrong treatment which can further worsen their health. Furthermore, a greater usage of genetic testing, hormonal testing and brain imaging could also be useful in diagnosing BPD. There is a great benefit to a person and society as a whole if this condition can be diagnosed early and more accurately as it can prevent a person from committing self-harm or being ruined by the symptoms which occur with this condition.
