Speaking of Changes: DSM-IV to DSM-V

What’s going to happen to Borderline Personality Disorder in the DSM-V? For that matter, what’s going to happen to any Personality Disorder in the DSM-V?

There is going to be a major reclassification of Personality Disorders in the DSM-V.  Apparently Axis-II disorders aren’t clear enough in terms of diagnosis in the DSM-IV so they need to be updated. Can’t completely disagree with their reasoning. The whole point of the DSMs are to accurately diagnosis disorders in order to aid the clinician and patient. Without proper classification and standardized diagnostic criteria it’s very difficult if not impossible to receive the most helpful treatment. If help is what you want that is. I’m sure we can all think of a few PD types that don’t need to change a thing 😉

The current DSM-IV:  Diagnosing disorders in the current edition of the DSM-IV involves two aspects.

First: Define what a personality disorder is. Currently, a Personality Disorder is defined as a pervasive pattern of “inner experience and behavior” that is deviant from a person’s cultural norms. These may be deviations in thoughts, emotionality, interpersonal relatedness, and impulse control. Deviations need to be pervasive, stable, present at least since adolescence, and not due to substances or another mental disorder. Importantly, these ways of thinking, feeling, or behaving need to be significantly distressful and problematic.

Deviant from cultural norms. This is inappropriate on so many levels. The most obvious being that since there are so many different cultures in the world what is considered a PD in one culture may be considered a different PD in another or more severely it may not be considered a PD at all.  Some cultures promote cannibalism. It’s a non-concern. I bet if I tried to apply that here and claim it was my standard proclivity to chow down on my neighbor I’d be tossed right into the ASPD category. People are food? Anti-social. Check.

Second: Define what type of personality disorder is present. DSM-IV currently lists ten Personality Disorders with a catch-all “not otherwise specified category”. Each personality disorder has a certain number of criteria, to which you must meet a cut-off. For example, To be Borderline you need to have five out of nine symptoms such as: self-harming, unstable relationships, fear of real/imagined abandonment, impulsivity, identity disturbance, etc.

There are a lot of problems with this system though.

First, the different personality types were poorly defined. They weren’t based on research-derived criteria, the individual symptoms were vague, and the idea of checking off abstract criteria such as “an exaggerated sense of self-importance” were difficult.

It does seem that the number of criteria required is arbitrary. Why are 5 qualifications better than 4? 4 symptoms may be significantly severe. For that matter, who decides what is significantly severe? Why are 7 met criteria more accurate than 5 if many of the 7 criteria are relatively subdued. Who’s to judge? 4 = “normal”, 7 = “abnormal”.  Regardless. Oh, I’m sorry. You only have 4 majorly severe symptoms present? You’re fine, go about your day. Next!

Another problem is that the criteria overlapped heavily. A person meeting criteria for one personality disorder usually met criteria for 3 or 4 others, as well.

No disagreements here. I for one am sure I qualify for Histrionic PD in many ways. From a cultural stand point I cross over into Schizotypal (if not for my ‘spiritual’ beliefs alone), and so on. Hey! Check out the PD test, that’ll give an “accurate” crossover chart.

The proposed DSM-V:

The proposed revision for the DSM-V is relatively complicated and has 3 essential criteria for PDs.

(1)  A rating of mild impairment or greater on the Levels of Personality Functioning (criterion A),

(2)  A rating of 

        (a)  a “good match” or “very good match” to a Personality Disorder Type or

       (b)  “quite a bit” or “extremely” descriptive on one or more of six Personality Trait Domains (criterion B).

(3)  Diagnosis also requires relative stability of (1) and (2) across time and situations, and excludes culturally normative personality features and those due to the direct physiological effects of a substance or a general medical condition.

Quite complicated indeed. However when you think about it, it fits. Normal personalities are complicated. Personality Disorders are complicated to the order of {insert large magnitude}.

Let’s look at each of these 3 new criteria:

1.) First, the general definition of what a personality disorder is has changed. It will now suggest that instead of a pervasive pattern of thinking/emotionality/behaving, a personality disorder reflects “adaptive failure” involving: “Impaired sense of self-identity” or “Failure to develop effective interpersonal functioning”.

See, now I disagree that it should be defined as {solely} an “adaptive failure”. This implies that Personality Disorders are strictly a product of your developmental environment. I’ve done a lot of research into biogenetic temperament, pathology, differences in brain affectations/structuring (all of which I’ll be posting on eventually) and there is a biological aspect to personality disorders. This definition seems to ignore those factors completely. Maybe they’re just focusing on the manifestations though. They can always do brain scans later. I for one want my brain scan.

The breakdown of “impaired sense of self-identity” and “failure to develop effective interpersonal functioning” is good though. They even have a little severity scoring system. I like all these scoring levels actually. It’s like a game of personality disorders. Step right up folks. Place your bets, put your credibility on the line. Spin the wheel of characteristic crazy and I’ll guess your personal pathology. Takers? Loser are the norm. Winners get a shiny new Personality Type. Woot!

