Cognitively Speaking….

Therapy. It’s useful. It’s useful to most people, not just those with characterological problems (a.k.a. personality disorders). There are so many different kinds of therapy and therapeutic techniques that it can be dizzying to decide which is best for you. Fortunately most people don’t have to worry about making this decision. If you’re stressed out from work, having issues with a spouse, not sleeping, fighting drug or alcohol abuse… there are a multitude of programs and therapies specifically designed and tailored for each of these. Especially Cognitive Behavioral Therapy which focuses on treating people that display all those Axis-I disorders that a good majority of the population experience from time to time.
That said, Cognitive Behavioral Therapy likely isn’t enough for someone with Borderline Personality Disorder. In fact, I’m not sure any singular type is as effective as a combination of therapies since not only are we an Axis-II disorder but an incredible majority of us also display comorbid Axis-I issues and disorders as well. It only makes sense to me that if you have a multitude of manias it would make sense that you should use a multitude of techniques to tackle the entire spectrum.  
The very nature of personality disorders means that the way we perceive the world, how we interact with the world, how we experience emotion and our very selves is quite different than your average Joe. By extension, how we are capable of utilizing, dealing with, and incorporating therapeutic technique is also going to be different. That’s not to say that we don’t want to work through things, obviously this may not be the case, but since our base functioning is different, we need to approach these problems from a different point of view.
Quite often traditional CBT makes basic assumptions of its patients that don’t apply to the “normal” state of someone with BPD. Normal is relative right? When ‘normal’ is incapable of feeling these things in the same way, these basic assumptions flounder and fail. Different strokes for different folks and all. So where might basic CBT therapeutic assumptions cause issue for the personality disordered?
Assumption 1: Patients will comply with the treatment protocol.
            Now this doesn’t translate as a desire to be difficult. The first time I went into therapy it was not from a desire to move beyond my borderline, but from a place of needing support to deal with an abusive significant other. I was more interested in obtaining consolation and recognition of my suffering than in understanding and fixing the problems that lead me to be in that situation in the first place. Hell, at the time I wasn’t even certain of the exact problems that fixed me into that black hole of emotional destruction. (I do realize it is unfair to black holes to compare them to my Evil-Ex). But because I didn’t understand the detrimental thought processes that kept me from leaving I couldn’t internalize the techniques that my therapist was giving me to help me cope. My point is, often for PD patients therapy is complicated and it’s not so straight forward for us to take on CBT techniques. With wildly fluxuating mood swings we might one day recognize that we have severe problems that we would give anything to be rid of, while the next we may rail against the idea that what is wrong with us is in need of fixing. It’s not easy to admit that there’s something fundamentally flawed with your make-up. It hurts and it’s hard to see that something you can’t control should hold such sway over your world beyond your ability. You were born this way, that means you’re supposed to be this way, right? What’s wrong with that? Ultimately we were given what we were given and it is our responsibility to manage ourselves. Life rarely turns out the way you expect it would. For anyone.     
Assumption 2: With brief training, patients can access their cognitions and emotions and report them to the therapist.
Cue the broken record. Someone with a Borderline Personality Disorder does not experience emotions the way a normal person does, by definition. Sometimes the buildup of emotion is so frustrating and such a jumble of so many different things that it’s impossible to distinguish individual thoughts or feelings. Or patients may block disturbing thoughts and images in a cognitive or affective avoidance of disturbing memories and negative feelings. When you learn that by avoiding negative stimuli you reduce your susceptibility to pain, it becomes ingrained into your habits and lifestyle. Breaking an instinctive pattern that you’ve developed as a maladaptive coping strategy isn’t easy. To first face those things that hurt you in order to finally move past them takes courage and time to reach that place of strength. Or you have someone like me that is dissociative on top of my other issues. Where something should inspire intense emotions all I can describe is…. A blank. A void of feeling like speeding to the pinnacle of Mount Everest with emotions ramping up higher and faster only to divert into a dark cave before you hit the top and, stop. How do you navigate the void?  
Assumption 3:   Patients can change their problematic cognitions and behaviors through such practices as empirical analysis, logical discourse, experimentation, gradual steps, and repetition.
The problem here is that our problems are rarely so straight forward. Our issues have issues.  “Because characterological patients usually lack psychological flexibility, they are much less responsive to CB techniques and frequently do not make meaningful changes in a short period of time. Rather, they are psychologically rigid. Rigidity is a hallmark of personality disorders. These patients tend toward hopelessness about changing. Their characterological problems are ego-syntonic: Their self-destructive patterns seem to be so much a part of who they are that they cannot imagine altering them. Their problems are central to their sense of identity, and to give them up can seem like a form of death – a death of a part of the self.” Do you know what it’s like to want to be rid of something, to despise it so much, and fear the losing of it in the same breath? Or to feel in your bones that something is so, despite all evidence to the contrary? I do.
Assumption 4: Patients can engage in a collaborative relationship with the therapist within a few sessions.
            I’ve been in therapy 8 months and I’m just now, in the past few weeks, beginning to bond with my therapist in a way that I can internalize. Oh I trust her, cognitively. I believe she wants to help me and has my best interest in mind. Throughout my life my interpersonal relationships with people have been marked by distrust and an expectation that they will implode. I don’t do it on purpose, it’s just happened so often that it’s natural for me to hold back. I don’t even have to try. When you’re so accustomed to having a hard time relating to others, it’s a natural extension that you would have a hard time relating to a therapist who is a relative stranger (at first).  From this point of view it makes sense that not only should a person’s personal problems be at the focus of therapy, but also a focus on developing the therapeutic bond between patient and therapist should come into play.   
Assumption 5: The patient is presumed to have problems that are readily discernible as targets of treatment.
Fill my emptiness please. What? You don’t have a prescription for that? No definitive list of reasons why this may be? It’s hard to treat a problem when you don’t have a clear idea of what the problem even is. Vague senses are difficult to discern for anyone, especially someone who has trouble connecting with how they feel in the first place.
So does that mean there is no hope? No, of course not. It just means that we need an expanded approach. Where we begin, where we go, what we seek and where we search for it will be in different places. Having our own individual reasons, subconscious or otherwise, for therapy means that we will have our own individual starting points. Sometimes it just takes a different approach to find the mark. Where one technique may fail, another may succeed. There are always more options. Don’t give up.
Being individual makes us human. Being human means we all have our own journeys.

