Where Personality Disorder Diagnosis Management is Still Lagging, with Katharine Nelson, MD

Katharine "Kaz" Nelson, MD

Credit: LinkedIn

A recent guideline published by the American Psychiatric Association (APA) provided a 20-year update on the standards for quality-of-care and treatment outcomes in patients with borderline personality disorder (BPD).

The guideline, penned by a team of a dozen specialists, tackled the heterogenous, persistent condition that which lacks a robust armamentarium of treatment options, and requires a refined approach to navigating patient needs by psychiatrists.

During APA 2024 in New York, NY, this week, authors and advocates of the updated guidelines spoke on the overarching need for a modernized, evidence-applied approach to managing BPD. One such author was Katharine “Kaz” Nelson, MD, who spoke with HCPLive on both the guidelines, as well as her session on clinical updates in both diagnosing and treating personality disorders.

HCPLive: What do you believe are our major areas of concern with regard to the current state of personality disorder diagnosis and care?

Nelson: My perspective is from the perspective of a clinical educator providing care to people with borderline personality disorder and other personality disorders at the interface of the clinical space, and as we've trained our next generation. So, I'm grateful to all the efforts of the APA to move the dial forward in how we do that. But really, historically, we're also balancing a challenge where the known science that is developed has a slow translation to the clinical space. And we're still sort of left with practices that are a couple of decades old in the clinical space.

So, where I'm concerned is just really how do we even integrate the science that is known currently, into best practices? There's a lot out there that's essentially outdated. I was a member of this writing group for the new treatment guidelines, and that's a very exciting development, because the previous guidelines were a couple decades old. But sadly, the amount of scientific developments between then and now has not kept pace with other serious disorders. So, the guidelines provide an overview of the science but we're really still trying to just get the basics right.

There still exists a lot of discrimination against patients with personality disorders in the clinical space.

So really, the first step—and the treatment guidelines go over this a little bit—is interfacing with patients with personality disorders, in the same manner and with the same compassion that you would approach any other patients in your clinic, and leaving behind some of the outdated notions that these patients can't improve, that they are treatment resistant, or that you won't be able to make progress. We need to leave those notions behind, because that's really not supported by our existing studies in the field.

HCPLive: You mentioned a lag in applying science to practice, which I think is unfortunately a consistent theme that we've encountered in a lot of the conversations we've had not just in personality disorders, but mood and behavioral disorders this weekend.

What specifically would you highlight as a clear example of that which is holding back advancement to more refined treatment and understanding for patients?

Nelson: One of the major developments in the personality disorder space, particularly as pertains to borderline personality disorder, is that there are evidence-based treatments, and there are documented cases and instances of people improving with these conditions. Meanwhile, we're left with guidelines that still say that these disorders are relatively stable and unchanging over time. Those 2 concepts are in conflict with one another, but as we teach medical students and residents in psychiatry, we're still teaching them according to this criteria that says these disorders are relatively stable and unchanging. Well, if that's the message that we're teaching our trainees in the early stages, they're not going to be open and receptive to paradigms that really approach these as treatable conditions.

HCPLive: What may some of those paradigms in personality disorder be that we should better implement into medical student and resident education?

Nelson: One of the problems that we're seeing essentially is that because of the discomfort associated with diagnosing and discussing the disorder itself, that sometimes people will avoid that conversation altogether and instead focus on other symptoms of the personality disorders, such as the depression and anxiety symptoms that can sometimes be part of it. Well, that leaves patients unfortunately with diagnoses of major depressive disorder or generalized anxiety disorder. And the treatments for those are different than the treatment for borderline personality disorder.

If the way you've been trained leads you to avoid discussing the BPD diagnosis and proceeding with BPD-specific treatments, you're going to be left with imprecise diagnoses that are, by definition, not responsive to the treatments for things like major depressive disorder, generalized anxiety disorder. And then you lead into a pathway of the patient feeling like they are a treatment failure at that point; they're a failed depression patient, rather than somebody who has not received a precise diagnosis and a precise treatment.

HCPLive: What strategies would you point to as a clear opportunity that we could be pursuing more aggressively for personality disorders?

Nelson: If you have a patient with many of the symptoms of borderline personality disorder, but they've never heard that term before or they've never had the opportunity to review with you the criteria for borderline personality disorder, it's worth doing that. It's worth getting out the existing criteria and going through them—seeing if it resonates with the patient, looking over their story, seeing if it fits. If it does, that can be really illuminating as to some of the challenges the patient may have experienced. It can explain why maybe some of their symptoms and experiences are different from people with perhaps just major depressive disorder or bipolar disorder, and can lead to a lot of insight and empowerment to the patient where they can actually receive education about their diagnosis, pursue disorder-specific treatments, and even education alone that helps with the management of the disorder.

So, I feel that we should not be serving as a gatekeeper from this diagnosis, and establish strategies to manage the diagnosis. We need to let the patients into the conversation directly.