Five personality types

2.a.) DSM-V has simplified the system by cutting down Personality Disorders from10 to 5:

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

Antisocial Personality Disorder (ASPD)

Borderline Personality Disorder (BPD)

Histrionic Personality Disorder (HPD)

Narcissistic Personality Disorder (NPD)

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

They plan to collapse these 10 into the following 5 buckets:

Antisocial/Psychopathic Type

Avoidant Type

Borderline Type

Obsessive-Compulsive Type

Schizotypal Type

Avoidant, O-C, and Schizotypal haven’t changed much. A/P Type and Borderline are apparently still pretty complex but hey! We made the cut! Take that Paranoid PD. Who’s watching you now? No one? Now you’ll never know. I’m actually not sure that this will make it easier to identify potential Personality Disorders. I don’t see why they couldn’t keep the established Personality Disorders and simply apply the new diagnostic techniques to them. This is supposed to be most helpful to clinicians who I suppose the DSM is specifically designed for, but it will make the information less accessible to the population at. Or, maybe the APA is trying to boost therapy sales by making it so confusing that patients need to seek professional help to figure out what’s wrong with them.

2.b.) Personality trait domains and facets

Finally there are a series of six personality “trait domains”. The six domains include: Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity and Schizotypy. Clinicians would be asked to rate each of the six domains on a 0-3 scale depending on how descriptive each is of the patient. The rating game continues.

Each of the six trait domains also comes with a subset of trait facets.  These are more descriptive indicators to help you decide which domains you fall under. I’m not sure these are enough. I fit all of these in some way, but then again, I have a Borderline Personality Disorder so Good Job! I think I just disproved my own concern. I guess when you pull the whole system together it will be able to distinguish maladaptive personalities versus, say, non-PD abuse victims, true A/P types versus your everyday douchebag.  Only time will tell I suppose.

3.)  And time is what it’s all about. One thing that has been kept from the DSM-IV is the fact that these characteristics need to be “stable”. I love that they use the term stable. Especially since the nature of half of these disorders is how generally unstable people with PDs can be. I know what they mean of course; these problems are persistent and unchanging over time and not situation dependent.

So there you have it. The new DSM-V.

I am curious as to where Narcissistic Personality Disorder will fall. Traditionally it’s a Cluster B group with BPD, Histrionic, and ASPD. My first inclination would be to say it will fall under the Borderline Type. BPD/HPD are highly reactive, often characterized by narc traits and there’s a more prevalent sense of needing people in some manner than is ASPD.  The inflated grandiosity and a pervasive pattern of taking advantage of other people suggests the A/P Type definition though(so obviously defined with narc traits). Maybe since narcissism is so pervasive in the PD spectrum the DSM believes it’s a symptom, a not a distinct problem. Sorry narcs, apparently you’re not important enough to have your own group anymore. Wow, that’s going to piss someone off; take that their egos! And for that matter, ASPD is also Cluster B and is even more commonly associated with BPD as a male/female flip side. It’s just so typical that the ASPDs would leave BPDs and take up with a more aggressive group. At least we still have the Histrionics. It’s gonna be a sexy fun time for the Borderline Types. Just sayin’.

Hypersensitivty: Conceptions of Borderline Personality Disorder – Part 4

Criteria 5 of the latest list from John G. Gunderson. Taking a deeper look into this one was the original reason I wanted to get into these conceptions more thoroughly. Along the way, in even a few days, my own perception of what this means to me has evolved.

– Hypersensitivity, meaning an unusual sensitivity to nonverbal communication. Gunderson notes that this can be confused with distortion if practitioners are not careful (somewhat similar to Herman’s statement that, while survivors of intense long-term trauma may have unrealistic notions of the power realities of the situation they were in, their notions are likely to be closer to reality than the therapist might think)

Hm. I’m wary of this because I don’t want to confuse it with distortion. So I found a couple of definitions that seem pretty accurate to me.

1.) Hypersensitivity (also called hypersensitivity reaction) – Hypersensitivity reactions require a pre-sensitized (immune) state of the host.  

–       This definition refers to the immune system, but I think it fits with the mental state of the Borderline Personality as well. We are pre-sensitized to the emotions projected from ourselves and from the world, making the additional pressure compound even more.

2.) Being hypersensitive could be described as being allergic to life. For the highly sensitive person (HSP) a seemingly ordinary day can be overwhelming. Even the most subtle of stimulants a person encounters on a daily basis can be over-stimulating. Energies associated with touch, noise, scent, light, etc. are often too quickly or deeply absorbed by the HSP. As a result, the HSP may become mentally confused, emotionally upset, and/or physically uncomfortable. Hypersensitivity is also associated with a heightened sense of awareness and intuition. This makes being a HSP or empath a two-way street.

For me, hypersensitivity comes most often in social interactions. Too many voices, too much noise, too many people, too close. Voices volleying back and force. The crush of noise pressing inside my head, filling my mind and making it frantic, reaching for the quiet. Bodies sharing my space, not leaving me enough room, not enough air to breathe. Too many eyes falling on me, dissecting me. Turning me inside out so all I can feel is the falling back into myself.

Flashes, too bright, 8 mm film reels, projection noise, film flapping, screeching halt, Go, padded hallways constricting as you make your way through, goose down filling your lungs soft and suffocating.

It’s almost impossible to follow one line of thought, every external conversation clashing with the internal monologues branching off and running away in my own head. The noise is deafening, lost in the static. Everything comes too fast, and I can watch myself, too slow, cover my ears and hold myself together.  That slow motion screen shot of a woman screaming, curled up in a corner, pulling at her hair to make it all stop…. Except it’s just another day, at the dinner table, in a friends living room, out to lunch with co-workers.