Get over it ~and~ Push Away-Pull Back: Controversy in Borderline Personality Disorder – Part 6

Previously I’ve talked about Controversy in Borderline Personality Disorder (starting here). I also said that I’d continue to update them as I stumbled upon more. Well, unsurprisingly I have found more so I’ll be adding to my previous blog series today. So, here are a couple more Controversies and Misconceptions about BPD:
Misconception: You can bring about recovery in a person with a Borderline Personality Disorder through your own actions.
Fact: Personality Disorders are Real Mental Illnesses – and they don’t depend on what anyone else does, or doesn’t do, said, or didn’t say. You can’t cure a personality disorder with love, anger, submission or ultimatums. That’s like trying to hit a puppy by throwing a live bee at it (points if you know where that line is from).
Man, if only this were true. Let a friend or loved one know you have a mental issue, let them wave their hand around your head and Poof! no more personality disorder.
I can’t tell you how many times I’ve had friends and family sit down with me, give me advice or tell me to just get over it. Growing up my dad did the latter very often. He invalidated my feels, told me suck it up and get over it. I don’t think he was intentionally trying to be mean, but he clearly wasn’t helping me develop a healthy emotional state. Granted, if I wasn’t predisposed to having such emotionally charged response to things I may not have elicited these response from him so often. They did make me afraid to show my emotions though. Like when my grandmother died, instead of allowing myself to grieve naturally I locked myself away in my closet to cry instead of voicing my hurt. I needed to suck it up and be strong for my brother and sister. Instead of processing my emotions in a situation that actually was very appropriate to be upset, I repressed how I felt because I believed that showing these feelings was bad and wrong.
My parents love me. They love me a lot. Even today my mom continues to send me holistic articles on releasing negative emotions and gaining a calmer state of mind, as if reading an article will help cure me. I know her intentions are good and she just wants me to get better. It’s her way of showing she cares, but it’s almost completely useless and makes me feel guilty for not being able to be better for them.
The point is, no matter how much you care, how guilty you feel, how much you talk about and give advice to someone with a Borderline Personality Disorder, you can’t magically make it go away. That’s not to say that you shouldn’t be there when they need you (please don’t abandon us), give your love and support, just understand that it’s not your fault if it isn’t cured.
Controversy: People with BPD can get better if they just try harder.
Fact: Although management of symptoms is possible through a combination of medications, therapy and personal work, they can’t make the disorder disappear altogether. Personality disorders are mental illnesses based on neurological differences for which there is no known cure.
This goes right along with the previously mentioned myth. Sometimes I have doubts, sometimes I’m afraid to give up the familiar feelings, sometimes I fall to hopelessness, but I don’t think anyone really wants to deal with this. If we could get better by willing ourselves into a more normal state, of course we’d do it. Personality disorders are deeply ingrained disorders built up over a lifetime, biological dispositions, and/or a combination of both. They’re characterological, not a choice. They chose us, we didn’t choose them, and we can’t tell them to take a hike whenever we want. Hell, a huge, huge number of those with Borderline Personality Disorder are not diagnosed, will never be diagnosed, and have no idea what they are going through even has a name because they don’t have the help and support they need. How do you fix something that is so much a part of you when you don’t even know there is something to work on. Even when you do, it may take years of therapy and medicinal help and encouragement to learn better coping mechanisms to deal and heal wit BPD. It is not easy to change a lifetime of living in turmoil. I’m trying. I’m trying really damn hard. I think I’m seeing progress, but I have a long ways to go.
Controversy: People with BPD are basically just selfish.
Fact: Personality Disorders have been shown in some studies to be rooted in neurological differences in the way different regions of the brain communicate with each other. This isn’t suggesting that people with PDs shouldn’t be held accountable for their own behaviors – they absolutely should. But it would also be a mistake to regard people who suffer from PDs simply as mentally healthy people who are being selfish.
This one is tricky. Everyone is selfish. Everyone. Even those people that are seemingly altruistic derive a sense of well being from helping others that brings about a feeling that they are doing good. That feeling is for that person. People don’t generally do things that make them feel bad just because someone else needs something. That said, it’s not bad to be selfish, it’s just a byproduct of being human. So yes, someone with BPD can be selfish, but this isn’t our basic nature.
Someone with BPD though, can be very needy. Extremely needy. We often need validation that are feelings are real, that someone loves us, won’t leave us and therefore a lot of attention to ‘prove’ this. We covet this and don’t want to lose it. This isn’t something we set out to do though. We don’t wake up in the morning and say, “Gee, I think I want to monopolize someone else’s mental state, attention, and resources. Selfish powers activate!” Maybe some do, but there are plenty of ‘normal’ people that do this (maybe not the ‘selfish powers activate’ part). It’s not just a product of Borderline Personality Disorder. For the most part I think it’s a fear response. Fear that we will be left, that we aren’t worthy of being loved, that people are lying and trying to use us… an endless list of other things. We need reassurance and it takes a lot of energy to show us that. Unfortunately it’s a part of our nature to need this, feel smothered by it, push it away, fear the loss of it, frantically try to retrieve it, and repeat the cycle endlessly, for as long as someone will let us. So it does appear that we are acting mostly on our own behalf. This doesn’t negate the fact that we do care about the people in our lives, this doesn’t change the fact that we love the people in our lives and want to take care of those around us. That we do have so much to give. We just need to be shown this in return to a degree that many don’t require.

I do want to stress accountability. We are responsible for our own actions. Just because we feel incredibly out of control does not mean it’s ok to Act Out. I know it’s very, very difficult to reign this in sometimes, but we do need to try. Otherwise it just ends up hurting the people around us and acts to push them away.  

