The Diagnosis of Borderline Personality Disorder: What Does It Really Mean?
A diagnosis of borderline personality disorder could, theoretically, mean that the psychiatrist made a serious attempt at evaluating defense mechanisms and ego integrity; or at least a matching of symptoms to DSM criteria. It's theoretically possible, yes. Other things that are theoretically possible include alien abduction, peace in our time, dual eigenstates, user friendly Movable Type upgrades, political discussions that don't rely on information from John Stewart, Daleks, recession with low unemployment, Independents, Madonna/whores, a benignly rising Russia.
Let's assume there's a difference between a diagnosis and a heuristic.
A diagnosis is based on pathology, or at least on a set of predetermined criteria. I diagnosis must be both reliable-- multiple doctors would find the same diagnosis when given the same information, and valid-- the diagnosis actually is the thing you say it is.
Many psychiatrists devalue diagnoses into heuristics, that is, they have intuitive "rules of thumb" that are extensions of their own cognitive biases. This isn't automatically good or bad; the heuristic is only as helpful as the bias. For example, if the last ten people who you saw that smoked crack also had syphilis, on the 11th you might apply the heuristic, "where there's crack, so there be syphilis, better get a blood test." Unfortunately, it could be applied the other way: the 11th patient with syphilis you see gets prejudged as a crack addict.
The diagnosis of a personality disorder is supposed to be valid, it's supposed to mean something. However, in general they are diagnosed very unrigorously, if such a thing can be imagined of psychiatrists. They carry nearly none of the implications of causality (except, once in a while, sexual abuse), nor do they reflect a distinctive understanding of a person's personality (e.g. borderline as distinct from narcissism.)
A good example is borderline. If a psychiatrist calls it borderline, it may or may not be, actually, borderline personality, a la Kernberg. So if a patient happens to know she was diagnosed with borderline (which she rarely will-- it's kept secret or encoded as "bipolar") it doesn't mean she can look it up on the internet for more information, because that's not what the psychiatrist meant by the diagnosis. "Articulate" has a certain meaning, look in the dictionary; it is fairly consistent throughout all settings except one: when it is used by a white guy to describe a black guy. In that case, the word suddenly means something completely different than it ordinarily does: it means "not hung up about race." Here's the point: the black guy may actually be articulate, or not be articulate-- who knows? But white people know exactly what it means in that context. Similarly borderline: you may, indeed, have a borderline personality, or may not; but the diagnosis to the psychiatrist means something else. n other words, it's not at all a diagnosis, it's a heuristic.(1)
Devoid as these personality disorder heuristics are of their originally intended meanings, they do, however, reliably imply the same things to other psychiatrists. Those "things" however, are uncoupled from the "official" diagnosis. The heuristic may have a lot, or absolutely no, relationship to the diagnosis. In other words, the term "borderline" is immensely reliable among psychiatrists, but not at all between psychiatrists and non-psychiatrists, who think it means something else. What psychiatrists should have done is invented their own special word for the heuristic of "borderline." But they're lazy.
So, as a public service, I'll tell you what psychiatrists mean when they say borderline. Once again, I'm saying that this is how the diagnosis is used by many psychiatrists. If you email me and say that I'm a jerk for not understanding the term, then you need to go buy yourself a helmet.
First, borderline is a heuristic of countertransference: if the psychiatrist feels frustrated, or exasperated, then the patient is borderline.
Second, borderline is meant as a synonym for any of the following: needy, argumentative, touchy/hypersensitive.
Third, it is generally reserved for the following four types:
- Very attractive female, who comes for problems the psychiatrist considers ordinary: men, work/school, problems with parents, etc. It is diagnosed here most often by female psychiatrists, and carries the connotation: "Grow up."
- Overweight, typically white, female, who needs/wants benzos, especially Klonopin. The implications are lack of self-control, and reliance on external supports.
- Thin female with a lot of anger. By example, the woman who comes for treatment of "depression" but describes most life events in terms of attacks, sleights, harm, etc-- i.e. power differentials.
- Gay man.
Again, these aren't even accurate descriptions of the formal diagnosis borderline; number 3, for example, is better described as narcissism, especially when anorexia (restricting type) is involved. But her anger makes the psychiatrist uncomfortable, so it gets labeled as borderline.(2) I hope you see two obvious problems: first, the term is used pejoratively; but, more importantly, giving something a label alters the environment, in this case in the wrong way. The above #3 female doesn't need limit setting, she needs mirroring transference, etc. (And don't forget about the narcissistic injury.)
But again, even though the term is used improperly and probably leads to worse treatment for the patient, it does mean the same wrong thing to most psychiatrists. So when I'm being referred a "30 year old borderline," I know almost exactly what I'm getting, even though it has nothing to do with borderline. Frustrating? You betcha.
But the sleight of hand is that it sounds like personality disorders are crappy and unreliable diagnoses and have little in common with their original meaning. In fact, most psychiatric diagnosis are equally crappy and unreliable. When you read articles saying "borderline is a pejorative term, and these patients are often really bipolar" what you need to understand is that "bipolar" is not a more valid or reliable diagnosis, it's simply another heuristic. It isn't less pejorative, it isn't more "real." It carries a different set of implications, but it isn't a more rigorous, more "biological" classification. It's not like saying, "it's not a unicorn, it's a rhinoceros." It is like saying, "it's not a unicorn, it's a pegasus."
This, by the way, is the reason why so many defenders of psychiatric diagnoses can't accept that "borderline" and "bipolar" are equally subjective terms. They say, "the diagnosis of borderline has very poor inter-rater reliability; bipolar has high inter-rater reliability." But reliability is not the same as validity. If you take twenty thousand members of the KKK, and ask them to "diagnose" the problem of contemporary society, their answer will be the same, i.e. reliable. But it's wrong, obviously. The diagnosis of bipolar is reliable, but in the same way as the KKK's diagnosis of society's ills was reliable. It may be completely wrong, it may be completely right, it may be partly right, partly wrong, in some cases but not others, etc.
If you want to know why I've used racial analogies throughout this post, it's because these are all, in essence, prejudices. "It's bipolar." "It's borderline." "It's poverty." "It's bad parenting." "It's..." Well? It's not really any of those after all, is it?