Other days it’s like feeding off of other people’s energy. Calm people are the best. This is one reason I do like Friend so much. When it’s just us, the influence between us is very calm, almost silent. Still. Other people, most people, have fragmented energy, turbulence that rolls off of them in waves. It’s clear in the motions, their manner and speech. Impossible to ignore, it permeates the thin skin separating us and their energy leaks in, pushing our own out. It’s too easy to feel what they feel. Confusing. I have a hard enough time figuring out my own feelings most days. The last thing I need is to figure out someone else’s and pick it apart to figure out which is mine and which is foreign on top of that.

Most days being hypersensitive isn’t too much of a problem. Eyes are the worst. I hate people watching me, looking at me. I keep to myself. Keep random conversations to a minimum. I’ve perfected a determined pace and lack of eye contact that keeps my interaction as little as possible.  Oddly, I love being out in the machine shop or the lab floor. I’ve always loved being out in the shop. The metallic smell, the loud machines, everything running and operating, noisy and dirty… mechanic. Machines. Not people. Machines don’t overwhelm me. Just people.  

Other times I think this contributes to reading too much into other peoples actions. Bridging the emotional gap between a normal relationship and the distorted one. Every compliment is uplifting, creating a warm glow. Every small gesture a glimpse into what another person is feeling. If you can see it, it must be there. You can read more in a person’s body language than from what they’re actually saying more often than not. Picking up on the unspoken cues, especially when they’re in conflict with the verbal ones, is a mess. Thoughts collide and become a confusing mash of disbelief and desire.  Not knowing what to believe and what you want to be true. Even the smallest negative reaction, building on other actions pointing down a path you don’t want to travel. Noticing everything. When someone pushes back, even a little, it’s obvious. Why? Because we look for it. Hoping it’s not there, but expecting it, seeing it, is frightening. Then what do you do from there?

All of it. It makes me cringe. Stops my breath and curl into a ball. Flight. I can’t fight it out and expect anyone to treat me as sane. I walk out, walk away. Learned to hold it in, until I can get myself out. Getting out is the only thing I know to do. Remove myself from the source, the scene, until I can get a handle on my reality and calm down. Stabilize myself enough to go back and keep going. It doesn’t always work. Sometimes I have to leave completely, go home and go to bed, or just drive aimlessly, left alone to the quiet night. I like the darkness. My monsters lurk in the light.

Distortion: Conceptions of Borderline Personality Disorder – Part 3

Getting back to our look at Gundersons’ Conceptions of BPD… 


– Distorted thoughts/perceptions, particularly in terms of relationships and interactions with others

Ugh. Yes. These come in various forms for me. 

Wanting there to be more than there is. ::sigh:: I do this at some point, in almost every relationship, be it romantic or platonic, that I’ve ever had. There’s an time where I could fall in love with everyone I let close. If I have a significant other, this can be a fleeting moment. More often I want to be more to people than I want them to be for me. Once I’ve let someone in, once they’ve become very close to me, the relationship builds in my mind. I have a hard time distinguishing between healthy platonic love and romantic love, almost obsessive desire. I want it to become more. I see more. If there’s more, then they won’t want to let me go. They won’t walk away, won’t leave, won’t abandon me. If I’m more, if I can provide everything someone needs, they’ll need me in a way that does not make me expendable.

Or, the extreme opposite… wanting someone to want absolutely nothing more than there is. To not be any closer, to not confide in me more, to not touch me, sit near me… keep a very distinct distance. I have a very difficult time with blurry lines and familial relationships. They’re either very close, or a mile apart.

Splitting. All good. All bad. Hero or villain. I generally give people a wary benefit of the doubt at first.  I can take a lot. I can deal with a lot. I put up with a lot. Until I can’t. Sometimes this fluxuates. It depends on how things were the last time I saw someone. If I’ve been slighted, hurt, embarrassed, clearly this person doesn’t give a rats ass about me anymore. Everything we’ve been through together has been a lie. All they’ve done is use me, to torment me, to push me further from people that would actually care in an attempt to break me. They’re terrible. And so am I. If they could treat me this way, I must deserve it in some way. Right? Wrong. Or they’re wonderful, considerate, closer to me than anyone else in the world.  I can trust them completely and know they always have my best interest in mind. I’m someone of value to deserve such wonderful friends. They can do nothing wrong. Until they do. Then redeem themselves. Back and forth. There’s no middle ground. No grey area. No understanding that just because someone messes up, that it doesn’t nullify every other aspect of the relationship.

Or in some instances, and really there have been a lot…. I take so much, I absorb so much of people’s energy, believe them so good, for so long.  Give them more support than I can manage for myself, be there at all hours of the night, providing everything I can to comfort or console or provide some semblance of happiness… until they’ve sucked up all I have to give, and I can’t give anymore. Oh somewhere along the way I usually fuck something up, something not terribly important, but I’m human and it feels more important than it should be, then everything I do is wrong. Nothing I do is good enough anymore, they keep putting more on me until finally the weight of their needs and expectations and my guilt, breaks me. And they’re forever ruined to me. Once this happens, it’s done. There’s no going back, no longer anything to salvage. It’s just over. The near endless energy I have, is severed. If you’re close enough to me that I will pour every emotional ounce into you, leaving very little to take care of myself, and you refuse to allow me any flexibility to be human, I break under the pressure, and some things simply cannot be rebuilt. And I no longer want to try. I move on.

