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BORDERLINE
PERSONALITY DISORDER
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Should
BPD be on AXIS I?
Understanding the Issue
By ROGER PEELE, MD |
Summary
of Debate with Roger Peele, MD & John Oldham, MD
2003 American Psychiatric Association Annual Meeting,
San Francisco, California
 One
of the major issues the Treatment and Research Advancements National
Association for Personality Disorder (TARA NAPD) has brought to
the attention of consumers, families, advocates, clinicians, researchers,
and academics is the unfortunate segregation of “personality”
disorders from virtually all other psychiatric disorders by its
placement on Axis II. Segregating people with personality disorders
onto Axis II harms them clinically and economically while thwarting
the development of new research and dissemination of knowledge.
It gives managed care companies an excuse for withholding payments
to persons with personality disorders. It also encourages misdiagnosis
as clinicians often prefer their patients receive insurance coverage
rather than an accurate diagnosis. This leads to the frequent
practice by clinicians of diagnosing patients with Borderline
Personality Disorder or Personality Disorder as suffering with
Depression or Bipolar Disorder. When advocates ask for increases
in treatment facilities for Personality Disorders in the community,
they are often denied because it appears that a sufficient number
of cases of personality disorders, especially BPD, to justify
increased treatment funding do not exist. The
cases are certainly there but are hidden due to the misguided
general practice of using other diagnoses to guarantee coverage
by managed care companies.
Summary
of the rational leading to this segregation, the consequences
of this segregation and the effort we are making to rectify this
harmful classification.
The
American Psychiatric Association (APA) developed the Diagnostic
and Statistical Manual as a means to classify or categorize psychiatric
disorders. An axial system for categorizing or classifying psychiatric
disorders did not exist until 1980 when the Axis I, Axis II axial
system was made part of the third edition of the Diagnostic and
Statistical Manual [DSM-III] of the APA. Subsequent DSM’s preserved
this multiaxial system of classification. {DSM-IIIR [1987], DSM-IV
[1994], and DSM-IV-TR [2000]}.
What
was the reason for this segregation of personality disorders?
It was devised to ensure “that consideration is given to the possible
presence of disorders that are frequently overlooked when attention
is directed to the usually more florid Axis I disorder.” In DSM-IV,
only personality disorders and mental retardation are segregated
onto Axis II. All other psychiatric disorders are on Axis I. [Axis
III includes physical disorders, Axis IV includes lists of stresses,
and Axis V identifies the person’s functional level.] This concept
was preserved in DSM-IIIR and DSM-IV. DSM-IV, however, stated
that there was no fundamental difference between Axis I and II
disorders, that they were only being segregated so that they would
“not be overlooked.”
The
multiaxial system was well accepted when it first came out in
the 1980’s. By the end of that decade, I felt that the multiaxial
system was a mistake and, while a member of the DSM-IV Task Force,
made a motion to it. While this motion failed, the Task Force
did agree to include a notation in DSM-IV that stated “a
non-axial system was OK” [DSM-IV-TR. Page 37]. Although
a majority of private psychiatrists probably use a non-axial system,
our one-page “victory” has not changed the attitudes or public
policies based on the multiaxial system.
The
question remains, has the segregation of personality disorders
helped personality disorders to “not be overlooked” among researchers
and clinicians? The opposite seems to be the case. Valerie Porr,
MA, President /Founder of the TARA NAPD, discovered through a
Freedom of Information Request, that the National Institute of
Mental Health funding for the year 2000 for research amounted
to one half of one percent for borderline personality disorder.
Blushfield and Intoccia, 2000, in an article in the American Journal
of Psychiatry: “Contrary to the authors' prediction, the growth
of the literature on personality disorders was slower after the
publication of DSM-III in 1980 than it was before that date,”
that is slower after being segregated.
Restated,
segregation is a misguided way to become recognized. TARA NAPD
has led the way on asking the APA to integrate these patients,
having sent the APA thousands of forceful letters and e-mails
and brought petitions to a series of APA Presidents. Although
some APA officials privately agree with TARA NAPD’s position on
this issue, to date the APA has not officially agreed to the change.
Why
can’t the American Psychiatric Association [APA] develop a means
to quickly integrate these patients onto Axis I with all other
psychiatric disorders? The DSM timetable seems to be the problem.
DSM-V is not due to be published until approximately 2011. It
is rare for the APA to make a substantial change in the DSM between
editions. Despite the fact that many psychiatrists within the
APA have asked that we act now and not postpone integration for
a decade, our efforts have not yet met with success. The APA
currently has a committee exploring this issue however a decision
before publication of the DSM-V will be difficult for the APA
to reach.
An
outside development might increase our chances for a quicker decision.
The United States now uses an outdated version of the International
Classification of Diseases – 9 [ICD-9]. ICD - 10 was published
a decade ago and is used in many countries. Switching from ICD-9
to ICD-10 would cost government and private industry in this country
many millions of dollars, probably accounting for their reluctance
to do so. If the Federal Department of Health and Human Services
decided to switch to ICD – 10, we would likely see a new DSM much
sooner than 2011, creating the opportunity for a quicker decision
to remove this obstacle to treatment and to integrate people with
personality disorders into the mainstream of psychiatric treatment.
In
May 2003 at the APA Annual Meeting, I debated Dr. John Oldham
on the Axis placement of Personality Disorders. Robert Spitzer,
MD, a key leader in the DSM-IV Task Force, publicly announced
that he had changed his mind, reversing his opposition to moving
personality disorders to Axis I and now agreed with our position
for change. Subsequently, the American Association for Researchers
on Personality Disorder has taken up the debate. The issue will
also be debated at the upcoming October 9-12, 2003 meeting of
the International Society for the Study of Personality Disorders,
where Valerie Porr will surely make a strong case for moving Personality
Disorders to Axis I.
No
one thinks that DSM-V will continue this untoward situation, but
obtaining an earlier decision remains a challenge for TARA NAPD
members and the rest of us who support this change.
Roger Peele, MD, LDFAPA
Chief Psychiatrist, Montgomery County, Maryland |
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