Next up: The Strength of Borderline
------
1. Referencing a joke from Fear of a Black Hat: "what's the difference between a slut and a ho? A slut sleeps with everyone. A ho sleeps with everyone but you." So here, the term "ho" actually has nothing to do with how many people she has slept with, under what conditions, money, etc-- in other words, it isn't the definition in the Oxford English Dictionary-- the single implication is that she didn't sleep with you, a fact which is actually not in the official definition. So she may, indeed, be a "ho" under the Oxford English Dictionary definition, or may not be. But when the word is used in conversation, everyone "knows" you didn't have sex with her.
2. Narcissism as a heuristic is reserved for either successful, or threatening, men; the countertransference is defensive condescension, as in, "go ahead and rant; you think just because you're a millionaire lawyer, you're going to intimidate me?"
3. (Wait, there was no 3?-- Here's a day to day description of what borderline is supposed to be.)
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October 23, 2007 3:32 PM | Posted by : | Reply
What you wrote is something I've suspected for a while.
FYI it's Jon Stewart not John.
October 23, 2007 4:14 PM | Posted by : | Reply
What do psychiatrists mean when they say Narcissist? What is the synonym for narcissism and what types is it generally reserved for?
Alone's response: I wrote a few posts on narcissism, search on "narcissism" in the box, but psychs use the term more loosely (another heuristic) as I defined it in this post. But I'll write about it soon.
October 23, 2007 4:30 PM | Posted by : | Reply
Within the VA medical system personality disorders are not seen as impairing enough to be worthy of compensation, while a "bipolar" diagnose is a true disability @###!??*?@!?
Great Blog!!
Thanks-- refer the blog to others, for the love of God!-- yes, the insurance influences dx, but keep in mind that the dx alters reality...
October 23, 2007 4:44 PM | Posted by : | Reply
Do you think it's more difficult to recognize relatively subtle prejudices like this in your field, where if bias creates an error the result isn't necessarily visible immediately, or is it really fairly obvious to anyone stopping to look, like my assumption that Mac users calling me for help have syphilis?
Alone's response: it's seems like every shift in a field has come from a non-specialist of that field (Wittgenstein:math, Kuhn:physics; Freud:neuro, etc) and it does seem like if you are too much in the world, you can't see the flaws of thinking. I think that's what they call confirmation bias.
wait, they don't have syphilis?
October 23, 2007 4:58 PM | Posted by : | Reply
I've been seeing exactly what you describe in action at the hospital where I'm interning--If a patient makes life difficult for the staff, 99% of the time she/he comes out with a diagnosis of BPD.
Oh, and BPD is the *only* axis II disorder the Docs ever seem to diagnose.
You, ma'am, have hit the nail exactly on the head. Borderline, OCPD, and sometimes dependent PD are the only one's ever _diagnosed_, though narcissism is discussed (but never written down. And the reason why the others aren't isn't because we don't see them, but because they are conflated into other diagnoses, or the above three PDs. Those three are not conflated, however, because they describe a countertransference reaction. They're not describing the patient AT ALL-- they're describing the (expected or experienced) feelings of the doctor. Again, the dxs may, in fact, be correct-- or they may be completely wrong-- they have no relationship to reality AT ALL and cannot be relied on to communicate the information they were defined to communicate. THEY NOW MEAN SOMETHING ELSE, AND THAT SOMETHING ELSE IS FOUNDED ON COUNTERTRANSFERENCE.
October 23, 2007 4:59 PM | Posted by : | Reply
What do you think of Dr. Robert Friedel's book, "Borderline Personality Disorder Demystified"??
Alone's response: um, what?
Let me get back to you on this one.
October 23, 2007 6:13 PM | Posted by : | Reply
What happened to the fifth type?
Alone's response: I'm an idiot, unfortunately.
October 23, 2007 6:48 PM | Posted by : | Reply
Your slut/ho differentiation reminds me Kinsey's definition of a nymphomaniac: "Someone who has more sex than you."
But regarding this post: From a non-psych point of view, whenever I look at psychiatric "disorder" definitions, it often seems as though they could apply to nearly everyone, in some instances. It seems to me that a psychiatric setting is very likely to create a compartmentalised view of a person and put a disproportionate emphasis on particular types of behaviour. In some ways,I think diagnosis can "work" the same way astrology does: There is just enough generality to apply a label, if the giver or the receiver wants one.
Perspective are hard work and it often seems like the "border" for labelling a pathology is far too dependent on the bias of the observer, compounded by the context in which the "patient" is viewed.
Psychiatry, in my view, is a difficult profession, with an extraordinary amount of intellectual and emotional rigour required. Not all psychiatrists can live up to that, or live up to that all of the time. That doesn't absolve them of their responsibility by any means. When labels are used in the way you describe above, it is a sad indictment on the limitations of current psychiatry.
Well, I agree in part-- certainly the diagnosis of, say, bipolar, is sufficiently maleable to allow many people to be diagnosed with it, when they don't actually have it-- but this begs the question, what exactly is "it?" Because there's nothing else in psych diagnoses except our definitions, when we deviate from those definitions we are changing the reality of them. (and since medications become involved, this is bad.) But that said, what's even more powerful is that a psychiatric diagnosis is assumed simply by the act of seeing a psychiatrist, volitionally or not. While most psychiatrists are quick to tell you they write, "no psychiatric diagnosis" on the chart "all the time" in fact that's rarely done, if for no other reason than insurance won't pay. So it gets some vague dx, like "adjustment disorder" or "depression NOS" etc. But again, labeling something changes the environment. The diagnosis isn't just a description of reality, it changes reality, both for how the patient sees himself (and thus acts) and how the doctor sees the patient.
October 24, 2007 6:46 AM | Posted by : | Reply
What would you consider 'objective'?
My experience has been that I can say something is subjective, and mean that we gravitate toward psychologically enticing concepts that don't map precisely to the phenomenon we think we're describing, and people with similar educational backgrounds will know what I mean, but people outside of that often think I'm saying that the phenomenon doesn't exist at all and we shouldn't take claims for its existence seriously.