Paranoia. Paranoia isn’t such a problem for me. Well, I mean, it is, just not my biggest problem. I always think people are taking digs at me, trying to make me uncomfortable or alienate me, undermine my intelligence… but I can usually keep these thoughts controlled enough that I don’t make a scene from them. I hold them in, let them fester, and then silently implode instead of directly confronting the person(s) that make me feel this way. Which if I would do from the onset, civilly, ask if that was what they meant or if I was just interpreting it wrong, but that would be rational, and when you’re rather paranoid, well, it would also be embarrassing to show people just how paranoid you really are.

It’s always intense. Wild euphoria, heady love, blistering revenge or seething wrath. Not, slightly prickly or mildly satisfied. In between states of emotion are uncommon. Sure there are calm days. Days of relative contentment, but they’re disproportionately rare. 

I’m sure there are other ways for other people. Anyone experience other ways? These were the three things that popped out at me as I’m writing this. 

Rescue me: Conceptions of Borderline Personality Disorder – Part 2

I’ve talked about self-destructive behavior before but not from a damsel in distress sort of perspective. John G. Gunderson’s next conception of BPD is: 


– Repetitive self-destructive behavior, often designed to prompt rescue:  

Self destructive behavior is always an indicator that 

something is wrong. What exactly is wrong is sometimes impossible to pin point. There may be no rational idea of what it is, only a feeling that something isn’t right, necessary, and not there. When you can’t identify the cause in yourself, it’s a natural extension to look outward, to someone else for ‘answers’. When you can’t help yourself, maybe someone else can. Now, I will say that a lot of people that embrace self-destructive/masochistic behaviors may not be looking for rescue or help. It is an indicator that there is something wrong but many people that display such tendencies keep these hidden. I’ve fluxuated though I tend to keep it hidden.

For those that don’t make an attempt to hide these behaviors, they are very often a cry for help. When you have no idea what is causing such empty, hollow, toxic feelings it’s like your mind has been dropped into a pit of despair with no way to claw yourself out. This might be a foundation for why people with BPD latch on so tightly to those close to them. Look to them for help to pull themselves up. Or to be their savior and pull them out of the dark completely.  Talking through problems is normal, but someone with BPD doesn’t feel things normally. Feelings are intense, often brutal, needing release /right now/, causing the person to act out in ways that will gain them attention. Attention that will make people notice /right now/. Act, right now. Attention from someone that will care for them, care for them enough to stop them, to protect them from themselves and the emptiness or hurt that is so pervasive. Rescue them from themselves. 

In general and especially when I was in college I kept my self destructive behavior completely hidden. I didn’t want help. I didn’t want to let anyone in. I didn’t want anyone to know I was in pain. I didn’t want anyone to know I was vulnerable. It was my way of coping, reminding myself that I was still alive, connected to the world when I had no one to lean on.

It’s incredibly embarrassing for me to admit that I have ever done this with the intention of gaining someone’s attention. In high school I did this more times than I care to admit (though not as much as I could have), but only with one specific person.  Be it a cry to help stop my eating disorder or threats of suicide, I needed to know someone cared. Someone that I wanted so badly to care for me, to care. Oddly when I was cutting or burning I rarely let anyone know and hid this as best I could.

Evil-ex would spin me out of control so bad that I would have complete nervous breakdowns, destroyed by the shear levels of anxiety and inability to maintain my own sanity. I needed to remember that I was connected to something. Instead of cutting I would beg him to take my knives away and keep them from me. This got his attention but also contempt. I never got the care or support I so desperately needed. Eventually I no longer needed to injure myself. Dating him, living with him, was more painful than anything I could do to myself.

The few times Boring-ex and I broke up were the only times I got emotional with him at all. I couldn’t stand being with him most of the time. But I was frantic at the thought of losing someone else once I had ended it. The last time we broke up was actually a shock to me and I acted out without thinking, made a veiled threat of suicide… he needed to know how badly he had hurt me. I needed him to remember I wasn’t someone he could throw away. Wanted him to take back what he’d said and want to take care of me. (This was immediately after we broke up so of course I wanted him back). While I did injure myself, I didn’t actually have any intention of killing myself, but he didn’t know that. This got the cops called on me and a trip to the psychiatric ER. Fail.  

The only commonality between these incidents; none of them have ever gained me the outcome I’d hoped for. Never once, did I get the kind of love, protection, or caring that I wanted. Utterly ineffective and only resulted in more pain and drama for everyone involved.

Considering I have an 18 year history of self-harm the times I’ve done it with the desire to have someone care for me are relatively rare. Except in my most turbulent periods, generally I’ve never believed in anyone enough to rely on someone to rescue me.  I have to rescue myself. Everyone else just let’s me down.

I’ve also come to the realization that this is a terrible way to get attention. While yes, in the short term it may inspire immediate reaction and attention, once the initial shock is over, it often inspires fear, disgust, and the people you want to be closer to push away. Most people can’t handle, or don’t want to be the rescuer. Regardless of how much you may want someone to rescue you, someone else will not see it this way. Having such a big responsibility thrown at them is scary and may cause them to draw away in order to avoid the drama and frustration of dealing with someone that is incapable of dealing with themselves. Your average person also isn’t equipped mentally or emotionally to handle such situations. Going to someone you care about, telling them that you need help and support to get professional help is a much wiser course of action that will be much healthier in the long run.  

