What's in a name? Understanding Borderline Personality Disorder and its links with other disorders.

Professor Jayashri Kulkarni
Director of Monash Alfred
Psychiatry research centre

“People are not as scared of something when they begin to understand it.”

by Matt Jane

A team of Monash University researchers and clinicians are at the forefront of taking important steps to understanding and treating a frequently misdiagnosed mental illness.

Borderline Personality Disorder (BPD) is thought to severely affect 6% of the population and a further 20% of people sitting on the trauma spectrum who do not present to hospital. Due to the lack of understanding of the disorder, many individuals are often misdiagnosed and therefore do not receive adequate treatment. Unfortunately, like so many other mental illnesses, BDP can be an extremely stigmatizing diagnosis. The name ‘Border Personality Disorder’ often carries negative connotations and can cause harm to those who suffer from it.



Thanks to field leaders such as Monash Professor Jayashri Kulkarni, there is a significant push to change the name from Borderline Personality Disorder to Complex Trauma Disorder (CDT).

To try and understand the harm caused by the current label and gain greater insight into the condition, it is necessary to break down the current language and unpack the reasons for the change.

There are two key components when looking at the terminology ‘Borderline Personality Disorder’ and why it is harmful: first, the choice of language used from a patient’s perspective; and second, how clinicians view patients with BPD.
Professor Kulkarni highlights the dangers of the current name, citing how both aspects cause a feeling of invalidation for the patient.

“The word ‘borderline’ is seen to be undermining.  The idea of sitting on the border of having something and being unable to make your mind up is extremely invalidating to patients.

“The second aspect of the name, ‘Personality Disorder’, is just as harmful. If you think about it, what makes up the essence of somebody? It’s their personality.

“If you tell a patient that their personality is disordered, it is often interpreted as ‘I’m completely stuffed, there’s nothing you can do for me - or worse - that I’m a manipulative person who is just trying to get what I can and there isn’t a real mental illness’. So again it brings back the invalidation.”

However, it is not only patients who are made uneasy by the BPD label. Due to the complicated nature of the disorder, there is also a sort of therapeutic nihilism among clinicians who are faced with BPD patients.

“We have antipsychotic drugs to treat people with psychosis, we have anti-depressant drugs to treat people with depression, we have antianxiety drugs but we don’t have an anti-BPD drug.”

Clearly evident is the significance trauma has to play in the development of this disorder. In about 85% of cases, early life trauma is present. This includes emotional neglect, emotional abuse, physical abuse or sexual abuse. Many patients sit somewhere on the trauma spectrum.

Professor Kulkarni stresses the importance of continuing to validate and empower people.  Changing the name is just one step in the right direction.

However, it’s not just Professor Kulkarni’s activism and clinical work that continues to see her excel in her field. Recently Professor Kulkarni reviewed nine studies looking at the links between Polycystic Ovary Syndrome (PCOS) and women with BPD.

The review of others’ work and the continual study within her clinic has led to the hypothesis that trauma leads to a cortisol increase or dysregulation.

This altering of the hypothalamic/pituitary/adrenal (HPA) axis has a flow-on effect to the hypothalamic/pituitary/gonadal (HPG) axis. This determines the circulating levels of the sex hormones, oestrogen, progesterone and testosterone.

In these women, the balance between oestrogen and testosterone is altered and leads to an increase in testosterone levels. This imbalance may be seen in women with polycystic ovarian syndrome. It may also present in other cases of infertility, obesity, premenstrual depression and sleep disturbance, amongst other disorders. This altered hormonal system may also affect neurocircuitry that changes with the stress response.

Although the diagnosis of BPD can be stigmatizing, Professor Kulkarni has found that doing further research into the BPD-PCOS link has been possible due to many women establishing the link themselves.

“The populations we are dealing with are keenly interested and easy to work with, as many of these women have made this intuitive connection. Women tell us ‘I feel worse in the week prior to the menstrual period’. And in the 45-47 age group, they feel much worse in the premenopausal stage. The women we are working with have already made their own observations, so in a sense when we study them, we are validating something they already know“.

Despite there being a willingness for patients to undergo tests to see if the two conditions, PCOS and BPD, are intrinsically linked, the unfamiliarity surrounding BPD means that many individuals are often misdiagnosed.  Thus the correlation between the two may still not be accurately drawn.

Professor Kulkarni is seeking to work with her counterparts within the University and beyond. With a PCOS clinic at Monash Health, there is a platform to test individuals for both disorders, a system that is reciprocated in the psychiatric clinic. By providing empirical evidence the correlation can be drawn and begin to circulate in the wider medical sphere.


For further information about Professor Kulkarni's work please see: http://maprc.org.au/




REFERENCES

Tan R YM, Grigg J, Kulkarni J. Borderline personality disorder and polycystic ovary syndrome: A review of the literature. Australian & New Zealand Journal of Psychiatry, 2017 September 9. doi: 10.1177/0004867417730650.