As a research/diagnostic interviewer, it’s my job to determine if a patient’s symptoms are severe enough to be labeled “clinically significant” and thus to warrant a psychiatric diagnosis. This is much easier said than done. 

Diagnosing clinical syndromes, such as depression or anxiety, is much more straightforward than diagnosing personality disorders. To meet criteria for a personality disorder diagnosis, the patient must have several traits characteristic of that particular disorder – a whole pattern of traits. Thus, diagnosing personality disorders is a two-step process. The first step is to determine if the patient meets the threshold for various individual traits. The second step is to determine if the patient has a sufficient number of traits within each category to qualify for the diagnosis.

Common personality disorder traits    

Recently, I have been entering information about personality disorder traits that patients have met into a database, and I have noticed several personality disorder traits that are the most common among patients at The Menninger Clinic. One is “rigidity or stubbornness,” which is one of the traits considered in the diagnosis of obsessive-compulsive personality disorder. According to the current data, more than a third of patients meet the criteria for the “stubbornness” trait. The Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) gives no guidelines regarding the prevalence of this trait. Based on our findings, a substantial minority of patients either believe they are stubborn or have been told by others that they are stubborn. This begs the question: Exactly how stubborn does someone have to be to meet the criteria for the stubbornness trait? 

The Merriam-Webster Dictionary defines stubborn as “unreasonably and perversely unyielding.” The DSM-IV description is a tad more in-depth. Persons who are stubborn are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals meticulously plan ahead and are unwilling to consider changes in plans. Such persons are wrapped up in their own perspective and have difficulty acknowledging the viewpoints of others. Their rigidity frustrates friends and colleagues. Furthermore, persons with this trait might recognize that it is in their best interest to compromise, but they stubbornly (for lack of a better term) refuse, arguing that it is “the principle of the thing.” The diagnostic trait of stubbornness or rigidity means more than simply being “unreasonably and perversely unyielding.”

Borderline personality disorder

Another common trait I observe is “chronic feelings of emptiness,” one of the traits of borderline personality disorder. In fact, one third of patients have this trait. Merriam-Webster defines empty as “having no purpose or result” or “marked by the absence of human life, activity or comfort.” The DSM-IV adds little to this definition beyond the point that people who suffer from chronic feelings of emptiness get easily bored and are continually seeking something to do. “Emptiness” is left to the eye of the beholder.

The DSM-IV offers some explication of stubbornness and emptiness, but the decision is left to the interviewer as to whether a patient indeed has the trait at a clinically significant level. There is no clear line distinguishing normal from clinically significant levels of a trait. This is a judgment call for the interviewer, taking into account the degree of functional impairment that the trait causes. For example, a person’s stubbornness may be so extreme that it inhibits him or her from maintaining mutually satisfying relationships. Similarly, persons may feel so empty inside that nothing provides them with joy. For a trait to be functionally impairing, there must be an enduring and pervasive influence on the person’s behavior or attitude. It is important to note that traits are only a part of the constellation of the associated personality disorder.

Traits vs. clusters

Moreover, the distress or impairment is not based on any simple trait but rather several traits that make up the disorder. For example, other traits of obsessive-compulsive personality disorder include preoccupation with details, perfectionism, excessive devotion to work, unwillingness to delegate tasks and so forth. We must also keep in mind that individual traits (stubbornness) and clusters (obsessive-compulsive personality disorder) can be beneficial in moderation. Having too little stubbornness might lead to being too easily swayed or influenced.

Other obsessive-compulsive characteristics such as a need for order, structure and organization can certainly be helpful. Think of Steve Jobs: He was notorious for his need to have things exactly right, and he was tremendously successful because of it. Once again, it all comes down to the level of clinical functional impairment that a trait or cluster causes. In personality disorders, this occurs mainly in the context of relationships. As I have illustrated, the diagnostic manual goes beyond the textbook definition found in the dictionary.

More generally, there is an inherent difficulty in drawing a bright line when all traits come in degrees. It is important to avoid overdiagnosing. When we overdiagnose we risk stigmatizing the patient. When given the diagnosis of a personality disorder, patients are liable to misinterpret it, thinking they are being told they have a “bad personality.” Not true: The diagnosis refers to a specific problematic aspect of personality functioning, not the entire personality. A person might have a personality disorder coupled with many positive personality traits. In my work as a diagnostic interviewer, I aspire to pinpoint problems to help guide treatment. Yet treatment must be based on a full understanding of the whole person.