Alone's response: it's arguable that we as humans can never know objective reality, because we need to perceive it, thus rendering the information subjective. But most psychiatric diagnoses are definitionally about interactions between people-- it makes no sense to call the Omega Man a narcissist. Since psych diagnoses, especially personality disorders depend heavily (read:exclusively) on a judgment about the quality of interactions-- both reported (by patient history) and experienced (countertransference and just experiencing it in the session), they are all going to be subjective.
Which doesn't mean they are less true or real, potentially-- as long as we agree on our terms. If the definition of ho is "sleeps with everyone but me" then that, at a minimum, is what a ho should be, even if we want to start attributing other characteristics to her. In that sense, the term "ho" becomes objective, not subjective (or, more accurately, it becomes analytic a priori knowledge.)
so while the term "borderline" is completely arbitrary and invented, it means something specific. Same with bipolar. But what happens now, in clin psych, is that we use these terms loosely, then completely unrelated to their actual definitions. I hate to get all Matrixy, but here are the stages of the diagnosis: 1. Sign represents reality. 2. Sign replaces reality. 3. Sign masks the fact that reality has been replaced. 4. The sign has no relationship to reality.
October 24, 2007 7:29 AM | Posted by : | Reply
"she needs mirroring transference"
Yes, because psychodynamic approaches have so much validity and reliability behind them...
Alone's response: well, that's a valid criticism. But even if a psychodynamic approach, or at least an approach informed by psychodynamics, is unhelpful, certainly using the wrong psychodranamic approach for the wrong diagnosis is even worse...
October 24, 2007 8:18 AM | Posted by : | Reply
I know what it's like to be labeled Borderline Personality. It's not fun. It's dehumnanizing, literally. When my label changed people treated me differently. Not better, just differently. No matter the diagnosis, the human element gets lost.
Alone's response: the problem is that we think these are diagnoses the way diabetes or CHF is a diagnosis. They're really just labels, some pejorative, some descriptive, some idiotic, etc, but labels nonetheless. They should be used as descriptions of specific facts; but they instead serve as "signs"-- they communicate information that isn't obviously in the words. For example bikini girls in beer ads communicate something; calling blacks articulate communicates something; calling borderline communicates something. What's weird is that information that is communicated is never formally discussed-- there's no where you can go to look up the meaning of "blacks and articulate" yet everyone seems to know exactly what is meant.
So when you say the human element is lost, that's not accidental, that's the purpose of the label. It's intended to reduce you to an easy to understand sign, to be able to make predictions about your behavior and origins. Well, that's great if you're selling beer, not so great if you're a person, primarily because-- and this is what no one ever seems to want to discuss-- labeling someone as something actually changes that person, even if they refuse the label. In other words, psychiatry wields an immense power over people when it labels them-- it actually changes the course of their lives-- all because someone "in authority" called you something.
October 24, 2007 11:32 AM | Posted by : | Reply
You're a psychiatrist so you can write stuff like this and not get called crazy which makes it seem courageous. Thanks.
Alone's response: Oh, no, you are wrong, I get called crazy all the time, especially for stuff like this.
October 24, 2007 5:17 PM | Posted by : | Reply
Could one reason for using bipolar in place of Borderline is that insurance companies won't pay for treatment of Axis II diagnoses?
Alone's response: sure. But even if that's true-- even if the psych knows it's not really bipolar, the simple act of saying "bipolar" changes everything. First, the patient now thinks he's bipolar, and whatever associations he chooses to link to it. Second, the patient _doesn't_ think he has a personality disorder, which for this example is what he really has-- so e.g. he spends time learning about medication options rather than working on structure, etc. Third, anyone who sees/hears about the case also thinks he's bipolar. Fourth, the term bipolar now has expanded to include types of people like this guy, and eventually bipolar becomes universally ackowledged to be a valid dx for this type of person-- which means that now medications are actually the "standard" treatment for him. Fifth, and most importantly, and no one believes me-- even though the psych knows he is inventing the bipolar dx to bill the insurance, inevitably the word works its way into his brain and he begins to _believe_ that the patient "has a little features of bipolar" then "has some bipolar features" then "is an atypical bipolar" then "is bipolar II" etc, etc. LANGUAGE CHANGES REALITY.
October 24, 2007 8:35 PM | Posted by : | Reply
Countertransference is a bitch.
Everybody does it, so why is there such a stigma around admitting and discussing it?
Recognizing and working on countertransference would be the more professional thing to do, seems to me.
October 25, 2007 1:16 AM | Posted by : | Reply
The part I don't get is how there can be people for whom bpd is an accurate diagnosis treated in the same practices as people "diagnosed" by way of the heuristics you describe without some kind of cognitive dissonance on the part of the clinician. On the one hand are people as described in your prior post who careen through life trying to grab hold of anything and anyone they can that might fill their psychic voids, engaging in parasuicidal behavior, splitting, black and white thinking, throwing my clothes out on the lawn once a month, etc. (Do you think there would be a market for "borderline hag" t-shirts btw? They would have to be green to cover up the grass stains.) On the other hand are people given the diagnosis because they are difficult patients. How is it not obvious that these are not the same thing? It's not like bpd is subtle.
October 25, 2007 8:44 AM | Posted by : | Reply
Thanks for your post. The points on BP presented in an accessible way is greatly helpful.
As a note on the flip side of the coin, what is also tricky, is getting a correct diagnosis of borderline (as far as I can tell) by a relatively competent psychiatrist and a good psychologist but everyone else assuming it's the "angry-difficult female" diagnosis instead. It makes it hard to find out what to do for the actual (rather than the heuristic) disorder. Especially, as pointed out in other comments, as the "support" resources seem to be all about the poor victims of BPs saving themselves from us, rather than what to do as a BP.
Counselling helps a bit, meds quite a bit and heilkunst homeopathy has also helped a lot, but if anyone has heard of any new, good books let me know.
October 25, 2007 9:35 PM | Posted by : | Reply
BPD can also be code for:
*Maintain boundaries
*Counselee has high liklihood of suing you so keep deflector shields up and write careful notes in case you and the records are subpoenaed by attorneys further down the road
*Disclose nothing personal about oneself
* Counselee's issue scare the living bejeezus out of you because they trigger latent little kid issues within the therapist--stuff the therapist should have worked through during training or with his or her consultancy group...but has not.