Conceptions of Borderline Personality Disorder: Intense unstable relationships

As I was just discussing Gunderson’s work I will continue with another of his conceptions of BPD. It’s not necessarily new information, but it’s succinct and gets right to the heart of borderline behavior and thoughts.

Gunderson, a psychoanalyst, is respected by researchers in many diverse areas of psychology and psychiatry. His focus tends to be on the differential diagnosis of Borderline Personality Disorder, and Cauwels gives Gunderson’s criteria in order of their importance:

• Intense unstable relationships in which the borderline always ends up getting hurt. Gunderson admits that this symptom is somewhat general, but considers it so central to BPD that he says he would hesitate to diagnose a patient as BPD without its presence.
• Repetitive self-destructive behavior, often designed to prompt rescue.
• Chronic fear of abandonment and panic when forced to be alone.
• Distorted thoughts/perceptions, particularly in terms of relationships and interactions with others.
• Hypersensitivity, meaning an unusual sensitivity to nonverbal communication. Gunderson notes that this can be confused with distortion if practitioners are not careful (somewhat similar to Herman’s statement that, while survivors of intense long-term trauma may have unrealistic notions of the power realities of the situation they were in, their notions are likely to be closer to reality than the therapist might think).
• Impulsive behaviors that often embarrass the borderline later.
• Poor social adaptation: in a way, borderlines tend not to know or understand the rules regarding performance in job and academic settings.

Intense. Unstable. Relationships. In which the borderline always ends up getting hurt. Why am I repeating this? Because it’s true. The inability to regulate emotional control does not allow for a borderline to maintain emotional safeguards. Whether the issues that arise are due to the other person or internal (or external) conflict brought about by someone with BPD, it is all felt internally, as an emotional attack. With no way to shield from {self} inflicted damage, no protective emotional layer, it’s nearly impossible for someone with BPD to escape unscathed from a relationship. Any amount of change, fear of abandonment, or even perceived excessive closeness can disrupt the fragile stability that a borderline holds to. This can cause an almost simultaneous fight, flight and fear response. When emotions run so intensely there is an inner conflict of needing to protect oneself and needing to be protected. Wanting someone close, and needing space in order to not get hurt. Especially after several relationships of always getting hurt and expectations that this will continue. When someone gets too close the need to run away, push away, pull back to preserve the tenuous sense of self is increasingly strong. To not let someone close enough to hurt them again, is even stronger. In order to do this someone with BPD may lash out, pick a fight, or any number of ways to fend off a suffocating closeness – to fight free.  If not immediately, soon after, these feelings are replaced with fear, panic at the thought of being alone. The need to regain what could be lost forever if it is not won back right away. Emotional displays, promises, intense affection, apologies, anything to regain what a borderline fears to lose may be done to regain an emotional stability. It’s difficult for someone without BPD to understand this intense clash of emotions, and even more difficult to deal with at times. Someone who doesn’t understand what is going on is likely to respond in kind to whatever action is being taken. Someone with BPD, in the moments of panic, cannot always internalize their own role in what is happening. They can only feel what is being directed at them compounded on top of their already unstable emotions. Even if the non-BPD person tries to do the opposite; be kind, understanding, it may also be met with conflicting emotions. A borderline will feel even more smothered, increasing the need to run, making him/her feel even more misunderstood because what they need is not being recognized. The rub though, is that someone with BPD doesn’t always recognize what it is that they need. They only feel that someone/thing is wrong or too much or detrimental or out of their reach without knowing how to rationally work to fix this.  The result is an intensely fluxuating relationship of needing to be close and safe and needing to preserve a sense of self… to be safe.

I wasn’t originally going to discuss each of these criteria on their own, but while writing this I realize I  have too many thoughts on many of these points so I’ll make this a multi-part series.

Social and Cultural Factors: Origins of BPD

Back to the theories of John G. Gunderson… 

Social and Cultural Factors

Evidence shows that borderline personality is found in about 1 -2% of the population. There may be societal and cultural factors which contribute to variations in its prevalence. A society which is fast-paced, highly mobile, and where family situations may be unstable due to divorce, economic factors, or other pressures on the caregivers, may encourage development of this disorder.

I’ve already mentioned the percentage of the population that is suspected to have BPD. That the pervasiveness in our society has to do with the failings of society itself is interesting. With fear of abandonment, separation, instability, inability to attach, emotional upheaval … it’s easy to see how society could influence this. Especially if the numbers of BPD have increased exponentially or in a manner disproportionate to that of normal population growth. With the destruction of the typical nuclear family, both parents in the work force, constant moving to accommodate a moving job market… all make it difficult for children to find stability. I don’t think this is enough though. Just as many people with BPD are abuse victims, more than that number have suffered abuse and don’t develop personality disorders at all. A society that expects more, pushes harder, is more likely to adversely affect those with the predisposition for BPD (or other personality disorders), but I don’t think it’s enough to say that it is a primary cause. The pace and change in society is not new, it’s on going and ever present and millions, if not billions of people deal with it every day. I do think that if the predisposition for BPD exists that these things could certainly contribute, but I don’t think they are a cause in and of itself.

Aside:  It makes me wonder about the military brats in particular. I wonder if there is a higher discrepancy in the military community for BPD than in regular society.  It would be an interesting study in ratios if it could be done. 