Where are all the men?: Controversy in BPD – Part 6

Discrepancy in Gender Diagnosis
Why does it seem that men have such a low frequency of Borderline Personality Disorder?  There seems to be two main reasons.
1.)    Men are diagnosed with something else.
2.)    Men are more likely to be treated only for their major presenting symptoms.
Some studies have reported that men are more likely to be diagnosed as paranoid, passive-aggressive, narcissistic, sadistic, or with anti-social personality disorder. I’ve done a lot of research into BPD (clearly) and I’ve often come across articles that focus on BPD with ASPD. Primarily the subject study group for BPD is women, and the study group for ASPD is men. This is not necessarily an accurate distinction though.
Men and women do often present with different symptoms when you break it down to Axis I and Axis II comorbid criteria. However these symptoms are still all encompassed in the range of BPD diagnostic criteria.
Axis I co-morbid disorders:
Men with BPD tend to have higher rates of substance use disorders, while women have higher rates of PTSD and eating disorders.
There isn’t a significant difference in frequency though. These things are pretty much expected with you take into account general psychopathology/temperamental differences in gender. In things like major depressive disorder, anxiety disorders, or mood disorders there was not found to be any significant difference in BPD diagnosed gender representation.
Axis II co-morbid disorders:
There is significant difference in how men and women present in Axis II disorders which are the presentation of other personality disorder traits. Men are found to have higher rates of antisocial, narcissistic, and schizotypal personality disorders.
When you take a look at the diagnostic criteria for BPD the only real significant difference is women tend to have greater frequency of identity disturbance. Men do present slightly higher in Intense Anger and Impulsivity criteria while women tended to be a little higher in Affective instability and Avoiding abandonment.
When it comes to diagnosis between genders in BPD it was found that the function of impulsivity, how men and women tend to differ in the specific type of impulsive behavior displayed, were often different, even though the frequency was negligible. That is, Acting In or Acting Out. While women might tend towards food (internalizing behavior) men might turn towards drugs or alcohol (externalizing behavior) for self-destructive behavior. But because men tend towards externalizing it is easier to overlook the other more passive/internalized symptoms.
More aggressive acting out is likely to overshadow other symptoms that are also present. So men will be referred to anger management or therapy will focus on that particular displaying symptom, what brings it out, how to react appropriately. Or try to. I don’t know how well this works if you’re only treating one symptom and not the entire problem. Or take something like alcohol/substance abuse for example. If a woman walks into therapy and says she has a drinking problem the therapist is likely to delve into the more emotional reasons for drinking. Social stigmas for men tend to focus on the physical problem, focus on rehab and detox. They might ask what events make them want to drink and suggest how to cope with these, but not as likely to look into why they are more prone to having these reactions that cause them to imbibe in the first place.  
Additionally, finding men to have higher co-occurrences of Personality Disorders is consistent with basic differences in how men and women relate to others socially. Women are socialized to be more interpersonally connected then men. A higher percentage of men with BPD also having antisocial, narcissistic, and schizotypal PDs shows increased difficulty in relatedness to others, a typical gender difference in the more pathological forms of these PDs. For example, in a sample comprised of inpatients and outpatients, men scored significantly higher on mistrust, manipulativeness, aggression, entitlement, detachment, and disinhibition, while women scored significantly higher on negative temperament, dependency, and propriety. Because the presentation of these symptoms is different, and there is a stigma towards the more passive symptom presentations, it is easier to overlook BPD as a diagnosis in favor of a more aggressive diagnosis, like ASPD for men.
All of this muddies the ability to make distinct diagnosis in men, because there may not be a distinct diagnosis for some men or they’re not being treated for their whole problem.
Maybe men should just seek psychiatric treatment more often so clinicians can get a better idea of how their PDed brains work and take some of the stigma off of us. Come on guys, help us out here. Just kidding.  Sort of. ::smiles::