(quote)Countertransference is a bitch.
Everybody does it, so why is there such a stigma around admitting and discussing it?
Recognizing and working on countertransference would be the more professional thing to do, seems to me. (unquote)
You got that right.
Susan Erikson Bloland, daughter of psychoanalyst Erik Erikson, wrote a memoir 'In the Shadow of Fame.' She revealed that both her parents had been in training analysis...and both found ways to sneak away and ditch their training analyses, right when the process began accessing thier personal vulnerability.
Despite prematurely terminating his training analysis, (which the apprentice analyst must bear and endure in order to get a conscious take on his or her countertransferance issues)...Erik Erikson was allowed to go forth as a psychoanalyst.
His daughter's book describes the consquences that ensued. It deserves to be more widely read and discussed. There wasnt much mentioned when it was first published...perhaps because it spooked the psychoanalytic establishment and tweaked various and sundry countertransferance issues.
That bit about Erikson is interesting, I did not know that-- I wonder if Susan ever married? A strange thing I've noticed is the daughters of famous psychoanalysts don't get married. Hmm. But the other bit about writing careful notes is interesting in another way-- if a therapist/doctor starts with a patient that they consider highly litigious or think there is an increased chance they will sue them, do you think they would/should write more detailed notes with more subjective comments ("I believe this patient is trying to manipulate me to get benzos") or less such subjective comments because they don't want to have to explain it if the patient ever asks to see her chart?
hey everybody, you do know you're allowed to read your chart, right?
October 26, 2007 10:10 AM | Posted by : | Reply
Nice summary, but I think I prefer Persimmon Blackbridge's as quoted in Merinda Epstein's “Let’s face it! She’s just too f*****d” – the politics of borderline personality disorder.
“The main thing diagnoses are good for is sussing out what your shrink
thinks of you – Bipolar Affective Disorder means they like you, Unipolar
means you’re boring, Borderline Personality Disorder means they hate you
and Schizophrenic means you scare the shit out of them because they can’t
keep up with your thinking."
Alone's response: I'd never heard that, that's pretty good. I'd modify it as: bipolar means you are white and easily agitated, or "intelligent." schizophrenic means you are poor and black and "hear voices." (That single symptom.) And schizoaffective means you fit the racial profile of one disorder, but the social characteristics of the other. Isn't psychiatry great?
October 26, 2007 1:20 PM | Posted by : | Reply
Yow.
What a disconnect between the neurobiologists and the shrinks.
Where are the objective tests? There are plenty of genetic and anatomical correlates to behavior, whatever label you want to put on the person. You can at least rule out some disorders, etc.
The good news is that patients can get plenty of information on the web, like here.
Alone's response: did you forget to put a link, or did you mean me? :-)
October 26, 2007 9:44 PM | Posted by : | Reply
Note: Susan Erikson did marry.
And she reported that the warping effects of her father's fame was such that it took her years before she could finally recognize she had an interest in psychotherapy...and eventually trained to become a therapist herself.
Its a fascinating book, worth tracking down. Erik Erikson became world famous when Susan was about thirteen and she describes how the fame dimension changed her family..and that fame did not assuage her father's distress. Instead, the public image became an additional burden for him.
One item that got me was the description of how, before he became world famous, Erik Erikson would put in dutiful appearances at parties, then leave just as soon as he could and retire to his study to resume writing. For..writing was part of his quest for fame.
But after Erik Erikson became famous, he became the focus of attention at the parties. And then he did not retire to his study as quickly as before. He stayed at the parties, because these had now become sources of attention and validation for his public persona in a way that the parties had not been, earlier.
What Susan learned both in watching her father and then later studying the careers of other famous persons, was that fame and a grateful public cannot heal a self that has been devalued and neglected--instead, fame and public affection aggravate the imposter syndome by aggravating the felt discrepancy between one's neglected true self vs the lustrous public persona..it is as if the public persona becomes parasitic and monopolizes attention, diverting it yet further from one's true self.
Alone's response: Perfect-- I think you summed it up really nicely, that's the sadness of it all, it's like a Photoshopped image, bits artificially forced together that appear to be correctly placed, an image that has value only because you artificially altered it. It's also the narcissist's trap (not implying Erikson was a narcissist). These stories usually end with whisky. Specifically whisky./
October 27, 2007 10:12 AM | Posted by : | Reply
Guys, maybe I am being naive here--that there are ways to find distinctions between bipolar and borderline, assuming that the person consulting us does not happen to have both.
(Note: This is a shot in the dark as I am a non professional and am using just anecdotal evidence which any statistician will shake a head at. And my coffee has not yet had time to kick in.)
I thought bipolar includes the following:
Episodes are often triggered by disruption of sleep. Manic episodes can be triggered during certain times of year or can be triggered by flying through time zones, causing circadian rhythym upset. There was a fellow at our church who, according to the old timers, routinely went manic in spring time, usually April. Another woman told me her time was mid to late summer.)
Manic phases start out gradually, the person begins by being happy, creative, but then gets increasingly hyper, wired, begins projects then leaves them unfinished. This is pleasurable and sustained.
(A coworker told me that her husband went manic after he stopped his meds without telling her, then stayed up at night with his brand new internet connection. While she was gone at work, her husband decided to remodel their bathroom, tore out the toilet, sink, and shower nozzle, then before he could finish the job, went yet more manic, forgot, and got involved with something else. My informant came home, went to the john to pee, opened the door and instead of a bathroom found a bare room with dangling pipes where the toilet sink and shower formerly had been)
That does NOT sound like how sufferers from borderline behave. (please correct this if I am misinformed)
The happiness of being bipolar manic seems to be the happiness of beign energized, creativity, open horizons...and if one has had the training, the talent to apply that energy. THe misery comes when the energy becomes too vast for you to manipulate, then plunges you downward into burnout depression...and the social consquences of burned out finances and frightened loved ones.
