Someone once told me that during his life, Winston Churchill would often refer to his depression as a “black dog” — a vile, loathsome creature that would shadow every decision and thought in his mind. But to me,
it was not just a dog, but something more sinister and predatory.

The beast followed me in the same way that a lapdog would follow its master, though there was no doubt of who was in charge. Behind every thought, decision and doubt in my mind, the black dog would be not too far away, waiting for a moment of weakness. Feeding off my shame, regret and self-loathing, its hunger knew no bounds and it could smell the fear that seeped from my skin.

For most of my adolescent years, that’s what it was like living with my depression. Every day was a new trial for me to fail and a new reason to undermine my existence. No matter what I did, no matter how hard I worked, I would always come home beaten and shamed. I was constantly making mistakes and no matter how trivial they were, I always punished myself. Every transgression I made was
a constant reminder of how worthless I was.

I never felt more alone than I did during those years. While my peers enjoyed themselves by going out, playing sports or singing in musicals, I spent my breaks eating my lunch alone. I always compared myself to them, asking myself why I couldn’t be like them. Each time, the conclusion was the same; it was because they were normal and I wasn’t. I felt there was something wrong with me, something I couldn’t fix. It was a period of time in which I felt my life was spinning out of control and my sanity was slowly unravelling.

The only thing keeping me alive was my desire to do medicine. Even before I met the black dog, becoming a doctor was all I ever wanted. To work in a craft that was centred around people and their ability to care. It was my calling in life and it was something that I needed to do. But most importantly, it allowed me to push past my depression and survive. No matter how hard things got, I had the strength to continue. I wanted desperately to speak to the school counsellor and confide in her all the pain and misery I was feeling. Maybe there was a cure. I owed it to myself to try. But what would happen if people found out that I was seeing her? What if my peers thought I was insane? The disgrace and humiliation I would feel if everyone knew would be too hard for me to handle. No, I decided. It was
my burden to bear and no one else needed to find out.

It wasn’t long before I tumbled. Months passed, the days became harder for me to bear and my depression deepened. As life continued and my peers moved forward, I was left behind, forgotten. It was as if everyone was in on a big secret that I was not privy to. The cruel isolation wreaked havoc on my self-esteem, pushing me further towards the brink of insanity. As my mind unravelled, my body ached with constant agony.

And then everything became too much. I felt numb and sick at the same time. Waves of nausea, spite and humiliation washed over me as all my mistakes flashed before my eyes. My breathing became laboured and what little tenacity I had left crumbled. I had finally convinced myself that I was a complete and utter failure. I wept. While I sobbed, I wondered what it was like to feel normal and why I lived a cursed life. I pleaded with the Almighty for sweet relief, one way or another. I didn’t care anymore, I just wanted out. As the depression took hold, I reached the chasm’s edge. One step and I would be committed forever. I asked a God I didn’t believe in to give me a break.

To this day, I am thankful for what happened next. After I confessed everything to the counsellor, she helped me realise that no matter how alone I felt, I had my family, my friends and the school to stand by me. That this unbearable agony
I was feeling was common. That people do care. It was something I needed to hear. I was quickly referred to a psychologist for further treatment and I began acceptance and commitment therapy, where I learnt how to acknowledge my faults and move on with my life. Just sharing my problems with someone else and feeling as if they cared was enough to relieve my grief. The pain and doubt that used to hound my every move had less of an impact now. With each session, I could feel the dog — my dog — being pushed further away until it was out of sight.

During the course of the next few months, I was able to complete my final year and secure an interview for medicine. As the date of my interview approached, I became nervous and anxious but I strengthened my resolve. It was my only chance to rectify what had happened to me and I wasn’t going to throw it away. When the day came, I gave it my all.
I talked about why I loved medicine and how I couldn’t see myself doing anything else. I showed them the passion I
had for the profession and the drive necessary to succeed. Afterwards, I was able to rest knowing that I did everything I could. My biggest fight was over.

One month later, I received a call that I had started to believe would never come. I was offered a place to study medicine. It was as if a burden was lifted off my chest. I finally had what I so dearly coveted. It made me realise that anything was possible. That I could live again. Despite being harder than anything I had ever done, studying medicine was the best thing that ever happened to me. I was no longer held back by the expectations that others had of me and was able to become whoever I wanted to be.

That said, I still needed to control my depression. At times, I could feel it edging back into my life and I fought to keep it in check. It was the little things, like new experiences and social pressure, that I struggled with. However, the hardest part was learning about depression at university. Learning about its causes and symptoms made me relive the trauma
I went through. But I always remembered what my life was like before medicine, and how grateful I am for my life now.

