I am not clear why discussions about Axis 2 are such a faux pas on the internet as a whole. Any diagnosis can be used pejoratively, that I understand, and avoid. As an example, clinicians have used the term ‘Borderline’ with much less than therapeutic intent throughout my career. But, over the few years I have been reading and commenting at mental health sites, the frank hostility and terse rebuttals I have read as both observer and discusser regarding such matters, well, it has only made me wonder if the internet is an unwilling accomplice to this perceived unspoken vice.
My problem is that managed care set the tone for this attitude in the mid 1990’s by declaring Axis 2 diagnoses devoid of reimbursement. I have since watched the profession come to ignore it as any role to symptoms and struggles in patients. What?! There is no quantifiable percentage of patients coming into offices who present with primary Axis 2 causes to problems? We have to potentially mislabel the patient with an Axis 1 mood/anxiety/(perish forbid a primary) thought disorder just to validate care?! And then risk mistreating the patient?!?
Here is just one opinion in the sea of mental health care: prescribing medication for people who are primarily characterological leads to complications; if not the risk of abuse/misuse of meds, at least a negative reaction I have seen repeatedly in my travels with patients that appear to have prominent Axis 2 features. Colleagues and patients have argued with me since I first formulated this hypothesis years ago, but think about it. What is rule #1 in psychiatry when a patient fails numerous medication trials for hypothesized diagnosis X? Maybe the diagnosis does not fit the treatment plan?
Yeah, it could be vice versa as well, but really, colleagues out there willing to read this opinion, do you honestly think Bipolar Disorder has been under diagnosed by 400-800% up to the 1990’s? Do mood swings equal manic depression until proven otherwise, just figure out which type, that DSM 5 will set at 5 types? 10?
You hear hoof beats, why are you looking for Atypical Bipolar diagnostic zebras, when a good history and provisional diagnosis of Mood Disorder NOS on Day 1 might reveal comorbid if not primary Axis 2 factors Day later in follow up? Oh, an Axis 2 diagnosis could equally be seen as a striped horse, but, why has the psychiatric literature basically ignored Axis 2 for the past 15 years? Coincidence? Or, Big Pharma can’t prescribe for that?
Another rule in my work: NEVER diagnose Axis 2 on a first visit with a patient! Why? Because no psychiatrist/psychologist is that good to know a patient personality to label it as a disorder from a first evaluation visit. How can a professional say otherwise, unless privy to collateral, unrefutable information? And even then, formulate your own opinion by working with the patient for some time.
Look at the diagnostic criteria for Personality Disorder in general, and it is about 4 criteria of A. inner experience and behavior that deviates markedly from the expectations of the individual’s culture regarding cognition/affectivity/interpersonal functioning/impulse control, B. is inflexible and pervasive across a broad range of personal and social situations, then C. leads to clinically significant distress or impairment in social occupational, or other important areas of functioning, and D. is stable and of long duration, with onset traced back at least to adolescence or early adulthood. “an enduring pattern…” is mentioned in all but letter D (except the last 2 rule outs on the list), which echoes it with “…pattern is stable and of long duration..” And as with any diagnostic category, rule outs of primary factors like medical disorders, substance abuse, and here for Axis 2, a true Axis 1 Disorder that trumps the symptoms of personality disorder first. If DSM 5 is going to continue with the application of Axis 1-5, umm, Axis 2 seems to be that second part to the diagnostic process. Doesn’t that mean consideration, even if not on day 1?
My point to this post is simple, for me at least: why are we ignoring the role of personality in chronic struggles and distress, usually already having failed several treatment interventions? PCPs won’t pick up on this as a factor, and god knows how complicated the presentation becomes with throwing meds at the patient like multi dodge ball at the gym in school.
I don’t get it, why is managed care and Big Pharma getting away with telling us how to diagnose and treat? Oh Yeah, $ !!! You, the readers out there, you happy with this?
(Editor note: still learning how to use the blog programs, so my intent to print out the px of DSM 4TR’s list of Personality DIsorder did not work. Give me time please.)