The happiness in borderline comes feeling perfectly connected, nurtured and mirrored in relationships and the misery is that this is so fragile and easily disrupted.
Could the qualities of being energized differ? THat perhaps one is energized from the *relationship* if one is borderline , rather than energized from within, by the biochemical shift characteristic of borderline.
IMO wouldnt the suffering experienced by a person with bipolar be different than that of someone who has borderline?
What I have heard repeatedly is that one is so happy and creative during the manic phases that it is a painful sacrifice to give that up and take stabilizing medications.
This does not sound like the pattern of suffering reported by persons with borderline. People with bipolar often function with distinction in the arts. A bipolar informant told me she has met so many bipolar CEO's in Silicon Valley that she is convinced that many revolutions and social movements may have been triggered by persons with bipolar. She even told me that if you want to network and meet shakers and movers, go to a biopolar support group
By contrast, if one has borderline, the hell is it is often so hard to fulfill one's capacities, both intellectually and relationally---there's a pattern of ecstacy and then abrupt terror when one fears abandonment.
The anger shown by persons with bipolar isnt from fear of abandonment but frustration when one's feeling of crusade meets with skepticism or outright opposition.
(But Sir, you have maxed out all of your credit cards...')
Alone's response: Well, you are making the same "mistake" I am, which is defining bipolar using the old, more rigorous way, i.e. with manias. That kind of bipolar is very easily distinguished from, well, anything. The problem is that psychiatrists are now using the word "bipolar" as a substitute-- not synonym, subsititue-- for bipolar, because they think borderline is pejorative (though it doesn't stop them from using it in the above context I've described.) But to emphasize, they are sometimes using the word bipolar for the same thing as _real_ borderline, only because they do not like the term borderline.
October 28, 2007 2:45 AM | Posted by : | Reply
I found that once I stopped seeing the psychiatrist my personality disorder cleared right up.
October 28, 2007 7:07 AM | Posted by : | Reply
I have gripes with the whole Axis II taxonomy. That doesn't look like science to me. There was an article in the New Yorker, The Dictionary of Disorder, about how Spitzer and his pals put the DSM together. No wonder you can have multiple diagnoses given the same inputs. It looks like the people who proposed the definitions have also made their money by applying them and by ginning up 'instruments' to test for them, like the Millon™ Clinical Multiaxial Inventory-III, for example. Now how can you argue with a Multiaxial Inventory? It has axes and stuff. So if Ted Millon tells me I'm Borderline, or schizotypal, or whatever, that's it. That's as good as a blood test.
Your comments about how 'bipolar' has come to mean what 'borderline' used to mean remind me of Lewis Carroll's Humpty Dumpty:
"When I use a word," Humpty Dumpty said in rather a scornful tone. "It means just what I choose it to mean - neither more or less."
"The question is," said Alice, "whether you can make words mean so many different things."
"The question is," said Humpty Dumpty, "which is to be master - that's all."
October 30, 2007 11:45 AM | Posted by : | Reply
"1. Sign represents reality. 2. Sign replaces reality. 3. Sign masks the fact that reality has been replaced. 4. The sign has no relationship to reality."
Shouldn't that read:
1. Arbitrary sign is uncritically assumed to represent alleged reality. Etc.
Not as concise or poetic, I know, but...
And, what is your take on so called 'somatisation' and 'somatoform disorders'?
..................
"I found that once I stopped seeing the psychiatrist my personality disorder cleared right up."
A therapy that is highly unpopular with the profession, and which will not make you any friends.
But it is amazing how often it proves highly effective.
Check out rbh's comment about Humpty Dumpty. As for somatoform disorders, in that same comment is referenced an article in the New Yorker-- read that.
October 30, 2007 1:31 PM | Posted by : | Reply
"As for somatoform disorders, in that same comment is referenced an article in the New Yorker-- read that."
Link don't work.
Google, man! http://www.newyorker.com/archive/2005/01/03/050103fa_fact
November 1, 2007 3:50 AM | Posted by : | Reply
The problem I have with the AXIS 2 diagnosis is that so many psychiatrists don't have the balls to tell the patient they've given them this diagnosis. If you believe it's true, then by god have the balls to say it to the patient's face.
November 1, 2007 8:00 PM | Posted by : | Reply
Now this is what I'm talking about. Great post, and worth the wait.
November 2, 2007 8:30 AM | Posted by : | Reply
I have the type of personality disorder where I get along with everyone except psychiatrists.
November 5, 2007 12:03 PM | Posted by : | Reply
Excellent post! A question, though. You allude to a difference between psychiatrists and non-psychiatrists. I haven't noticed all that much of a difference among my own in clinical psychology or among counseling psychologists or masters level clinicians. Most seem to apply the diagnosis defensively.
I'm curious about your thoughts on this.
I used "psychiatrists" because that's who I run with. It is very likely that many psychologists also use the term these ways, or perhaps have their own code, but I wasn't familiar with it so I decided not to implicate them in this. That said, I wonder if this borderline code has less to do with being a psychiatrist or a psychologist, and more to do with working in an environment where clinicians talk to each other, and so need these heuristics in order to communicate. In other words, perhaps (and I have no idea) the isolated private practice guy who doesn't discuss his patients with anyone, maybe he doesn't reduce people (to, say, borderline) because he never has to describe them to anyone.
November 8, 2007 7:11 PM | Posted by : | Reply
I like John Briere's take on the borderline personality disorder-- basicaly a result of complex trauma, and he asserts that effective treatment is a combination of psychodynamic and cognitive behavioral. (if my memory is correct)
While I love you for this post, I will hate you until you post on the strengths of borderlines. (kidding, although I am looking forward to reading about the strengths.)
November 28, 2007 7:13 AM | Posted by : | Reply
I like this post too.
Putting aside for the moment the question of whether bpd does exist, on the strengths of borderlines, the most interesting article/study I've yet to come across on the web is Giftedness and Psychological Abuse in Borderline Personality by Lee Crandall Park at http://www.leecrandallparkmd.net/researchpages/gifted2.html
And on the side of affective disorder there's a fascinating bit of serious research out just recently that divides "borderlines" into 3 subtypes, i.e. internalizing- dysregulated, externalizing-dysregulated and histrionic-impulsive. The most disturbing conclusion is not (only) that the first subtype is a "borderline" not to be found in the DSM-IV-TR description, but rather just how differently the psychotherapeutic approaches to each would have to be tailored in order to do any real good. Article is at:
http://psychsystems.net/lab/06_affectreg.pdf I'd enjoy seeing what others think of this research.
