As a couple of you may already know, I am working in Marsha Linehan’s lab doing clinical assessments for one of her grad students. Marsha Linehan, for those of you who are unfamiliar, combined traditional cognitive behavior therapy with skills training in emotion regulation and mindfulness techniques to create a highly effective therapy for people with Borderline Personality Disorder (BPD) called Dialectical Behavior Therapy (DBT). The study I am assessing for is trying to determine the effectiveness of DBT in treating Axis I disorders (specifically anxiety and depression) in people without BPD. A couple weeks ago, I had the distinct pleasure of doing an assessment on a man (whom we shall call Ted) who has complete Agenesis of the Corpus Callosum (ACC). This means, ladies and gents, that he was born completely without a corpus callosum. Woah. Curious as to how this would affect his behavior, I did a little research before seeing him. With regards to emotion, it seems that people with ACC have difficulties in processing faces, and as a result, frequently get misdiagnosed with Asperger’s or Autism. Also common are cognitive and motor disabilities.
Based on what I had read about ACC, I was expecting to meet someone who was visibly and/or obviously disabled in some way. I was surprised to find that I was shaking hands with a seemingly normal, albeit slightly awkward man. I was even more surprised to find, as the interview commenced, that Ted turned out to be one of most self-aware clients I’ve observed thus far. He knew exactly what his faults and inconsistencies were and had no trouble answering questions about his emotions and behaviors very precisely (typical borderline patients have poor insight into which emotions they're feeling and even poorer control over them). He discussed his “temper tantrums” at length, which had even gotten him arrested on domestic violence charges. He attributed these anger outbursts in part to his inability to recognize emotions in faces, telling me that he flat-out fails tests of facial emotion recognition. He has effectively had to actively learn the skills that most of us were born knowing intuitively—the ability to know that a smile signifies happiness or that a furrowed brow indicates concern. Ted had an uncanny ability to go over a situation in hindsight, but in the emotion-laden moment could not muster his intellectual knowledge of facial emotions enough to put it to use.
Ted also spoke of thinking completely in binaries, saying quite humorously that to him, a grey area is really just more black and white. Though he can barely add and subtract (he claims that an inability to do math is a commonality among people with ACC), he managed to struggle through enough math classes to allow him to become a computer programmer (where he can safely and happily think in binaries). Unfortunately, he met criteria for BPD and so did not qualify for the study I'm assessing for, despite the fact that the treatment seems perfect for him.
It bothered me quite a bit to have to diagnose this client with a personality disorder. Ted has an identifiable structural deficiency in his brain, so why is he being diagnosed with a disorder that uses a behavioral diagnosis and has nothing to say about the underlying biological mechanisms? This seems to be a problem with many DSM diagnostic criteria, in that a single diagnosis can be explained by a multitude of social and biological mechanisms. Is there a difference, then, between someone like Ted, with whom you can point on a brain scan to the root of his emotional difficulties, and someone who has suffered through childhood sexual abuse (typical of borderline patients) and as a result has developed problematic emotional regulation skills? Should we look at these two types of cases differently in terms of diagnosis? What about treatment?
As far as I know, the best and most accurate way to diagnose BPD is with a behavioral assessment. Why use something else if this is more precise? Even positing that BPD has a unique neural profile associated with it, there is a question of appropriate scope. As Alva Noe, a philosopher of mind from Berkeley says, you would not want to view nerve firings in someone's muscles to best understand running. Scope, as it applies to neurology and behavior, is an issue psychology has to deal with and has done a poor job so far I believe. As another philosopher I was reading said, biologists would not want to study all processes through the lens of quantum mechanics. It would be too minimizing. If they did, they would never have discovered DNA and RNA, the languages of evolution. Similarly, I think that neural science can often be a red herring for psychology: it is too minimal in a direction that loses predictive power and explanation. Furthermore, treatments are often based on behavioral or cognitive adjustment. As of yet, it is very difficult to know how exactly to alter neural firing. Understanding what is going on in the brain is useful, but should not replace all other levels of inquiry because it is somehow more "primary" or important.
ReplyDeleteColin, while I understand your point, my worry is more about pragmatism. I agree that the mind is not just the brain, and that was not my argument. My question is if we are missing something by just looking at surface behaviors, and self-report behavior at that. Insight, for example, is a key feature of these reports that can make all the difference in differentiating diagnoses. In addition, it has been my experience that many of the "threshold" behaviors for BPD are purely the result of circumstance. Turbulent relationships in which the person's feelings go back and forth between love and hate is one of the diagnostic criteria, but some of the relationships that are above that diagnostic threshold seem perfectly reasonable given the circumstances; who would not hate a family member that sexually abused them for years? But as these things are often kept under the radar, and if the parent were to act "normal" most of the time, it seems reasonable that the child would both love and hate the parent. Yet this would qualify for a BPD behavior. To me, this seems wildly different than someone who was born without a connection between brain hemispheres. It is absolutely fascinating that a treatment such as DBT may be effective for both of these cases, but it is also a therapy that casts its net very wide and thus is bound to capture many aspects and types of "maladaptive emotion regulation." Perhaps this is all just stemming from my own personal reluctance to diagnose someone with a personality disorder who has just been dealt all the wrong cards and is acting the only way they know how. In that case, my worry is about the resulting stigma of the diagnostic process and of the diagnosis in general. A personality disorder is not something that goes away, like an axis I disorder, and something just doesn't feel right about telling someone that their personality needs to be treated. Unfortunately, it's also about the only way to get help in the current mental health system. But you're definitely right--brain interacting with environment is exactly what is happening in both cases; the ACC guy adapts to make up for his lack of hemispheric connectivity, and the abused person adapts to deal with high levels of environmental stress, but each needs help in altering these adaptive strategies to be more in line with the norms of social interaction. So perhaps they really aren't so different after all.
ReplyDeleteThat being said, you mention that the only way to diagnose BPD is behaviorally. That is true, but only because that's all BPD is; it is merely a set of behaviors that captures what the creators of the DSM think to be similarly dis-ordered. There is no BPD outside of those behaviors, which is what I believe is lacking. I'm not trying to say that we should be trying to find a biomarker or pathway or gene or whatever that is BPD (for the very reasons you stated above). I just think that there's more to the story than what the DSM has to offer us. Adding dimensionality to our knowledge of these multidimensional behaviors may aid in treatment (though it seems to be happening the other way around).
You are certainly right. It is a tricky subject and I think unfortunate that diagnosis is so prominent in the area of mental health. As far as brain research goes, it is very important and we should always use it in conjunction with other epistemological techniques, such as behavioral and physiological research. My fear is a broader one than your post covers, and it is primarily that psychology has been trending in a direction, due to some combination of funding and insecurity, of only studying the brain and ignoring everything else.
ReplyDelete^make that funded insecurity and insecure funding.
ReplyDelete