Female Problems: Controversy in BPD – Part 5

Myth: Only women have BPD, it’s female disorder. 
That’s not to say that BPD isn’t diagnosed more often in women. It certainly is with a 3:1 ration or approximately 75% of people diagnosed with BPD are women. But men have it too. There are a lot of theories about why women are diagnosed with BPD more often:
          Sexual abuse, which is common in histories of BPD patients happens more often to women than men.
This in itself is debatable. Women tend to report these things more often, but does that mean men don’t have a similar frequency?
          Women experience more inconsistent and invalidating messages in this society.
Fortunately I think this is beginning to change, but there’s still a ways to go. And it doesn’t make up for the fact that women have been treated differently than men for most of documentable history. Especially in recent decades of greater communication women have had strong messages of how we’re supposed to act, behave, look, dress, take care of others, etc. imposed upon us… and any deviation from these cultural norms has not been met with open acceptance.  We’re often told it is acceptable to be one way, but when we are it is met with negativity and sentiments of being difficult and different.
          Women are more vulnerable to BPD because they are socialized to be more dependent on others and more sensitive to rejection.
This goes along with the cultural norms imposed upon women. Personally I was taught independence to a fault, and railed against the conflicting messages of the control my parents tried to assert.  I hate the idea of being dependent on anyone. Functionally, in terms of my job, my finances, the day to day aspects of my life this holds true and anyone that questions my ability to do these things is met with a rather volatile response. I hate the idea of emotionally dependent as well. I hate it. I hate it more that this is something that I can’t control when it comes to the people I get close to and involved with. The magnitude of emotional attachment that comes with BPD is part of what makes it a disorder in the first place. Becoming dependent on someone for emotional validation does make the idea of rejection so scary. Especially when there is a tendency for black and white thinking, splitting. If you do one thing wrong, you’ll lose the love and caring of that person. If they reject one thing, they’ll reject all things, and all that will be left is loneliness and abandonment. It’s not rational, but what about this disorder really is? It’s what it feels like that makes it so devastating.
          Clinicians are biased. There have been studies that show professionals tend to diagnose BPD more often in women than men, even when patient profiles are the same.
It’s not that men aren’t diagnosed with anything, their diagnosis is just different. Men tend to display symptoms differently and meet some criteria for paranoid, passive-aggressive, narcissistic, sadistic,
and antisocial personality disorders, which leads to a diagnosis of these even when BPD is a more accurate diagnosis. Since BPD has a feminine association, it’s ruled out for men almost automatically.
          Men seek psychiatric help less often.
It’s hard to diagnose someone with something when they don’t seek help for a problem. I can’t tell you how many guys I know that refuse to even go to the regular doctor when they’re ill, let alone seek therapy. I think it has to do with a culturally cultivated concept of the male ego and how men are supposed to behave. But I could be wrong.
          Men are more likely to be treated only for their major physical presenting symptoms, not necessarily the emotional associations that correspond to them. Their BPD symptoms go unnoticed because it’s assumed to be a woman’s disorder.
          Female borderlines are in the mental health system; male borderlines are in jail.
While Acting In and Acting Out are major issues for anyone with BPD, women acting out still tends to be directed towards themselves or of a magnitude that is not so outwardly destructive. Men tend towards aggression and act out towards other people leading to different consequences.