December 7, 2007 9:58 AM | Posted by : | Reply
I hope I'm not carrying on a monologue here, but since I've given this a great deal of thought over the years - it's a subject that interests me (obviously), so I think I'll carry on a bit more.
Question: how many subtypes can a "personality disorder" have before it cancels itself out?
One study affirms the existence of two distinct subtypes of persons with BPD, labeled 'autonomous' and 'dependent' states:
"...autonomous sub-type was characterized by problems of being overly assertive, lack of intimacy, and keeping others at a distance. The dependent subtype was characterized by submissiveness, having little influence over others, difficulty conveying needs, obtrusiveness, and low self-confidence."
Then from Millon's "inventory" (four types) we have:
Discouraged (avoidant, melancholic or dependent features)
Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.
Petulant (negativistic features)
Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic and resentful; easily slighted and quickly disillusioned.
Impulsive
(histrionic or antisocial features)
Capricious, superficial, flighty, distractible, frenetic and seductive; fearing loss, becomes agitated, gloomy and irritable; potentially suicidal.
Self-Destructive
(melancholic or masochistic features)
Inward-turning, intropunitively angry; conforming, deferential and ingratiating behaviors have deteriorated; increasingly high strung and moody, possible suicide.
Yet another study from the Attachment Behavior perspective found three types:
"...six factors that clustered into three groups corresponding to an avoidant attachment pattern, a preoccupied attachment pattern, and a fearfully preoccupied pattern. The preoccupied pattern showed more concern and behavioral reaction to real or imagined abandonment, whereas the avoidant group had higher ratings of inappropriate anger. The fearfully preoccupied group had higher ratings on identity disturbance, although only at the trend level."
Then there is a study (actually there's a few along these lines) that suggests that DSM-IV BPD may mix two sets of unrelated items, part of which would belong to a Bipolar II diagnosis: "an affective instability dimension related to BP-II, and an impulsivity dimension not related to BP-II, which may explain the opposite conclusions of several reviews."
This would seem to go along with another study, this time on identity disturbance in bpd: "...data also provided further evidence for an emerging empirical distinction between two borderline personality disorder types: one defined by emotional dysregulation and dysphoria, the other by histrionic characteristics."
There is also of course the study on affect regulation in bpd (three types) that I quoted in my last letter.
What's clear is that there are no "pure" personality types, as there are no two people exactly alike. It's worth noting however that someone as involved in studying "borderline personality disorder" as Mary C. Zanarini has come to the conclusion that the "essential nature of borderline pathology" is "the intense inner pain commonly reported by borderline patients and the awkward means they use to manage and express this pain."
Are we not getting awfully close to reducing human suffering to a "mere" problem of personality? Since the ancient Greeks Western culture has praised moderation and condemned excess. Is there not some deep seated reaction going on here based in our adoration of moderation at all costs?
P.S. If anyone wants to know where these quotes are from I'll gladly supply the sources, but all one needs to do is cut and paste them in a search engine like Google to swim back up the stream.
December 12, 2007 2:41 AM | Posted by : | Reply
I'm one of those people that's been diagnosed as bipolar since age 8 (violent, irritable manias and all) and started getting diagnosed as borderline when I got worse and went to the hospital at 18 years old. No extensive testing of my personality, no looking into my reasons why I was being an antagonistic little brat (I dislike locked wards intensely...get this. I am NOT IN CONTROL AND DO NOT HAVE THE POWER, and cannot do things for myself..BPD? What???) What amuses me about being diagnosed borderline twice in two different psych wards is that my regular psychiatrists (and psychologist) just define me as having cluster B and C traits (likely actually real OCPD). I'm extremely controlling and perfectionistic and obsessive to a fault with just a bit of emotional lability. I always buddy up with the people at the top of the heap and try to attain a position of dominance in any new group. I don't ditch people because I'm afraid of abandonment, I ditch them because of their bad behavior that I'm afraid they're going to drag me into, and that would violate my unreasonably high standards, wouldn't it? Silly psychiatrists not asking about these things. Otherwise they'd be thinking narcissistic much, much more. Heh. But BPD? Nah. *waves hi to Velvet Elvis a long time ago*
December 28, 2007 2:18 PM | Posted by : | Reply
I think this article makes allot of valid points. there are good and bad people in every profession how ever... i think that being lazy in this profession is very dangerous and stupid..people come for help to understand them selfs yet then when someone wants to just slap a lazy term on because they are putting people in a stereo type, well just shows how borderline the doctors are :) I can say well said! thanks for the read
January 6, 2008 6:39 PM | Posted by : | Reply
The institutionalized dishonesty surrounding identifying and articulating the diagnosis of BPD reinforces the invalidation that borderlines and their children (my mother has just been "labeled" as having BPD at age 68) endure. I suspect that mental health professionals knew years ago that her spectrum of symptoms was related to the borderline personality disorder, but because no one would ever "label" it or they would choose to label it with diagnoses that clearly did not fit, those of us who had to deal with her bizarre behavior were left to wonder if WE were overreacting or misinterpreting the situation. She failed to see the need to seek the kind of intensive therapy help she needed (whether she would have or not is unclear) because her doctors kept trying a revolving pharmacy of pretty much ineffective drugs for diagnoses she didn't actually have. Basically, they ignored the actual underlying pathology in favor of putting band-aids on the easier to diagnose symptoms--depression, anxiety, "bipolar traits," paranoid thoughts, etc. Because she was not told honestly about her diagnosis, the difficulty in treating it and the need for long term therapy, she believed in a chemical solution to her emotional problems. Maybe, armed with the right information, she would have had incentive to try a different approach. Even more than her seeking help for herself, which I realize may not have happened in any case, her children would have had better direction when pursuing their own help. Since her diagnosis, I've read the book "Understanding the Borderline Mother." It's the first time in 40+ years--after years of therapy actively trying to make sense of what I lived through--that I understand what happened in my family. Because there is a name for it and because the pattern so clearly fits my mother's behavior, my perceptions and the experience I had growing up have finally been validated. I have no doubt that the diagnosis of BPD is misused. I also am not a mental health professional, and my perspective is not based on any special knowledge or experience other than my own. It just seems to me that failing to label can have consequences that are equally as destructive as inappropriate labeling. In a meta sense, labeling has become a label--always assumed to be pejorative when maybe it could be beneficial.
