Effects of Comorbid BPD and MDD on Personality Disorders

(Part 2 of 3)

Comorbid bipolar disorder or major depressive disorder is high risk and affects personality disorder treatment, says James A. Jenkins, MD, staff psychiatrist, Emerson Hospital, Concord, Massachusetts. In this video, Jenkins also talks with Psych Congress Network's Senior Digital Managing Editor Heather Flint, about the common misconception that narcissistic personality disorder and borderline personality disorder (BPD) are major mood disorders.

In the upcoming part 3, Dr Jenkins, who recently gave a session titled "Narcissistic personality disorder: where we are and where we are going" at Psych Congress 2021 in San Antonio, Texas, explores the impact of substance use disorders and tips for clinicians who are diagnosing these disorders.

In the previous part 1, Dr Jenkins explains the differences between narcissistic personality disorders and BPD and how these 2 disorders often get misdiagnosed as bipolar disorder despite a lack of evidence to support the diagnosis.

Read the transcript:

Heather 

I hear you saying diagnoses and not mood disorder. Is that a common misconception and why do you think that is?

Dr James A Jenkins:  It is. I think it has to do a little bit with how we're trained as psychiatrists. For many of our psychiatric diagnoses, we use a method called categorical diagnoses. We have a list of symptoms, and we look to see how many of those symptoms a person has. If they hit a certain threshold, they're given the diagnosis.

Whereas for things that are much more apparent that they're on some spectrum, something like personality. We all have a personality. We all have certain traits and aspects of personality that are on a continuum somewhere. I may fall a little bit higher on neurotic side.

The question is, how do we know whether that is a disorder or not? It gets into the question of state versus trait. Personality and understanding personality has a lot to do with understanding what a person's underlying traits are and their continuous enduring patterns in a person's emotional response or thoughts or behaviors, regardless of situation.

State, on the other hand, is a deviation. For most of the mood disorders, the impairment and the distress comes because there is a state change. There is a change from a baseline to a new state, and that new state will last for a period of time. Then, even with or without treatments, they'll come out of that. That's how mood disorders work.

For personality disorders, it's trait-based. These are abnormal functionings. They're deeply ingrained, and they're persistent. They're across multiple different domains. They're rather inflexible. They tend to not change over time.

It's really important to understand the difference, also. We have many good medications for treating mood disorders. No medications to treat any of the personality disorders. There's something about that difference between what's a state and what's a trait that has an impact, at least, on pharmacologic interventions.

Flint:  I thank you. I appreciate you taking the time to explain that because it is a common misconception. Even the research out there, people talking about it, it does get classified incorrectly. It's nice to actually get a breakdown of what that looks like.

Dr Jenkins:  It doesn't help that 80-90% of people who have BPD also have a mood disorder. This is what's really hard about this group of people is organizing a treatment where someone has depression, substance abuse, trauma, a personality disorder.

This is my bread and butter, but it can be really tricky. What do you go after first? How do you separate these things? How do you prioritize? That's hard for a lot of clinicians, especially under the time constraints that most people have.

Flint:  Talking about the fact that so many people are both having a mood disorder and BPD, what mood disorders are the most comorbid?

Dr Jenkins:  I can't say for NPD because I don't think we have good data on that. For BPD, we have, I think, it's somewhere between 80-90% will meet criteria for a major depressive disorder, about 20% of people with BPD will meet criteria for bipolar disorder, and 10% of people with BPD will meet criteria for bipolar 1.

Bipolar 1, of course, is when people have manic episodes. That bipolar 1 plus a personality disorder, it's a combination that they can present a lot of challenges in treatment, and it's quite high risk actually. You really do want to balance paying attention to the personality disorder, but also not neglecting a potential mood disorder that might be there.

Flint:  Would there be any interactions for the treatments that people would get for their major mood disorder and then borderline personality disorder? Are there medications that could be contraindicated between the 2 disorders because you did mention that there are treatments for BPD? I was wondering if you want to go into that.

Dr Jenkins:  The treatments for BPD are all evidence-based psychotherapies. We don't have any medications that are FDA-approved for the treatment of borderline personality disorder. For narcissistic personality disorder, we don't even have evidence-based psychotherapies.

We're in the process of learning how to adapt the evidence-based psychotherapies that have been helpful for patients with BPD to account for the unique challenges that patients with NPD have, but we're not quite there yet.

I will say that the one class of medications that I see time and time and time again, that individuals with personality disorders get placed on, and it's really not a good idea, are benzodiazepines.

These are medications that they acutely decrease anxiety, and these people, it's like they're on fire. If they have BPD or NPD, they're suffering terribly, but giving them a medication, which disinhibits them and worsens impulse control and has addictive potential and can dramatically shift their mood states is not the best idea.

Flint:  You do find that maybe folks with these personality disorders do have substance use issues, as well as are one of the higher, more pronounced comorbidities that you find?

Dr Jenkins:  Yeah, they do. Even without a substance use history, prescribing things like benzodiazepines dramatically increases the risk of completed suicide. It worsens the behavioral manifestations of a personality disorder because whatever little control that the person has...It's like you're getting rid of the brakes on a car that's heading downhill. It's just not a good idea.

Flint:  It's a great analogy to give people a big perspective of what that looks like.

James A Jenkins, MD, spent his residency gaining expertise in a variety of psychotherapies and milieu treatments for people with complex psychiatric diagnoses and co-occurring personality disorder diagnoses. His advanced training includes certification and expert supervision in Dialectical Behavior Therapy, Mentalization-Based Therapy, and Good Psychiatric Management. Dr Jenkins is a former medical director of the McLean Hospital Cambridge Residence, a residential program for transitional age youths with emerging personality disorder diagnosis who are preparing to exit the mental health system. He was also a staff psychiatrist at the McLean Hospital Gunderson Residence, an intensive residential treatment program for adult women with complex personality disorder diagnoses and refractory psychiatric symptoms. Dr Jenkins is interested in the integration of medication management, milieu treatment, and evidence-based psychotherapies to provide the most comprehensive treatment for those whom prior treatments have failed. Additionally, he is interested in increasing accessibility of these treatments and their implementation in less resourced or traditional environments. Recently he joined the psychiatry department at MassGeneral Hospital and is working to help translate the principles of Dr John Gunderson's Good Psychiatric Management to the consultation-liason service and also in their psychiatric emergency room. Dr Jenkins is an active member of Alpha Omega Alpha and Gold Humanism Honor Society.