For the past week, the vast majority of sports media has focused on the end of the labor lockout in the National Football League. With a spate of free agency announcements, trades, signings and wage negotiations, the lockout has provided sports fans considerable drama in a short amount of time. Amid the fervor surrounding millions of dollars exchanging hands, however, one announcement stood starkly apart from the rest.

Brandon Marshall takes on borderline personality disorder

On Sunday, Miami Dolphins’ wide receiver Brandon Marshall announced in a press conference that he had been diagnosed with borderline personality disorder (BPD) earlier in the year, and he had subsequently sought treatment at McLean Hospital in Massachusetts.

The Beast and his behaviors

Marshall, 27, spoke all of 30 minutes during the press conference, describing a series of events from child abuse to a rash of arrests for various offenses that led him down a dangerous path. From driving under the influence and disorderly conduct arrests to misdemeanor battery charges, there was enough weight in the court of public opinion for most to consider Marshall aptly deserving of his nickname “The Beast.”

Things came to a head this April when Marshall was hospitalized after his wife, Michi Nogami-Marshall, reportedly stabbed him in the stomach (Marshall filed charges and then dropped them). And while Marshall had already been conducting phone talks with clinicians at McLean before the altercation, he cites this incident (where he admittedly tried to trap his wife in a closet to keep her from leaving) as one of the chief precipitating factors in pushing him into treatment.

Battling stigma

After three months of treatment and therapy, Marshall knows he is not fully “healed or fixed,” but understands he now has the necessary tools for his recovery. What’s more, rather than merely publicly admitting to a BPD diagnosis, Marshall has taken on the mantle of dispelling the stigma associated with borderline personality disorder. As he said to the Miami Sun-Sentinel,

“I’ll be the face of BPD. I’ll make myself vulnerable if it saves someone’s life because I know what I went through this summer helped save mine.”

In an upcoming documentary (whose trailer is featured below), video cameras follow Marshall on his journey through treatment. His brave efforts to raise awareness of BPD, combined with a candid look inside his treatment experience, could introduce a large portion of the public to an updated perception of treatment, one that isn’t filled with stereotypes in white lab coats, caricatures in straight jackets and an endless hallway of seclusion rooms.

Now this is the kind of science I can get behind: French psychiatrists and psychologists, who are clearly using their time well and are probably not at all putting off more pressing work, have written a letter to the editor of the journal Psychiatry Research titled “Is Anakin Skywalker suffering from borderline personality disorder?” This, my friends, might be the best letter to the editor of a scholarly psychiatric journal ever. I kind of want to take back all the mean things I’ve said about the French.

While I’m sure you’ll agree this is a wonderful use of science that should be encouraged, that doesn’t mean the subject matter is a joke. Borderline personality disorder (BPD) is a serious mental illness. Individuals who have it generally exhibit unstable relationships, a negative sense of self, inconsistent moods, a high degree of impulsiveness and a sometimes crippling fear of abandonment.

Eric Bui, a psychiatrist from Toulouse University Hospital in France, watched Episodes II and III of the prequel trilogy and realized that Anakin was a good candidate for the diagnosis. According to LiveScience,

Skywalker hit six out of the nine borderline personality disorder criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. He only needed to meet five criteria to qualify as suffering from the disorder.

For instance, the future Darth Vader showed both impulsivity and anger management issues as an overexcited, lovelorn Jedi. He went back and forth between idealizing and devaluing Jedi mentors, such as a humorless young Obi-Wan Kenobi.

Abandonment issues also surfaced. Skywalker had a permanent fear of losing his wife, Padme Amidala, and he went so far as to betray his Jedi mentors and companions to try to prevent her death.

“From what we know of the future DSM-V, Anakin is a ‘good’ to ‘very good’ match to the future BPD,” Bui said.

Darth Vader meets Hello Kitty

Bui analyzes more of the films if you follow the above link, and it’s a pretty light read if you don’t want to get all science-y. I like to think that Anakin’s wild mood swings are probably responsible for this version of the Darth Vader costume.