January 7, 2008 11:56 AM | Posted by : | Reply
You have rather turned this conversation around Michele! Without any desire to contradict you, the problem as I see it though is that first of all, using the DSM-IV-TR there are presently 256 combinations that can earn one the diagnosis of Borderline Personality. Reading one's horoscope is hardly less accurate. Secondly there is a clinical reality called hostile-irritable depression that the DSM hardly touches on except in its criteria for BPD. This highly suicidal depression, which is surely dysphoric in nature is also present in bipolar disorders, probably most often as a "mixed state". (Dysphoria as I see it: a Molotov cocktail of self-hate, guilt and shame, irritability and anger out of conscious control, alternating with a kind of dissociative numbing of the senses alternating with extreme anguish, terror, severe inner agitation and psychic pain so unremitting it blocks out any positive feelings whatsoever, mixed with desperate moments of explosive rage towards a world blind to this pain - understandably so because this pain is outside of “normal comprehension”). It's almost always a manifestation of this extreme negativism that gets a patient "diagnosed" BPD. But it is also a clinical reality in both "borderline" and affective disorders, it can and does respond to divalproex, valproate or other medications. Tragically a BPD label often ignores this fact and the sufferer will not get the meds or the attention he/she needs to survive.
Nod to bovinedefenestration - I admire your French, and your flare!
January 8, 2008 10:31 AM | Posted by : | Reply
Hi Juniper
I don't feel contradicted--just confused. As I read about BPD on websites maintained by mental health professionals, I am stunned by the inconsistency in describing the syndrome and assessing the prognosis or even deciding whether or not it is an actual diagnostic entity. I'm not comfortable with sites for children of people diagnosed with BPD. If you think mental health professionals are derogatory about BPD, try communicating with a group of family members! The standard term used by members of these groups for their borderline mother is "NADA." No one can explain to me what the acronym actually stands for, but they are clear that "person of no value--nada, zilch, nothing" is how they view their parent. I understand the anger, but I'm trying to figure out how to deal with my own anger and don't feel helped by communicating with people whose anger is their defining feature in dealing with this issue.
I guess it's not surprising that a topic that is so controversial for mental health professionals would be even more difficult for lay people who have no frame of reference to understand the controversy over the name BPD. In my case, having the label applied to my mother was helpful--gave me access to information I didn't have before and actually made me more empathetic to her pain (and my own) and more reasonable in my expectations. At least, that is my perception right now--it's very early in the process. It sounds like this is not the typical experience with the presumed diagnosis of BPD, however.
Anyway, thanks for the info on hostile-irritable depression (hadn't heard of it) and dysphoria (thought it meant "mild" altered mood states). I'll do some reading. I don't know if my mother has ever been on the drugs you mention, but I know she is open to trying new things if you catch her at the right time!
January 9, 2008 10:17 AM | Posted by : | Reply
Of course "dysphoria", just like any other word used to describe human character traits or moods, exists on a continuum from mild to extreme. However in all the confusion one fact commonly agreed on is that, at the moment of diagnosis anyway, people suffering from "Borderline Personality Disorder" are EXTREMELY unhappy and EXTREMELY negative - so for me it goes hand in hand if there is dysphoria (and personally I'm convinced that there most certainly is) they are also going to be EXTREMELY dysphoric.
Note: Googling "irritable-hostile depression" + akiskal will kick up some interesting stuff.
And if anyone is totally sick of thinking about what Borderline Personality Disorder means and would just like a good excuse to throw it overboard, you might check out the "Fear and Anger equation" at www.mcmanweb.com/fear_anger.htm
January 26, 2008 4:21 AM | Posted by : | Reply
This was a great entry, although I think you missed one point that's always struck me: quite often, clinicians seem to gloss over a simple phrase in assessing the PDs -- "persistent and pervasive pattern of behavior."
Context counts for an awful lot. Let's say I give you a ride somewhere, and you have a fit when I stop for you to get out. If we're parked in front of your door in a safe neighborhood, that might be borderline-like "frantic efforts to avoid abandonment." If we're thirty miles into the middle of the woods, on the other hand...
One quibble, though: I think Anorexia Nervosa restricting sub-type is generally associated with the Cluster C PDs, not Cluster B. The binge purge subtype is often associated with Cluster B, though...
Oh -- and I think the fifth type of individual who gets the BPD dx might be a middle aged woman who's good at math or science...
March 7, 2008 6:14 PM | Posted by : | Reply
I read all of your entries regarding BPD with interest. I was "secondary" diagnosed as BPD, with a primary diagnosis of DID back in Jan. 2007. The therapist saw me for 8 months before refusing to treat me because I overdosed. I was self harming back then and her "treatment" for that was to tell me she would abandon me as my therapist if I continued. She claimed to be an expert, was a PhD and wanted me to start in her DBT training skills group (I have since begun another DBT group somewhere else). I went for my regular appointment and she accused me of stealing her clock, which never happened. I was already on an emotional rollercoast from the 8 months of on and off hospitalizations (I had never experienced that before seeing her). Out of the blue she told me I emotionally blackmailed her, was manipulative, a thief and made her have sadistic thoughts that made her want to "slap me upside the head."
Obviously at this point she couldn't stand me, but it was confusing because the week before she was hugging me for an hour and telling me she'd never leave. At any rate, I overdosed that day and never spoke to her again. She later sent me a bill for $1000 and told me I didn't have to pay if I didn't want to and she'd not seek payment further. It took me 3 months of trauma therapy to undo what she did and to get me back from being suicidal.
