Cluster Me

Huddle up. Cluster B.
I really hadn’t planned on doing a DSM-IV style series but as I’m already headed in that direction let’s keep on it.

Personality Disorders are described as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts” and “are inflexible and maladaptive, and cause significant functional impairment or subjective distress”.

According to the DSM-IV there are 10 different personality disorders + 1 catch all ‘personality disorder not otherwise specified’. These disorders are broken down into 3 Clusters (A,B, & C). The purpose of these Clusters is to further organize these disorders into groups that are related to each other by their symptoms.


Cluster A – Odd or Eccentric Behavior – includes Schizoid, Paranoid, and Schizotypal Personality Disorders.

Schizoid Personality DisorderA pervasive pattern of detachment from social relationships and a restricted range of expressions of emotions in interpersonal settings. Those with SPD may be perceived by others as somber and aloof, and often are referred to as “loners.”

Schizotypal Personality Disorder A pervasive pattern of social and interpersonal deficits marked by acute discomfort with reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior. This disorder is characterized both by a need for isolation as well as odd, outlandish, or paranoid beliefs. In social situations, they may show inappropriate reaction or not react at all, or they may talk to themselves.

Paranoid Personality Disorder A pervasive mistrust and suspiciousness of others such that their motives are interpreted as malevolent. Although they are prone to unjustified angry or aggressive outbursts when they perceive others as disloyal or deceitful, those with PPD more often come across as emotionally “cold” or excessively serious.

Cluster B – Dramatic, Emotional, or Erratic Behavior – includes Antisocial, Borderline, Narcissistic, and Histrionic Personality Disorders.

Antisocial Personality Disorder A pervasive pattern of disregard for and violation of the rights of others. APD is characterized by lack of empathy or conscience, a difficulty controlling impulses and manipulative behaviors. This disorder is sometimes also referred to as psychopathy or sociopathy, however, Antisocial Personality Disorder is the clinical terminology used for diagnosis.

Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses. This mental illness interferes with an individual’s ability to regulate emotion. Borderlines are highly sensitive to rejection, and fear of abandonment may result in frantic efforts to avoid being left alone, such a suicide threats and attempts.

Histrionic Personality Disorder A pervasive pattern of excessive emotion and attention seeking often in unusual ways, such as bizarre appearance or speech. With rapidly shifting, shallow emotions, histrionics can be extremely theatrical, and constantly need to be the center of attention.

Narcissistic Personality Disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Narcissism occurs in a spectrum of severity, but the pathologically narcissistic tend to be extremely self-absorbed, intolerant of others’ perspectives, insensitive to others’ needs and indifferent to the effect of their own egocentric behavior.

Cluster C – Anxious, Fearful Behavior –  Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders.

Avoidant Personality Disorder A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation and are unwilling to take social risks. Avoidants display a high level of social discomfort, timidity, fear of criticism, avoidance of activities that involve interpersonal contact.

Dependent Personality Disorder A pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation. Dependent personalities require excessive reassurance and advice, and are extremely sensitive to criticism or disapproval.

Obsessive-Compulsive Personality Disorder – Also called Anankastic Personality Disorder display a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. They can also be workaholics, preferring the control of working alone, as they are afraid that work completed by others will not be done correctly.

My questions is: Are these clusters necessary?

Once you know which personality disorder someone has you’ve got it pegged. It would make more sense to use clusters to further narrow down behavior before diagnosis.

If the patient is obviously dramatic and emotional it is easier come to the Cluster B conclusions and therefore rule out disorders characterized by other clusters. However there can easily be overlap and therefore confusion. With Borderline (Cluster B) there’s an intense fear of abandonment, often paranoia that something will happen and people will leave, which is why we attach so hard to people regardless of there being any evidence to support this paranoia. To me this indicates anxious and fearful behavior which would be Cluster C, even though Paranoid PD is Cluster A. Confusing, no?

Being Borderline I’m grouped into Cluster B. I can tell you with absolute certainty that my personality characteristics fit almost all Cluster A criteria. In Cluster B I obviously hit Borderline but also Histrionic PD. As far as ASPD goes, I have at least the difficulty controlling impulses and manipulative behavior. For NPD a case could be made for being self-absorbed, intolerant of others’ perspectives (if they don’t satisfy what I need at the moment), and indifference to the effect of egocentric behavior. For ASPD and NPD my motivations are fundamentally different though. Maybe that’s the deciding factor. Motivation. Not consciously of course, but those underlying factors that set us apart from the other PDs that we’re not diagnosed with. To me this conclusion is obvious. It boils down to which behaviors are most predominant. This still doesn’t explain what the point of further breaking personality disorders into clusters is. In all of my research, so far, I have not found a single reason why these clusters are necessary.