Psychological Factors: Origins of Borderline Personality Disorder

Some of this information is a bit repeat-o from things I’ve mentioned previously, but I feel it’s important to provide the findings of various experts on the subject of BPD as it is all relevant and useful. So continuing on with the theories of John G. Gunderson M.D…. 

Psychological Factors

Like most other mental illnesses, Borderline Personality Disorder does not appear to originate during a specific, discrete phase of development. Recent studies have suggested that pre-borderline children fail to learn accurate ways to identify feelings or to accurately attribute motives in themselves and others (often called failures of “mentalization”). Such children fail to develop basic mental capacities that constitute a stable sense of self and make themselves or others understandable or predictable. 

One important theory has emphasized the critical role of an invalidating environment. This occurs when a child is led to believe that his or her feelings, thoughts and perceptions are not real or do not matter. About 70% of people with BPD report a history of physical and/or sexual abuse. Childhood traumas may contribute to symptoms such as alienation, the desperate search for protective relationships, and the eruption of intense feelings that characterize BPD. Still, since relatively few people who are physically or sexually abused develop the borderline disorder (or any other psychiatric disorder), it is essential to consider temperamental disposition. Since BPD can develop without such experiences, these traumas are not sufficient or enough by themselves to explain the illness. Still, sexual or other abuse can be the “ultimate” invalidating environment. Indeed, when the abuser is a caretaker, the child may need to engage in splitting (denying feelings of hatred and revulsion in order to preserve the idea of being loved). Approximately 30% of people with BPD have experienced early parental loss or prolonged separation from t heir parents, experiences believed to contribute to the Borderline patient’s fears of abandonment.

People with BPD frequently report feeling neglected during their childhood. Sometimes the sources for this sense of neglect are not obvious and might be due toa  sense of not being sufficiently understood. Patients often report feeling alienated or disconnected from their families. Often they attribute the difficulties in communication to their parents. However, the BPD individual’s impaired ability to describe and communicate feelings or needs, or resistance to self-disclosure may be a significant cause of the feelings of neglect and alienation.

Persons who have been adopted are statistically more likely to develop BPD than the general population. Adopted children often fantasize that their “real” biological parents could have and would have protected them from the frustrations and hurts they have experienced. Indeed, the hope and belief that if only such idealized and nurturing caregivers could be found, then life’s problems would be solved, is central to what BPD patients (whether adopted or not) pursue in relationships with others.

I can NOT attest to physical or sexual abuse when I was a child. But as mentioned in this post I have very strong, distinct memories of having my feelings and accomplishments invalidated. Also the ‘traumatic’ experience of thinking my mother abandoned me when she was in the hospital giving birth to my brother. For many years following this though, I didn’t see my mother much. My parents believed that one of them should ALWAYS be home with us so my dad worked days, and my mom worked nights. Subsequently when my mom was home, she’d be asleep, and when she would wake up it would then be time for me to go to bed. So I didn’t get to see her very much until high school and I had a greater attachment to my father, who was not the most adept with an emotionally challenged daughter. I was often expected to respond like a boy would respond; no emotions, no crying, suck it up, deal. With my mom so often being absent during my weekdays, I didn’t really have a chance to learn to express or deal with my emotions properly. I felt the need to suppress part of myself, couldn’t relate to myself, or my dad. I definitely don’t think he understood what I needed. Hell, I still don’t think he understands what I need emotionally, but I’ve since given up trying.

My problems with this may have started with my parents, but they relationships and friendships I developed when I became older certainly did not help. My splitting developed in much stronger ways once I was older. Probably starting around the time I was 13, and amplifying steadily through high school and especially over the last few years.

I’m intrigued by the adoption theory. I can easily see how this would manifest in adopted children. Especially when I was a teenager I used to WISH that I was adopted. I had these same fantasies that I might be adopted and my real parents might actually understand me, might actually care enough to fix me, could actually save me from myself. Of course this wasn’t the case. I’m not adopted. What’s more? I actively refused help and pushed away anyone prohibiting the possibility that someone might understand me.

It’s odd writing about this some days. I have these very clear memories, but writing them down, writing about them, seems so clinical. Like it wasn’t me that went through this, I just watched someone else that looked like me go through it all.  Recording objectively. 

Inborn Biogenetic Temperaments: Origins of Borderline Personality Disorder

There is not one thing that leads to the development of BPD. Nature vs. Nurture, Psychological Factors, Social and Cultural Factors, Pathology… these things and more lead to the presentation of a Borderline Personality Disorder. I’m going to start looking into these things, take a more in depth look as some of the influencing considerations.  

In an article called A BPD Brief by John G. Gunderson, M.D. he talks about the Inborn Biogenetic Temperaments that lead to the development of BPD.

The degree to which Borderline Personality Disorder is caused by inborn factors called the “level of heritability” is estimated to be 68%. This is about the same as for bipolar disorder. What is believed to be inherited is not the disorder, per se, but the biogenetic dispositions, temperaments. Specifically, BPD can develop only in those children who are born with one or more of the three underlying temperaments or phynotypes: 

1.) Affect dysregulation

2.) Impulsivity

3.) Disturbed attachments 

Such temperaments represent an individual’s predisposition to emotionality, impulsivity, or relationship problems. For children with these temperaments, environmental factors can then significantly delimit or exacerbate these inborn traits.

