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?
