BPD & NIMH

Interview transcript for Wayne S. Fenton, MD

And under our prior director, Steve Hyman, and our current director, Tom Ensel, I think there has been an effort to take a look and refocus the Institute's efforts on public health issues, particularly ones that have been neglected. And this is really close to the top of the list.

FEATURES OF BPD

When you look at people who are labeled borderline personality disorder, what you see is dysfunctions across several dimensions. One, of course, is impulse control and impulsivity. A second is affect regulation, that is the ability to manage one's emotions. There are also, in some instances, dysregulation of cognitive function, difficulty thinking, particularly in particular circumstances when the person is overwhelmed emotionally.

In approaching the disorder from a scientific perspective, we believe that these dimensions such as affect dysregulation, such as impulsivity, are really more approximate to brain functioning in brain circuits. And the research that we supported to date is beginning to provide some clues with respect to what areas of the brain are involved, for example, in regulating emotion or regulating affect and impulses.

BPD INFORMATION AND SERVICE GAPS

I think that there is both an information gap and also, importantly, a services gap. The information gap clearly has some roots in clinicians' training. For example, when I was trained as a resident at Yale, we were taught about borderline personality disorder in the context of child development in that there were certain similarities between the emotional behavior of an 18 month old child and the emotional behavioral patterns of an adult with borderline personality disorders.

I mean, this is such a difficult condition that if science yields a new treatment, clinicians are going to be interested in it because, and families are going to be interested in it, not to mention individuals who suffer from the disorder because current treatments are very substantially inadequate.

Obviously, one of the underlying issues is that clinicians feel very ineffective when it comes to treating this and in many instances, as we discussed earlier, have not had access to some of the new tools, some of the new ways of thinking about this disorder, some of the training in some of the new therapies that are more effective.

LACK OF COMMUNITY RESOURCES

And while that often does work for particularly individuals with serious in-treatment-resistant schizophrenia, bipolar disorder, major depression and borderline personality disorder, the resources we have in the community just are not there to meet the clinical need.

COURSE OF THE ILLNESS

There's been a few long-term studies of personality disorders. First, the studies that came out in the '80's and early '90's were sort of retrospective studies, based on patients who had been discharged from hospitals like the New York hospital or Chestnut Lodge Hospital. You found that the patients with BPD tended to, in a certain sense, the illness tended to be at its worst when the people were in their 20's and early 30's.

When you looked at how it is that these recoveries came about, there were two broad patterns. One of the patterns was that some of the patients came to recognize that close relationships with other people were just too difficult for them to manage so that they almost reconciled themselves to having more distant relationships with other people and threw themselves into some other area of life such as work and became very successful.

Another group seems to have had a diminishment of some of this dysregulation that underlines the interpersonal problems but also through treatment learned to modify their patterns and, as it were, self-manage the illness. And that was a second group.

I think there are really two threads of research that are going to have important implications going forward. The first is really getting a better understanding of the underlying neurobiology of these behavioral dimensions that are dysregulated in this disorder.

However, we can't wait for that research to bear fruit. Patients also need something now so that while we work on the basic science underlying the disorder, we also have to work on treatments that can be implemented now and hopefully implemented at a cost that's reasonable enough to be able to be put in the community.

So that for example, dialectical behavior therapy we know from over half a dozen randomized clinical trials is really effective in reducing suicidal behavior and hospitalizations for these patients. We're now trying to disaggregate the components of this study or the components of this therapy to see if, for example, the social skills component alone would be effective or the individual therapy alone would be effective as a means of essentially finding perhaps a more cost effective way of taking this treatment that we know works and getting it out across the country.

ROLE OF THE FAMILY

I think the family plays a critical role in determining the outcome. I think it's important to probably recognize and acknowledge right from the start that for many people with borderline personality, the family really is a critical social support. These are, in many instances, people who would be in homeless shelters, who would be in the back wards of mental hospitals, if it weren't for their family's continued willingness to care for them, often under very, very difficult and emotional circumstances.

So I think one has to give an enormous amount of credit to families who are able to, as it were, stay with their children who are afflicted with this sort of condition. That being the case, I think that attempting and acting as an advocate to try to help the person with BPD to access effective treatment is certainly one critical issue.