Many studies have shown that disorders of emotional regulation or impulsivity are disproportionateloy higher in relatives of BPD patients. The affect/emotion temperament predisposes individuals to being easily upset, angry, depressed, and anxious. The impulsivity temperament predisposes individuals to act without thinking of the consequences, or even to purposefully seek dangerous activities. The disturbed attachment temperament probably starts with extreme sensitivity to separations or rejections. Another theory has proposed that patients with BPD are born with excessive aggression which is genetically based (as opposed to being environmental in origin). A child born with a placid or passive temperament would be unlikely to ever develop BPD.

Normal neurological function is needed for such complex tasts as impulse control, regulation of emotions, and perception of social cues. Studies of BPD patients have identified an increased incidence of neurological dysfunctions, often subtle, that are discernible on close examination. The largest portion of the brain is the cerebrum, the upper section, where information is interpreted coming in from the senses, and from hich conscious thoughts and voluntary movements are thought to emanate. Preliminary studies have found that individuals with BPD have a diminished serotonergic response to stimulation in these areas of the cerebrum and that the lower levels of brain activity may promote impulsive behavior. The limbic system, located at the center of the brain, is sometimes thought of as “the emotional brain”, and consists of the amygdale,  hippocampus, thalamus, hypothalamus, and parts of the brain stem. There is evidence that the volume of the amgydala and hippocampus portions of the brain, so critical for emotional functioning, are smaller in those with BPD. It is not clear whether such neurological irregularities have either genetic or environmental sources.

In summary, research indicates that individuals who have difficulty with impulse control and aggression have reduced levels of activity in t heir brains in a number of key locations. It is theorized that in personas with BPD, mild to moderate impairments in severl systems result in “errors” in the gathering, dissemination, and interpretations of data, and they are consequently more likely to respond with acts of impulsivity or aggression.

Can’t say as I have any arguments against this one. It seems pretty natural that someone with an emotional regulation problem would have the inborn genetics that predispose them to not regulate their emotions well.

I manage to fall into all 3 of the phenotype classes. Some more than others.

Affect dysregulation: Check.  My constant depression and anxiety aside, my temper flares, small things that any normal person would dismiss, bury themselves deep under my skin, set my fury on fire, I can’t let go of the thoughts and actions (intentional or not) that hurt me, and sink me into a murky mental grave. Every. Single. Thing… seems to affect me. Unless I go numb, shut myself off from the world, the people in my world, I can’t escape the barrage of sensations that affect my mood. I won’t say this is all the time,  I do manage to have short periods of times, sometimes a few days at a time, that are stable and okay, where my thoughts and moods don’t run away with me, but in the end, these don’t last.

Impulsivity temperament: Check.  I’m not so much with the not thinking about consequences. I can’t not think about consequences. I think about everything. I analyze things to death. Every path, every permutation, I think about it. Now ask me if that stops me. Not usually. I know the dangers, and I do it anyways. I’m too smart to ignore the consequences, but not smart enough to stop myself from pursuing the dangers, or maybe not smart enough to force myself to care about the consequences. I throw myself into things, the dangerous and the safe, the helpful and the harmful. I take it all in, until it all wears me out.

Disturbed attachment: Check.  Extreme sensitivity to separations and rejections. Some of my earliest childhood memories are of being afraid of rejection, not being able to please my father with my coloring, not being good enough, worrying that my mother wouldn’t come home from the hospital because no one told me she wouldn’t be gone forever.  These things are so small, so innocuous, I can’t imagine my reactions to these were normal. Who fears their father will stop loving them, or be gripped with anger, anxiety, and disappointment because a picture was ‘ruined’?  I had good parents that love me a lot, I don’t think they ever meant me any harm or intentional hurt, yet even in my earliest memories I read so much hurt and anxiety into the things that rocked my little world. I don’t believe it was anything they tried to do to me.

So , do I believe that my BPD is based, at least in part, to inborn traits? Yes, yes I do.

That’s not to say that the events and environments in my life didn’t contribute and exacerbate my problems. There’s no denying that. I can’t help but wonder though, if I wasn’t predisposed to feel, react, the way I do, would all these things ever have affected me the way they did? Still do?

Maybe I’m just hoping that there can be a genetic marker to pin point the brain dysfunction. If there’s a biological indicator, than there’s potential for a medical ‘cure’. Something that can be done to regulate those parts of the brain that don’t function to normal levels. I’m not sure you can actually cure a ‘personality’ {disorder}, but if there’s a genetic factor, than there’s possibly some scientific tinkering to help. I have a lot of faith in science (ß— Irony).

What causes BPD? Linehan Theory – Part 4

Continuing my 4 Part series of Dr. Linehan’s theory I’ll now explore Unremitted crisis vs. Inhibited grief.

Unremitted crisis– uninterrupted; constant, unpardoned (as a sin) feeling that a condition of instability or danger leading to a decisive change which the trend of all future events, esp. for better or for worse, is determined by a dramatic emotional or circumstantial upheaval in a person’s life. Steadily maintained.

Ok, yes. Especially with my depression and trying to hold onto the thought that people care about me and aren’t going to leave, I always feel like I’m struggling to hold on. Everything feels dire or like there’s impending doom whether it’s externally perceived or battling my own internal thoughts and feelings. I NEED to understand what’s happening and what’s more I need those that care for me to understand, intervene, be there for me to lean on if I need.