* I was incredibly destructive and explosive. I absolutely took out my problems on myself. However I constantly picked fights with my family, explosive screaming arguments, I broke down doors, put my fist through windows and walls…though these things weren’t the kind of thing that could get me thrown in jail. However, the vandalizing, drinking, shop lifting all could have.
          There has simply been very little research specifically investigating the occurrence of BPD in men.
This couples with men seeking psychiatric help less often. It’s very difficult to form a study when you don’t have a target group to focus on. It also couples with the fact that men are diagnosed and treated with potential inaccuracy so those men where BPD does present are overlooked.
So, it’s not that Borderline Personality Disorder is only a women’s disorder it’s, again, given a biased perspective. It make me sad really, that there are so many misconceptions and biases in the mental health field. It’s getting better. In the past it was taboo, not something to ever be talked about or admitted. Today it’s pretty common to seek therapy, for men and women. There’s still a ways to go though. Part of my goals for doing this blog are to increase awareness and education for Borderline Personality Disorder. I’m in no way a clinician, but I know how I’m affected, how some people in my life are affected, and I am happy to do A LOT of research to futher my own process of change. Knowing what I’m/we’re up against, options, information, treatments… simply that we’re not alone in this struggle, is encouraging. Hopefully, and it seems to be so, others find this useful as well.
Tomorrow I’ll talk more about the difference in presentation of BPD symptoms in men vs. women.

Trash talk – Controversy in BPD

Myth: BPD is a “wastebasket definition.” Clinicians give patients this diagnosis when they can’t figure out what’s wrong with them.
Reality: “ BPD should be diagnosed only when patients meet the specific clinical criteria.
Janice Cauwels (1992) wrote: BPD is still a wastebasket diagnosis, a label slapped on patients by therapists trying to pretend that their illness is understood. It is also used to rationalize treatment mistakes or failures, to avoid prescribing drugs or other medical treatments, to defend against sexual issues that may have arisen in therapy, to express hatred of patients, and to justify behavior resulting from such emotional reactions.
In other words, some clinicians use the word “borderline” like some schoolyard bullies use the word “cooties.” But the fact that BPD is used as a wastebasket definition doesn’t make it a wastebasket definition, any more than calling grapefruit a fat burner makes it a fat burner. A patient should be diagnosed as borderline only if they meet the clinical criteria and only after a clinician has worked with the patient over time to verify that the BPD symptoms are persistent, extreme, and long standing”.
Basically this is more the fault of therapists. It comes about when a patient’s problems are not so clean cut and identifiable. A patient may have one or two or many problems but instead of taking the time to understand if these are separate issues the patients are thrown under the heading of BPD because it’s a disorder that encompasses such a wide range of symptoms. Actually getting to know the patient would require more effort on the therapist’s part. It’s easier to lump them under a more general category.  Regardless of whether these people meet the designated criteria. Because as we know, any patient that is emotionally problematic must have a personality disorder. Dumping them under the Borderline Personality Disorder label allows them to utilize the stigma associated with BPD and dismiss them as untreatable or as a disorder that they are not equipped to deal with {read: biased against}. In short, it’s easier for the therapist to not deal with a challenging patient.

