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On the Border


Journal of Psychiatric Practice®: July 2019 - Volume 25 - Issue 4 - p 241
doi: 10.1097/PRA.0000000000000398
From the Editor


July, 2019. The Menninger Clinic helds its Signature Luncheon in Houston in May, 2019, an annual event dedicated to fighting the stigma of mental illness. Our guest speaker this year was Brandon Marshall, well known as a talented NFL wide receiver. But the subject was not football. Instead, it was about his struggles with borderline personality disorder (BPD). I had the privilege of introducing Brandon, and I thanked him for his decision to come forward and talk openly about his personal struggles with BPD.

We now know quite a lot about BPD. It is a brain disorder. It can run in families just like other conditions like diabetes, depression, or heart disease. And it can produce extreme suffering and impairment in functioning, especially by tangling up and disrupting relationships with others.

People often ask me why it is called borderline. In the early days, it was thought to be in the border zone between “neurotic” conditions and psychotic conditions. But that concept hasn’t held up as we’ve learned more about BPD. These days, I tell patients and families at the Menninger Clinic that it’s called borderline because someone who has BPD is “on the border” of having a major mood disorder or a major impulse control disorder. People with BPD have a highly reactive limbic system, particularly the amygdala, so that this “emotional engine” is highly sensitive. Any little thing can trigger powerful emotions. But it’s a double-hit problem, because the prefrontal cortex, the top-down regulator system that can cool the emotional heat or slow down the reckless impulse, doesn’t work very well. The engine is running hot, and the brakes don’t work.

But the good news is that treatment works, and Brandon Marshall is an example of someone with BPD who sought treatment, in his case at McLean Hospital, and who speaks about how much it has helped him. Not infrequently, an obstacle that interferes with seeking treatment is that an accurate diagnosis is not established. Some of the symptoms of BPD overlap with other conditions, such as bipolar disorder, and it may take a while to clarify the diagnosis and then develop an appropriate treatment plan.

In this issue of the Journal, the winner of our annual resident paper competition focuses on aspects of the mood disorders/BPD spectrum. Congratulations to Dr Salem and colleagues on their outstanding paper entitled “Borderline personality features in bipolar inpatients: impact on course and machine learning model use to predict rapid readmission.” In this study, the authors examined length of inpatient stay and patterns of readmission in patients with bipolar disorder who also had either BPD or BPD features. Interestingly, they found that patients with bipolar disorder with more BPD features were more likely to have depressive than manic symptoms, were less likely to report or demonstrate psychotic symptoms, and had shorter lengths of stay. Innovatively, the authors also examined a “machine learning” model to evaluate their patients, which suggested that the presence of certain features of BPD might predict which patients would be more likely to have complicated courses and might need rapid readmission.

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