What’s more I often feel like people won’t forgive me for any small infraction. I get worked up if I’ve done anything wrong and have a nearly fatalistic attitude that people will walk out of my life. Dissolving in a puddle of self doubt until I can prove that I am not a bad person. Again, this has to do with my inability to believe that one action does not negate all previous actions. That people take me as a whole series of our interactions not just single episodes. I can’t say this is completely unjustified though. I have had people, people that I was very close too, walk out of my life at the first infraction (however big), or once a single mistake was made all further actions were then in question and I was made to feel like I wouldn’t be forgiven no matter what I did to make up for it. While this may be true, it’s not entirely unjustified, but now it permeates my experiences with people.

Fortunately my current apartment and roommate are a safe haven for me, I have some reprieve from the constant upheaval. Some, not always, but it’s at least a calm environment.

Inhibited grief – to restrain, hinder, arrest, or check keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret.

Definitely. I’m at constant odds whether I have a right to feel the way I do about any given situation. I don’t understand what I’m allowed to expect or what I deserve from other people so I constantly question whether my emotional responses are appropriate. Do people really owe me anything? What can I actually expect of them? What do I deserve from people when I need help? Do I have a right to impinge on their time and divert their attention from what they were doing? Especially if it’s from a loss. I’m sure things are often my fault, guilt, and I don’t know if I have the right to believe/expect that others should work things out with me. If I don’t have the right, then my feelings aren’t justified and I need to hold them in. But when I know something isn’t entirely my fault, I feel absolutely no remorse if the contributing party isn’t willing to communicate with me. Black or white.

I may want to pursue the topic, push someone to work things through with me but I restrain myself for feeling like I have no right to do so. I hold back and wait. Which only causes me to get more anxious and allows my thoughts to wander down all the possibilities that may be going through their minds and often come to the worst conclusions in my own mind. I feel the loss, sadness, over something that hasn’t even occurred yet. Or may never occur at all. I can’t quiet the distress that it creates and suffer for it in silence being unable to decide if I’m allowed to pursue a solution just to make myself feel better. Then I regret not being able to rectify whatever it was that occurred. This cycles back to making myself feel guilty for something that may or may not be my fault.

What causes BPD? Linehan theory Part 3

Up next we have: Active passivity vs. Apparent Competence

Active passivity – this is defined as: the tendency to be passive when confronted with a problem and actively seek a rescuer. 

 No. Not even a little. When confronted with a problem I confront it right back. I don’t run away from anything. I’m not afraid of people’s reactions in the way that is typical of BPD. I’m hate the thought of negative outcomes but I also believe that as long as a problem can be worked on, talked through, and people are willing to communicate it is possible to get through a problem and not have a devastating outcome. I suspect my Dissociative Disorder acts up in this arena as well. When faced with conflict my emotions turn off completely and I argue with pure logic. I can talk about emotions but not feel them. Then if it becomes inevitable that a situation can not be resolved I go numb to the negative emotions that should come of it. This doesn’t always work. However, I don’t need a white knight, I’ll save myself, thanks.

My personality tends to be too dominant, independent to rely on other people. I can see where some passivity comes into my life, and I guess if I’m really honest, I do hope for someone to come along, see me, and accept me for all that I am. Save me from a lifetime of loneliness. But I’m also not willing to latch onto every shmuck that falls my way. I have standards after all.

Apparent competence – appearing to be capable when in reality internally things are falling apart. Sure. Because I actually am extremely competent. I worked my ass off to be intellectually, logically, mentally competent in some of the hardest fields I could have chosen to pursue. Not to mention some very useful creative fields. I read constantly and I know A LOT about a great many things. That doesn’t mean that internally things aren’t still falling apart for me though.

After a lifetime of rollercoaster emotions I’m disgusted by my own lack of control in this arena. I’ve worked hard to control my emotions. I learned to mask my inner turmoil, not display it, so I always appear calm and rational. In my defense, I am rational. But sometimes it’s too hard to get past the overwhelming emotional upheaval to think straight. I often have the impulse to lash out and say things that reflect how I feel, but I’m sick of being ruled by my emotions, so I hold in my reactions. It doesn’t stop me from experiencing them, but it stops the expression of them. I try very hard not to unleash my emotions publically because the repercussions would only act to alienate me from the people around me. When this happens, I try not to be around other people. I hate anyone seeing me like this. I’d rather them continue to believe the calm, friendly façade. However, underneath the surface little by little it builds up until I can’t control it and I have to either physically vent my emotional frustration or have a self inflicted melt down, alone.

I’m learning how to deal with this though. Through therapy and my journaling I am learning to recognize the emotions that are not … for a given instance. Once you can recognize that a situation is not beyond your capacity to handle, can take a step back and analyze why a feeling is so intense it becomes easier to understand it and thus, manage it and learn to respond more appropriately in the future. It’s not easy, and it doesn’t happen overnight, but it does work. So maybe this field isn’t quite a ‘yes’ for me either because I actually am learning to competently deal with my emotions.

As a side note: I HATE considering myself an emotional person. Anyone that meets me and gets to know me a little would tell you I am one of the most rational women you’ve ever met. Not emotional at all. Just like one of the guys. Crude, funny, outgoing and witty. These certainly are parts of my personality, but they’re parts I put into focus in order to mask everything else beneath the surface.