::Alternatively::

Like many clinicians, my roommate who has her M.S. in clinical psychology, describes it differently.  They do not believe that BPD is an actual mental disorder. It’s not like Bipolar or Depression that is a chemical imbalance and can be quantified.  She does see it as a wastebasket definition. This stems from the fact that the Borderline Personality Disorder does encompass such a wide range of problems, it’s as if any problem that cannot be explained by another disorder/diagnosis is swept together into a catch all category and filed under BPD. There is no reason that the co-morbid symptoms that comprise BPD can’t simply be separate co-morbid symptoms. For example, she’s not convinced that all of my issues don’t stem from Depression and a General Anxiety Disorder (which was the diagnosis I received from my first therapist). Except my depression and anxiety are alleviating and I still have a mess of issues.
I can understand this perspective even if I don’t agree with it. Even if it were a catchall for all these extraneous symptoms it doesn’t make it an invalid designation. Again, it provides a label that helps identify the wider range of problems that comprise the patients’ symptoms and allows for a means of recovery. Recognizing BPD as its own disorder also recognizes that these symptoms contribute to one another, compound, and are not necessarily separate entities. That there are co-morbid symptoms does not mean that these symptoms don’t stem from a common origin.
Personality disorders are tricky little bastards. You can’t quantify a personality. You can’t quantify emotional experience or relationships. All we have are our reactions and responses to the world around us. Personality is the lens through which we perceive that world. It permeates our entire being providing the means to interpret what we see and feel.  Recognizing how we relate to the world around us is what allows us to function in it. For someone with a Borderline Personality Disorder, that range is expansive, so yes, it does encompass a lot, maybe too much, but then again, most days we feel too much.

A Matter of Severity: Controversy in BPD – Part 2

I thought to add this to the previous post, but I’m adding things as I find them so …. Another controversy revolves around the question:

Is it possible to distinguish between a normal personality and a personality disorder, how do you do it, and where do you draw the line?

Without a clinical measurement of severity in personality discrepency it’s difficult to recognize where you draw the line between a healthy, relatively normal personality and something severe enough to be considered a disorder. Not only that, but who’s to say what is normal for one person is not normal for another? Unfortunately {in terms of diagnosis} people are all different so it’s nearly impossible to devise a steady measurment from patient to patient. So how do you decide on a distinguishing factor…
“It has become increasingly clear that some form of severity assessment is necessary to decide on the priorities to use for the management of personality disorder. The notion of severe personality disorder is central to much of the work in the area of forensic psychiatry. What is clear from empirical research studies is that those with more severe personality disorder do not have stronger manifestations of one single disorder as often postulated, but instead their personality disturbance extends across all domains of personality. Although severity is not normally taken into account when classifying mental illness, it is important in personality disorders, as normal personality and personality disorder are both on the same continuum. Unfortunately, there is no measure of severity for personality disorder in the DSM or ICD classification, and the absence of these measures is of significant concern. Indeed, treatment is justified when it is likely to ameliorate distressing or disabling syndromes, even when the patients fail to meet the full diagnostic criteria of psychiatric disorders and, consequently, the measure of severity is highly relevant to the planning and provision of treatment. A reliable way of assessing personality disorder is to use 3 levels of severity (SeeTable Below). By using this measure of severity, it is possible to use the cluster system to get a measure of severity and this measure is also relevant in assessing those with the most severe personality disorders in forensic psychiatry.”

