October 23, 2007

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:

  1. 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."
  2. Overweight, typically white, female, who needs/wants benzos, especially Klonopin.  The implications are lack of self-control, and reliance on external supports.
  3. 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.
  4. Gay man.
If you are a patient, my point in telling you this iss not "why did they diagnose me with borderline?" but rather, "oh my God, are you telling me he thinks I'm borderline just because I told him if I don't get my twice a day klonopins, I'll freak out?"

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?


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.)