Despite my terrible ordeals, I feel that my depression has made me more empathetic. As I remember my clinical experience as a patient, I find it easier to understand what the patient is going through. This recognition allows me to identify with the patient and develop rapport. I know that the dog is not gone forever and I still have bad days. But for the first time in my life, I think I can handle it. I am ready for the next step and this time I’m not alone.

The release of the fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5)1 classification system, scheduled for May 2013, will create controversy due to the expanded range of problems now classed as mental disorders. However, in our view, it is unlikely to improve clinical care. The ultimate test for any system of diagnosis is its clinical utility. That is, does it assist clinicians to improve their selection or sequencing of treatments and enable them to make more accurate prognostic statements in keeping with newer concepts and knowledge? We propose that a refinement to traditional diagnostic practice — clinical staging — is more likely to improve clinical care and inform future research into the causes of mental disorders.2–5 Further, clinical staging draws the practice of clinical psychiatry closer to general medicine, especially with regard to chronic disease management.

In the past century, a major challenge for psychiatry was a lack of international consensus on diagnostic categories. For many decades, DSM and other international systems strived to enhance the reliability of psychiatric diagnoses. Recent field trials for DSM-5 indicate that acceptable reliability remains elusive.6 However, even diagnostic categories with modest reliability have limited validity. A major weakness is that the diagnoses refer to “categorical phenotypes” that fail to address critical differences in clinical presentations associated with age of onset or stage or course of illness.2–5 Most criteria reinforce categories derived from observations of middle-aged people with long-established stable illnesses, who have often been treated extensively by specialised mental health services. Inevitably, these map poorly onto earlier, less specific clinical presentations seen in general outpatient, primary care or community settings. They also presuppose that independent causal pathways exist for each clinical phenotype — an assumption that is not supported by contemporary family, genetic, neurobiological or risk factor research.2,3

What are the alternatives? Twenty-first century health care places an increasing premium on personalised or stratified medicine, with the goal of delivering more tailored treatments. Consequently, there is increasing international support for applying the concepts of clinical staging, particularly for adolescents and young adults with significant mood or psychotic disorders.4,7 Given that 50% of major mental disorders begin between 15 and 25 years of age, a focus on enhanced care and novel clinical research during this critical developmental phase is a timely test of this framework.5,8,9

At its core, the clinical staging model recognises the full spectrum of illness experience. For example, for ischaemic heart disease, the staging model identifies individuals at risk (because of genetics, lifestyle or other risk factors), those with symptoms or related syndromes that suggest illness progression (eg, hypertension, metabolic syndrome) and those with overt evidence of cardiac disease (eg, angina). Further, treatments differ at each point on the illness continuum, with interventions with lower risk–benefit ratios being provided at earlier stages (ie, dietary change or increased exercise for the at-risk stage, and more complex medical treatments for later stages). In psychiatry, this approach also differentiates at-risk individuals (stage 0; eg, family history of severe mental disorders) from those with early subthreshold or attenuated syndromes (stage 1; eg, brief episodes of psychotic or hypomanic symptoms) from those meeting threshold diagnostic criteria (stage 2) or with established or persisting illness (stage 3). Importantly, staging suggests that disorders emerge via a limited set of overlapping and fluctuating symptom clusters (microphenotypes), some of which resolve, while others progress and stabilise into clinical presentations (macrophenotypes) that ultimately resemble more traditional diagnoses.2–5 The clinical staging model is compatible with clinical reality and can be tested for reliability, predictive validity and patterns of association with developmental epidemiology and neurobiological markers.7,10

For mental health, the critical challenge is to help all patients entering care by reducing symptoms, promoting recovery and quality of life, and preventing progression to premature death or further disability.8 The means for achieving these outcomes may be better assisted by clinical staging rather than by prematurely assigning categorical diagnoses to an evolving clinical profile. Also, rather than encouraging early use of medical interventions, the specific intent of staging models is to mimic the disease-management principles now widely applied in general medicine, which enable clinicians to target stage-appropriate interventions from early in the course of illness. Thus, for most young people entering care before the development of full-blown mood or psychotic disorders, the emphasis is on providing relevant information and psychological strategies (including e-mental health), reducing known risk factors (notably alcohol and/or substance misuse), minimising self-harm, promoting resilience, encouraging self-monitoring and reviewing longitudinal course.8 In future, low-risk, evidence-based neuroprotective strategies (which are behaviourally, psychologically or medically based) may also become available.

Clinical staging revolutionised general medical practice, focusing attention on the benefits of intervening earlier in the course of life-threatening illnesses. For clinical psychiatry, it could enable appropriate matching of the timing and intensity of interventions to the specific needs of help-seeking individuals. Also, staging sheds light on the evolution of symptom networks and syndromes,5 and enhances our chances of validating specific pathophysiological pathways and of introducing more objective measures of illness risk, onset and progression.2 In medicine, the successor of clinical staging was clinicopathological staging. In the future, we hope that clinical psychiatry will also be based on the combination of objective markers of illness course and enhanced clinical care.

