Should BPD be on AXIS I? Understanding the Issue

Should BPD be on AXIS I?
Understanding the Issue

By ROGER PEELE, MD

Summary of Debate with Roger Peele, MD & John Oldham, MD
2003 American Psychiatric Association Annual Meeting,
San Francisco, California

One of the major issues the Treatment and Research Advancements National Association for Personality Disorder (TARA NAPD) has brought to the attention of consumers, families, advocates, clinicians, researchers, and academics is the unfortunate segregation of “personality” disorders from virtually all other psychiatric disorders by its placement on Axis II. Segregating people with personality disorders onto Axis II harms them clinically and economically while thwarting the development of new research and dissemination of knowledge. It gives managed care companies an excuse for withholding payments to persons with personality disorders. It also encourages misdiagnosis as clinicians often prefer their patients receive insurance coverage rather than an accurate diagnosis. This leads to the frequent practice by clinicians of diagnosing patients with Borderline Personality Disorder or Personality Disorder as suffering with Depression or Bipolar Disorder. When advocates ask for increases in treatment facilities for Personality Disorders in the community, they are often denied because it appears that a sufficient number of cases of personality disorders, especially BPD, to justify increased treatment funding do not exist. The cases are certainly there but are hidden due to the misguided general practice of using other diagnoses to guarantee coverage by managed care companies.

Summary of the rational leading to this segregation, the consequences of this segregation and the effort we are making to rectify this harmful classification.

The American Psychiatric Association (APA) developed the Diagnostic and Statistical Manual as a means to classify or categorize psychiatric disorders. An axial system for categorizing or classifying psychiatric disorders did not exist until 1980 when the Axis I, Axis II axial system was made part of the third edition of the Diagnostic and Statistical Manual [DSM-III] of the APA. Subsequent DSM’s preserved this multiaxial system of classification. {DSM-IIIR [1987], DSM-IV [1994], and DSM-IV-TR [2000]}.

What was the reason for this segregation of personality disorders? It was devised to ensure “that consideration is given to the possible presence of disorders that are frequently overlooked when attention is directed to the usually more florid Axis I disorder.” In DSM-IV, only personality disorders and mental retardation are segregated onto Axis II. All other psychiatric disorders are on Axis I. [Axis III includes physical disorders, Axis IV includes lists of stresses, and Axis V identifies the person’s functional level.] This concept was preserved in DSM-IIIR and DSM-IV. DSM-IV, however, stated that there was no fundamental difference between Axis I and II disorders, that they were only being segregated so that they would “not be overlooked.”

The multiaxial system was well accepted when it first came out in the 1980’s. By the end of that decade, I felt that the multiaxial system was a mistake and, while a member of the DSM-IV Task Force, made a motion to it. While this motion failed, the Task Force did agree to include a notation in DSM-IV that stated “a non-axial system was OK” [DSM-IV-TR. Page 37]. Although a majority of private psychiatrists probably use a non-axial system, our one-page “victory” has not changed the attitudes or public policies based on the multiaxial system.

The question remains, has the segregation of personality disorders helped personality disorders to “not be overlooked” among researchers and clinicians? The opposite seems to be the case. Valerie Porr, MA, President /Founder of the TARA NAPD, discovered through a Freedom of Information Request, that the National Institute of Mental Health funding for the year 2000 for research amounted to one half of one percent for borderline personality disorder. Blushfield and Intoccia, 2000, in an article in the American Journal of Psychiatry: “Contrary to the authors' prediction, the growth of the literature on personality disorders was slower after the publication of DSM-III in 1980 than it was before that date,” that is slower after being segregated.

Restated, segregation is a misguided way to become recognized. TARA NAPD has led the way on asking the APA to integrate these patients, having sent the APA thousands of forceful letters and e-mails and brought petitions to a series of APA Presidents. Although some APA officials privately agree with TARA NAPD’s position on this issue, to date the APA has not officially agreed to the change.

Why can’t the American Psychiatric Association [APA] develop a means to quickly integrate these patients onto Axis I with all other psychiatric disorders? The DSM timetable seems to be the problem. DSM-V is not due to be published until approximately 2011. It is rare for the APA to make a substantial change in the DSM between editions. Despite the fact that many psychiatrists within the APA have asked that we act now and not postpone integration for a decade, our efforts have not yet met with success. The APA currently has a committee exploring this issue however a decision before publication of the DSM-V will be difficult for the APA to reach.

An outside development might increase our chances for a quicker decision. The United States now uses an outdated version of the International Classification of Diseases – 9 [ICD-9]. ICD - 10 was published a decade ago and is used in many countries. Switching from ICD-9 to ICD-10 would cost government and private industry in this country many millions of dollars, probably accounting for their reluctance to do so. If the Federal Department of Health and Human Services decided to switch to ICD – 10, we would likely see a new DSM much sooner than 2011, creating the opportunity for a quicker decision to remove this obstacle to treatment and to integrate people with personality disorders into the mainstream of psychiatric treatment.

In May 2003 at the APA Annual Meeting, I debated Dr. John Oldham on the Axis placement of Personality Disorders. Robert Spitzer, MD, a key leader in the DSM-IV Task Force, publicly announced that he had changed his mind, reversing his opposition to moving personality disorders to Axis I and now agreed with our position for change. Subsequently, the American Association for Researchers on Personality Disorder has taken up the debate. The issue will also be debated at the upcoming October 9-12, 2003 meeting of the International Society for the Study of Personality Disorders, where Valerie Porr will surely make a strong case for moving Personality Disorders to Axis I.

No one thinks that DSM-V will continue this untoward situation, but obtaining an earlier decision remains a challenge for TARA NAPD members and the rest of us who support this change.

Roger Peele, MD, LDFAPA
Chief Psychiatrist, Montgomery County, Maryland