Who’s to say what the difference between these traits are anyways? Who defines what is erratic (Cluster B) and not eccentric (Cluster A)?  Lack of interest in social relationships (Cluster A) and social inhibition (Cluster C)? There is no solid, scientific way of distinguishing between clusters. There is a lot of overlap between the Clusters so they don’t help narrow down the playing field. Any conclusions reached about a person will point directly to a personality disorder(s) regardless of which cluster they fall into, especially as symptoms may indicate multiple clusters. In fact, the cluster groupings may work to limit the consideration treatment options that other personality disorders could provide insight to.

My conclusion is that they’re basically erroneous.

Hah, Ok. I just found this abstract on Neuropsychological, Psychophysiological, and Personality Assessment of DSM-IV Clusters:

Testing the construct validity of the three DSM-IV cluster groupings of personality disorders, in terms of neuropsychological, psychophysiological, and personality traits measures, was the purpose of this study. The results hardly confirm significant differences between B and C cluster groups in their neuropsychological functioning, but, instead, suggest that Cluster A could have some empirical validity based on executive prefrontal deficits (concept formation and sustained attention tasks) and clinical features. Similarly, no consistent differences among groups emerge when psychophysiological measures are compared. With regard to the Big-Five personality dimensions, the results also indicate that clusters may be more heterogeneous than the DSM-IV suggests. It appears, therefore, that the categorical division of DSM personality disorders into three discrete clusters may not be empirically justified.

See, no real reason for the Clusters. I win. (Apparently this was a competition.)

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
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’.

A rose by any other name…

Still dies, rots and decomposes like anything else, I suppose.