Until recently, borderline personality disorder (BPD) was considered to be a chronic ongoing condition with a poor prognosis and no effective treatment. However, the tide of research and clinical opinion has turned, and the prognosis for this disorder is now considered improved for most patients if one of a number of effective evidence-based treatments is implemented.1 On 15 March 2013, the National Health and Medical Research Council (NHMRC) issued the Clinical practice guideline for the management of borderline personality disorder, which outlines best practice.2

BPD was first described in 1938 when referring to a recognised group of people who were thought to be on the “borderline” between neurosis (depression and anxiety) and psychosis (schizophrenia).3 The term “borderline personality disorder” became accepted medical terminology in 1980 with its inclusion in the third edition of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders.2 The prevalence of BPD in the community is between 1% and 4%, but at least one-quarter of all mental health presentations to emergency departments or inpatient mental health units are people with a personality disorder.4

People with BPD may try to avoid abandonment by others, and they may have intense and unstable relationships, and feelings of insecurity and emptiness. They have difficulty with emotional regulation, manifesting as low mood, sudden anger, irritability, detachment and impulsivity in activities such as using drugs or engaging in risky sexual activity. The illness may include both anxious and labile mood, along with occasional more severe components such as transient stress-related psychotic-like symptoms, including paranoid delusions or hallucinations.

BPD is currently understood to be caused by a combination of biological factors (eg, genetic interpersonal hypersensitivity) and early environmental influences (eg, adverse childhood experiences).5 It cannot be said that BPD only derives from post-traumatic stress.6 Therefore, in view of current understanding, it is not “the person’s fault” or a result of “personal weakness” or “being manipulative” — labels that are sometimes prompted by the negative reactions of health care workers to people with the condition.

Clinicians are familiar with the problem of young people who self-harm, or who present as needy and impulsive, and who have a history of presenting to emergency departments in crisis. Managing these people can be a challenge, in part because they often have difficulty describing themselves.7,8 Such people can present sometimes as aggressive, entitled and disinhibited, but at other times as needy, timid and compliant. It is important to recognise that self-harm does not indicate BPD if it is the only presenting problem.

Psychological therapies are the treatment of choice. Over 25 randomised controlled trials have now demonstrated the benefits of specific types of psychotherapy that are known to be effective, such as dialectical behavioural therapy, mentalisation-based therapy, and transference-focused therapy.3 An important factor that is common to all effective therapies is the use of a specific form of communication focused on discussing current relationship difficulties and methods of problem solving with patients, so that they are able to choose healthier relationships and maintain study and work.9 Clinicians should avoid discussing past traumas in the early stages of treatment, as this has rarely been found to be helpful and usually worsens patients’ mental health and increases their risk of suicidality. Unlike depression, anxiety or schizophrenia, there are currently no approved medications that are “on label” indicated for the disorder, with Recommendation 11 of the NHMRC guidelines stating that “medicines should not be used as primary therapy for BPD, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder”.2

Effective treatments aim to strengthen self-esteem, and use the therapist–patient or doctor–patient relationship to provide a “safe place” for the patient to discuss alternatives to destructive behaviour and relationship insecurities, with an unhurried, step-by-step “here and now” approach to improve daily functioning. One of the principles of the NHMRC guidelines is that to be effective, doctors should try to “act consistently and thoughtfully . . . to make sure the person stays involved in finding solutions to their problems, even during a crisis”.2,10 The availability of resources to help doctors, patients and their families and carers to understand and better respond to the condition is important; the NSW Health Project Air Strategy for Personality Disorders10 (www.projectairstrategy.org) referred to in the NHMRC guidelines is an example of such resources being made available in one place. People who suffer from the disorder almost always experience receiving a diagnosis as helpful, because it allows them and their families to understand that this is a recognised disorder and that there are good psychotherapies that provide hope.

A major focus of effective treatment is to support families, partners and carers of people with BPD.2 Because of the interpersonal nature of the disorder, families often feel burdened by their relative’s condition, and also need to learn effective ways to communicate and cope with living with a person with the illness. The doctor or therapist can encourage families to stay connected to the person with BPD, even though this may be stressful.10 Doctors and therapists have an important role in supporting both patients and families to get the help they need, and in providing education about the latest developments in our understanding of the disorder. Most of all, doctors and therapists are in a powerful position to give hope to those with the diagnosis, and to work to overcome the stigma and prejudice surrounding BPD. This is particularly important, as people with the condition are now known to respond well to new treatments.