I find myself torn on this subject. On the one hand, it’s comforting to note that Bui thinks psychotherapy would’ve really helped in this case, and probably would have stopped Anakin from turning to the Dark Side. Of course, that would mean that the original trilogy wouldn’t exist, and I don’t want to live in a world where that’s possible.

I’m looking forward to Bui and company’s next article on the effects of the prequel trilogy on the psyches of Star Wars fans. I can think of plenty of people who exhibited “both impulsivity and anger management issues” after watching the train wreck that was The Phantom Menace.

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

A colleague sent me a recent David Brooks’ op-ed from the New York Times about Alcoholics Anonymous (AA) and its founder, Bill Wilson. And like a good op-ed does, it got me thinking; specifically, it got me thinking about two things:  1) how challenging it can be to overcome an addiction, bipolar disorder, borderline personality disorder or any other mental illness, and 2) how grateful I am that Brooks used his column to highlight AA’s profound impact while acknowledging the complexities of treating addiction, despite considerable advances in brain research and the mental health field.

In the piece, Brooks says “in a culture that generally celebrates empowerment and self-esteem, A.A. begins with disempowerment.”  True enough. And it’s my guess that is partly because mental illness, including addiction, is disempowering. It robs individuals of sound judgment, energy (unless, of course, you’re someone who experiences mania), direction, focus, hope, etc.

I’d even go so far as to say that this disempowerment is the definition of “rock bottom,” a common-enough phrase these days, which in my mind can only be a place of abysmal, unadulterated loneliness. It’s no place for a loved one, or even, dare I say it, an enemy.

Rock bottom

Once in, there’s only one way out and that’s up. And the only way up is through the good strong grip–maybe physically, definitely symbolically–of another person’s hand. In all likelihood, that hand will belong to a stranger, perhaps even to one of the 1.2 million members of AA, each of whom could probably teach the rest of us a thing or two about “rock bottom.”

Which leads me to another powerful statement of Brooks:  “Individual repair is a social effort.” When AA proves successful for one of its members, that success is predicated on the idea of social effort.

This makes sense to me, just as its opposite does:  individual disrepair is a social effort, too.

Between nurture and nature we’re each shaped by things beyond our control–not always entirely, of course, but often enough. These things (childhood abuse, death of a loved one, extreme poverty, family genetics, etc.) have a great affect on us as we mature and become independent adults (or at least try to).

Sometimes the convergence of these things makes us vulnerable as adults to addiction and mental illness. No one ends up dealing with alcoholism or mental illness because they’ve been living in a vacuum; so we shouldn’t expect people to overcome these problems on their own either. And when you get right down to it, the mental health profession has always been a social endeavor between patient and clinician. I mean, Freud wasn’t analyzing imaginary patients on his couch all those years ago….

Milieu therapy

At Menninger, you hear a lot of talk about milieu therapy, which is, according to the Oxford Pocket Dictionary of Current English 2009, psychotherapy in which the patient’s social environment is controlled or manipulated with a view to preventing self-destructive behavior. It may sound like a fancy term for group therapy, but it’s far more than that.

Patients here live for weeks with one another and often see each other at their worst. Because they spend so much time together, they reap the benefit of becoming, as Brooks describes AA members, “deeply intertwined with one another–learning, sharing, suffering and mentoring one another.” They see–and feel–the importance every single member of the group has on the rest of the group. It’s pretty potent, healing stuff, and it’s the social effort of the group members that makes it possible.

I’m really glad that someone as prominent as Brooks shared some of the history of AA. He’s got a big following, and it’s not everyday that addiction finds its way into such valuable real estate as this prestigious op-ed column. It’s clear that the stigma surrounding people with addiction, particularly alcohol addiction, has decreased dramatically since AA was founded, and I think Brooks has, whether he intended to or not, whether he knows it or not, has further destigmatized addiction by devoting a column to the topic.

Now if borderline personality disorder, bipolar disorder, PTSD, schizophrenia and all the rest of diagnoses in the world of mental illness can find their versions of Bill Wilson soon, there’ll be more and more of us who will find ourselves just saying “no” to stigma. Plus, Brooks will have more great stories to tell in future columns, and I, for one, am looking forward to reading them.