I hate having this BPD diagnosis. For some reason it feels shameful to have it and the comments made by a so-called therapist made that even worse for me. The DBT is helping and the therapist has repeatedly apologized for the ex-therapist's behavior, but it's little consolation since the damage was done.
I do wish there were more education about this disorder. I would rather be a paraplegic than to not have my mind.
March 10, 2008 5:15 AM | Posted by : | Reply
You've clearly been dx on axis I and axis II: Although BPD is probably best conceived as an emotional dysregulation disorder, it is presently on "Axis II" whereas DID (considered to have close links to what we used to understand as "Hysteria") is on "Axis I". My psychiatrist/psychotherapist years ago - who I do think is a great therapist although caught up in this classifying furor of our era - told me that I couldn't have "just" recurrent bouts of serious melancholic depression (in the worst of times, dysthymia in the best) hence BPD with avoidant traits...
This same professional was the first to make me see that "pure" BPD has absolutely nothing to do with true manipulation (needs foresight and planning), nothing to do with lying or emotional blackmail, and that it's high time to separate a true dx of "Borderline PD" (complex constellation of intensely painful dysphoric states, cognitive deficiencies, and a firmly rooted subjective experience of estrangement, inadequacy, and despair) from the name calling that seems to be epidemic at the moment.
The question begs to be asked - Heuristics aside, if BPD is considered to be strictly a personality disorder of one kind of personality, why is it that the whole gamma of personality traits (often amazingly introverted for a "cluster B"!) and personal biographies can be found mulling around at its epicenter?
Personally I would be more upset with a dx of DID.
March 17, 2008 12:54 PM | Posted by : | Reply
Stumbled upon your blog and was delighted..... amazing how a mysogynist "therapist" takes note when you disagree with his rantings and snaps to the conclusion that you are 1)BPD AND 2)narcissistic but fails to acknowledge your MANIA MANIA MANIA.... maybe I was speaking too fast for him and he couldn't keep up with the RAPID CYCLING BIPOLAR DISORDER? Score 1 for misdiagnosis based on self-indulgent personal opinions......
March 21, 2008 9:04 AM | Posted by : | Reply
This is extremely helpful for me in primary care. Thanks.
March 28, 2008 3:45 AM | Posted by : | Reply
With regard to personality disorders, what I would love to see addressed on this site are the high percentage of mental health workers with these disorders.
I worked for two years within the mental health system and left, not because of difficult clients, but because so many of my colleagues were so obviously disturbed. Specifically, there were a high number of (mostly male) psychiatrists with NPD and many female support workers and psychiatric nurses with BPD. Those with affective disorders, such Bipolar of Major Depressive Disorder, except on the odd occasion they experienced breakthrough symptoms, usually weren't a problem, just a bit highly strung and eccentric.
The psychiatric staff with personality disorders, however, conducted their business in such a game-playing, passive-aggressive, prevaricating, politically-correct, crazy-making atmosphere that it was easy to see why they had this gig: dysfunctionality was their natural habitat, but unlike their dysfunctional families/cultures of origin, THEY GOT TO BE IN CONTROL.
The whole bureaucratic, mealy-mouthed, soft-focus machievalianism of the mental health sector is something that was tailor-made for manipulating personalities who feed on the boundary-violations, prurience, power and intrigue that has been reframed and sanitised as humanist concern.
So many of these people were well-meaning, right-thinking, morally-superior left-liberals who found a ready-made mutual admiration society of other right-on sanctimonious types who were JUST AS FUCKED UP AND HYPOCRITICAL AS THEMSELVES.
I stuck it out for two years but, since this was a "day job" supplementing my other work, I didn't feel too guilty about leaving. I just feel enormous respect for the endurance and courage of those with mental illness who, in addition to living with their illness and the stigma that goes with it, have to navigate the minefield that is the mental health system, and who have to sort through the disordered personalities that populate the psychiatric profession.
I also respect those mental health practitioners who are clinically competent, mentally healthy, and who have integrity, who stay in their profession despite the behaviour and personalities of their disordered colleagues. It would be very easy to get disillusioned and quit, or become jaded and cynical, to acquire a detached "If you can't beat 'em, join 'em" attitude.
So, Last Psychiatrist, what are your thoughts on this?
March 30, 2008 5:50 AM | Posted by : | Reply
That at least made it clear that feelings of anger and hostility are not just confined to those "with BPD"!
I'm dreaming of a world that describes individuals without recurring to the terminology of the DSM. Psychiatry was exposed in the sixties by Foucault & co. as a disciplinary system overly sure of its entitlement to express (severe) moral judgments on people's character. It's response? Axis I and Axis II.
Is there not enough shame paralyzing the human race as it is, so that we have to use these labels to throw it on thicker, scorning and stereotyping all differences in thought, feelings and behavior from the "norm"? On what grounds do we feel our claims are legitimate? It's as if people can no longer be different, or difficult, or unhappy, or unlikable without our robbing them of all value as human beings, and, much worse than seeing them as sick, seeing them as defective, evil, as subhuman, as out-of-order, i.e. as "disordered" - as having NPD, HPD, BPD, etc. - as if we have forgotten that individuals are so much better described using other, much richer adjectives.
I watch in bewilderment how the language in the US has changed since "personality disorders" were invented. I shudder to think that it is only a matter of time before we, on the other side of the Atlantic will be infected.
Perhaps it's because English is now so universal that it is becoming so impoverished?
June 16, 2008 9:43 PM | Posted by : | Reply
Sorry to nitpick, since it's not the main point of this entry, but I think you're wrong about what white people think when they hear a black person described as "articulate". As far as I know, it has nothing to do with not being "hung up on race", which I take to mean that they aren't concerned about black power or civil rights or whatever. It is offensive to blacks for whites to say this because what they mean is that the black person doesn't talk like a black person, i.e. in ebonics. They mean that they talk, and act, more like a white person than like a stereotypical black person. I think that is pretty much the standard understanding of that. Did I miss your point somehow?
July 28, 2008 3:30 AM | Posted, in reply to , by : | Reply
In the UK, if you call a black person articulate, surprise surprise! It usually means they're articulate. We have racism here, but I dont think citizens of the US realise just how backward their country really is.
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