I think this ties into the idea that recognition and diagnosis of BPD is not stable. With so many different aspects and potential combinations of symptoms it’s difficult to pin point what are the distinguishing characteristics for BPD if some symptoms present, but only to a mild degree, wheras others present with much greater prominence. If something is less inhibiting should it be consider part of the dysfunction? Should only the most severe problems be included in diagnosis? Or should all manifestations be addressed and lumped together? I personally thing the 3rd is the best idea. However noting which problems are the most harmful to a persons functionality can provide a guideline for psych/therapists to map out a course of treatment addressing the most prominent features sooner.

Does Borderline Personality Disorder exist? – Controversy in Borderline Personality Disorder

 

There is a lot of myth and controversy surrounding Borderline Personality Disorder. This is due to the fact  that the nature of BPD is very complicated.
Controversy ranges from Diagnostic criteria, usefulness of medication, effectiveness of therapeutic techniques, gender discrepancy, possibility of recovery, Axis location, terminology, and whether it even exists as an actual disorder at all. There are many, many more. I can’t say I’m surprised though, we’re a pretty controversial group of people.
This will be the beginning of a series of entries surrounding the controversies with BPD.
So to start; I think it’s appropriate to begin with:
Does Borderline Personality Disorder even exist?
One of the myths I’ve found is that there is no such thing as BPD. However more than three hundred research studies and three thousand clinical papers provide ample evidence that BPD is a valid, diagnosable psychiatric illness.
The question about the existence of BPD comes from several claims.
1.)     The first being shear ignorance of current psychological research. Definitions and diagnosis of BPD have changed drastically in the decades that it has been recognized as a disorder and some clinicians may be overwhelmed, or choose, to focus on many other areas of specialization and just not know how this subject has developed.
2.)    Some clinicians believe that it is not a separate disorder. They believe it is a collection of symptoms that are better encompassed by Bipolar Disorder or Post Traumatic Stress Disorder.  I’ve talked about PTSD before {here} and why I believe these are different disorders.  Bipolar II is a bipolar spectrum disorder characterized by at least one hypomanic episode and at least one major depressive episode; with this disorder, depressive episodes are more frequent and more intense than manic episodes. As far as Bipolar is concerned; I can see how Borderline Personality Disorder could be confused with Bipolar II (Bipolar depression) from a mood disorder standpoint. People with BPD tend towards a chronic depressive state with instance of hypomania (this certainly fits me). However BP II doesn’t the address the “instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts,” markers that define BPD. (More on Bipolar II)
3.)    Some simply reject labeling because of the stigmas associated with BPD and find all psychiatric diagnosis limiting and misleading. This one in particular I find to be ignorant. Yes, BPD does have a lot of associated stigmas (which I will also discuss in a later post), and avoiding stigmas is beneficial to the personal interactions of a patient in the outside world. However, by refusing to provide a diagnosis it can be very difficult to provide a clear course of action in therapy. By extension, it makes it more difficult to find a path to recovery. Not to mention, someone with BPD doesn’t have to tell anyone that they have been given this diagnosis, which will also allow them to avoid the general stigmas. If the psychiatrist/ologist/therapist holds onto these stigmas, it’s best for the patient to find a professional that is better equipped to handle the challenges associated with the present symptoms.
4.)    Another reason stems from the fact that the categorical diagnosis and causes for BPD are often disputed among professionals.  While the DSM does provide a list of criteria, there isn’t a single dimensional model that clearly maps how to identify traits and how, or if, they correlate to one another. This means there is dispute over the importance of various criteria, whether they are related to one another at all or just coincidentally present in the patient, existing as distinct problems or pieces of various other disorders. So the root causes that are traditionally used to classify BPD are called into question.  
“There continues to be some debate as to which personality variables should be assessed to make a diagnosis of personality disorder in the normal/abnormal personality continuum. It would seem to be appropriate in this approach to choose those personality variables more likely to be personal and concerned with functioning, in order to assist in understanding the patient’s disabilities and obtain strong clues about them. The difficulties encountered in the diagnosis and study of personality disorder include inconsistencies in assessment across both instruments and raters. “

Most professionals agree that the symptoms that compose Borderline Personality Disorder are part of one clinical diagnosis. The symptoms themselves are not deniable. No doctor or therapist would look at a patient talking about their problems and tell them these issues do not exist. That is not the question. The question is mostly one of definition and categorization. Regardless of what anyone thinks, the problems are real and having the ability to recognize the distinction of various symptoms is an important tool in order to deal and work to recover.