personality plus; Psi 3

It's 3:00 AM and I am examining a patient for "medical clearance" for a psychiatric evaluation. Within 5 minutes, the patient has really pissed me off. I loathe this patient. This person makes me question my physician's oath. The patient has borderline personality disorder.

Borderline personality disorder (BPD) is defined by our trusty DSM as a pervasive instability in mood, interpersonal relationships, self image and behavior. The borderline is between neurosis (quirky) and psychosis (crazy). Their demeanor can change in an instant as they display anger, depression and anxiety. Crying and sympathetic one minute, cursing and questioning your ancestry the next.

Borderlines are impulsive, aggressive, self-injurous, and often substance abusers. They express feelings that they are unfairly misunderstood and mistreated. There impulsivity leads to splurging, bingeing, and risky behavior including sexual activities.

Borderlines are usually the victims of childhood abuse and neglect. They have an overwhelming fear of abandonment both real and imagined. Their behavior is a way of trying to avoid being abandoned. Suicidal threats and attempts are frequent and accompanied by anger not depression.

It is estimated by the NIMH (National Instutites of Mental Health) that 2% of the adult population has some degree of BPD. Women are more likely to have BPD than men. I treated an attractive young woman in the ER a few years ago. She was crying and relating a history of abuse, depression, drug use and suicidal thoughts. There was a certain degree of "seductive" posturing during the interview and exam. I told her that a mental health worker would come and evaluate her for psychiatric treatment. She mentioned her need for medication to treat her substance abuse problem. I offered appropriate medication but not the specific drug of choice. Her response was instantaneous. The tears were replaced with a snarling, cursing, spitting hellcat. The diagnosis was obvious.

The psychiatric literature is replete with articles about effective treatment with medications and therapy that can allow patients with BPD to lead a near normal life. For those of us who deal with these patients in the ER, a large security force and attention to one own's safety are the priority.

While I am opining about non-psychotic disorders, let's discuss a few additional topics. OCD, GAD, and DID are only occasionally treated in the ER but are often the basis for journalistic articles and TV shows.

OCD stands for obsessive compulsive disorder, think "Monk". This sometimes disabling condition is characterized by recurrent unwanted thoughts (obsessions) with or without repetitive behaviors (compulsions). My coworkers will attest that I am definitely compulsive. I "need" to clean my computer station in the ER before starting to work. The keyboard, phones and mouse are disinfected. Any papers are filed or discarded. My trusted coffee cup and hand sanitizer are to my left, and the phone and a box of tissues to my right. The PA's, nurses and techs are extremely indulgent of my "quirks".

Although the manifestations of OCD are considered humerous by some, to the patient they are painfully serious. Repetitive hand washings, counting, touching and checking can immobilize the patient. The distress of their obsessive thoughts caused severe anxiety. Fortunately medications and behavioral therapy are effective in treating this condition.

DID or dissociative identity disorder was, in the past, refered to as multiple personality disorder ("Sybil"). Two or more separate and distinctive personalities control the individual at different times. These "alters", alternative identities, can number from 2-100, with an average of ten. DID patients experience episodes of amnesia and lost time as one alter changes to another. They have auditory and visual hallucinations, and are often depressed and suicidal. The alters develope as a response to physical and/or sexual abuse in childhood. They are an attempt to cope with the psychological and physical pain of abuse.

GAD is generalized anxiety disorder. Individuals with GAD are constantly worrying or obsessing about small and large concerns. They are always on edge. Restlessness, irritability, lassitude, insomnia, and difficulty concentrating are usually reported. Patients with GAD have physical symptoms from the high levels of stress hormones. Sweats, nausea, diarrhea, shortness of breath and heart palpitations are frequent complaints. Without treatment GAD can lead to a person becoming a shut-in, as one tries to avoid anxiety provoking situations.

PS: ODD or oppositional defiant disorder is a diagnosis given to adolescents and teens. My personal feeling is that this condition is too loosely defined and too easily bestowed. Teenagers are in the process of establishing their identity as distinct persons, independent of their parents. In their efforts to become adults, and due to the late development of the frontal lobes of the brain, teens often do the opposite of what their parents desire. My father had the solution to my ODD, it was a thick and heavy leather strap that he would diligently apply to my posterior when I exhibited oppositional or defiant behavior. I do not recommend and will not tolerate corporal punishment. Clear and consistent standards of behavior and withholding of priviledges is my prefered form of discipline. My opinion is that ODD is more likely to be caused by other underlying psychiatric conditions including bipolar, schizoid personality, and BPD.

PSS: PTSD is fortunately being more often recognized and treated. Soldiers in WW1 were "shell shocked" and in WW2 had "battle fatigue". My father who was in combat for three years in the Pacific theatre during WW2 exhibited all the symptoms of PTSD. He would have frequent nightmares of his war experiences. The only treatment he received was the love and understanding of my mother. Many victims of PTSD are not as lucky. The traumatic event(s) can occur in battle or at home. The intense fear, feelings of helplessness and pain are continually reexperienced. Medication and therapy can help those who suffer from PTSD. Untreated, patients with PTSD will often self-medicate with alcohol and/or drugs. Recent experiments have shown that giving betablockers, a type of medication for high blood pressure, immediately after a traumatic event such as a rape, may blunt or prevent PTSD. The formation of long term memory is impaired by the medication and this seems to be the mechanism for preventing PTSD from developing.

Remember that knowledge is the key to understanding. If you think you or someone you care about has one of these conditions get informed. There are many sources of information available.