Last week I talked about where Borderline Personality Disorder got its name. It may not stay that way forever though. Borderline Personality Disorder renamed? For some time now clinicians have been calling for the label of Borderline Personality Disorder to undergo official change. There are a number of different names used around the world and under consideration for the same disorder:
Borderline Personality Disorder (BPD) – Current
Emotional Regulation Disorder (ERD)
Emotional Dysregulation Disorder
Emotional Intensity Disorder (EID)
Emotionally Unstable Personality Disorder (EUPD)
Emotion-Impulse Regulation Disorder (EIRD)
Impulsive Personality Disorder (IPD)
Impulse Disorder
Post Traumatic Personality Disorganization (PTPD)
Complex Post Traumatic Stress Disorder
The most commonly used name today is Borderline Personality Disorder – or BPD – as defined in the American Psychiatric Association’s Diagnostic & Statistical Manual (DSM-IV-TR).
The term “Borderline” is a historic term coined to describe people who were diagnosed to be on the borderline between a neurotic and psychotic disorder. It is commonly felt that the “Borderline” label is misleading and stigmatizes the disorder. From the beginning the term Borderline Personality Disorder has been stigmatized and this has only been compounded by decades of misunderstanding. It implies that the entire person is flawed instead of looking at BPD as a medical problem. By renaming Borderline Personality Disorder it will be easier to move away from those stigmas that are automatically associated with the label. Originally it was termed Borderline Personality Disorder because it was thought to be on the ‘borderline’ of multiple diagnoses but not falling into any one category. However this is no longer believed to be the case. It isn’t on the border of anything. It is its own distinct problem; a disorder characterized by intense emotional experiences and instability in relationships, behavior, and emotions. Some clinicians don’t even want it labeled as a Personality Disorder because it implies that there is no hope for a cure when in FACT it has been proven that with psychotherapy and the aid of medication there is the ability to heal and live a life free from the symptoms that categorize BPD. They want it renamed and removed from Axis-II designation and placed firmly in the Axis-I category because of the high rate of comorbitity with other Axis-I disorders (as previously mentioned here).
Rumor has it that the fifth version of the Diagnostic & Statistical Manual (DSM-V) is likely to rename Borderline Personality Disorder (BPD) as Emotional Regulation Disorder (ERD) or Emotional Dysregulation Disorder (EDD). Indeed, Emotional Dys/Regulation Disorder is the most popular alternative for Borderline Personality Disorder. It’s felt that this more accurately describes the expression of the symptoms encompassed by BPD as it is just that, a disorder of regulating emotions.
Another term is post traumatic personality disorganization (PTPD) or complex post traumatic stress disorder, reflecting the condition’s status as (often) both a form of chronic post-traumatic stress disorder (PTSD) and a personality disorder in the belief that it is a common outcome of developmental or attachment trauma. I’m not sure I entirely agree with this because there are many people with BPD that don’t report any kind of traumatic event.  Personally, maybe, MAYBE, some arguable attachment traumas when I was a toddler, but even I don’t think this was so much environmental trauma as a predisposition to reacting the way I did. As I’ve mentioned in a previous post, I don’t agree that PTSD is an accurate diagnosis for me at all. I’ve had plenty of traumatic events to speak of but not until after my BPD began to present at a young age.  
Emotionally Unstable Personality Disorder…. Really? REALLY? Yeah, I see that diminishing the stigma that Borderline already has. Why don’t they just name it I-Am-Insane-And- Potentially-Violent-It-Is-In-Your-Best-Interest-To-Remove-Your-Children-From-My-Presence-Duck-And-Cover Disorder. IAIAPVISIYBITRYCFMPDAC Disorder is rather a mouthful though.  How about simply, BitchPleaseI’mCrazy Disorder. Seriously.
I’m against renaming Borderline Personality Disorder.  Renaming it doesn’t actually change a thing. Anyone with half a brain is going to know that ERD/etc is the same thing as BPD just with a new name, IF they even knew what BPD was to begin with. The symptoms are The. Same. Damn. Things. I mean, yeah it’ll take away the general stigma of BPD but then again, it may work to perpetuate others. BPD is already stigmatized as a female disorder. “Emotional this/that Disorder, Post Traumatic Something Disorder, those will all only perpetuate if not increase that particular stigma. It’ll make it more difficult for men to be diagnosed and make women an even easier target for ridicule. I can just imagine anytime a woman speaks her mind or has a strong opinion because she has an actual voice and isn’t a doormat, some douchebag guy is going to replace “is it that time of the month?” with “Emotional Disorders are treatable, get help for that shit”. It’s all ridiculous. In that way, Borderline is safer because a good majority of people don’t even know what it is so they can’t jump to asinine conclusions. So while, yes, ERD, encapsulates the fact that it is a disorder of emotional regulation, at the same time it almost trivializes the severity of what this disorder is. That is not okay.
Personally? I’m not sure I want it to be renamed. I like the term Borderline Personality Disorder. I like the idea that something can overcome the stigma and be understood for what it is; kind of civil rights activation for personality disorders, haha (for that matter I don’t like that there will be a full re-categorization of PDs from 10 to 5 in the new DSM V). I still don’t like admitting that I have a disorder of emotions because I was lead to believe that I needed to repress them for so long. At least Borderline doesn’t directly state a disorder of emotional problems (though obviously it is) since it doesn’t have Emotion in the title. It doesn’t stamp CRAZY BITCH on my forehead right away. Someone hears Borderline Personality Disorder and they may cock their head and ask, ‘what’s that?’. Someone hears Emotional Dysregulation Disorder and they’re going to start creeping backwards because this person is OBVIOUSLY emotionally unstable.
Idk, maybe I have no logical reason for it. Mostly it’s probably due to my attachment issues. I have a hard time giving anything up that I’ve become accustomed to and this label is one more example of that. I like the name, I don’t want it to change. I’m familiar with it. I mean… BPD is a disorder characterized by abandonment! Don’t make us abandon our label! It’s mine. I’ve embraced it. Don’t take it away from me! (Jokes. Sort of). And quite frankly, all the other names for it are kind of lame.
While I’m on the topic of continued designation of things; please return Pluto to its previous planetary status; “Dwarf planet“ is just insensitive.  

Judging Me: Stigma of Borderline Personality Disorder

 Please, don’t judge me before you know me.
I’ve mentioned this in various posts but I wanted to pull it all together. I’m talking about the stigma that accompanies Borderline Personality Disorder.
What is a stigma: a mark of disgrace or infamy; a stain or reproach, as on one’s reputation; a distinguishing mark of social disgrace; any sign of a mental deficiency or emotional upset.
Stigmas are a negative judgment based on a personal trait.
What is a stigma: a mark of disgrace or infamy; a stain or reproach, as on one’s reputation; a distinguishing mark of social disgrace; any sign of a mental deficiency or emotional upset.
Stigmas are a negative judgment based on a personal trait.
These are a very real problem for anyone with a mental illness/difference/disorder Personality disorders especially and notably for someone with a Borderline Personality Disorder. Compared to many other disorders it seems to have a surplus of stigma.
1) theories on the development of the disorder, with a suspect position placed on parents;
2) frequent refusal by mental health professionals to treat BPD patients;
3) negative and sometimes pejorative web site information that projects hopelessness;
4) clinical controversies as to whether the diagnosis is a legitimate one, a controversy that leads to the refusal of some insurance companies to accept BPD treatment for reimbursement consideration.
Many clinicians and people believe that Borderline Personality Disorder is not a characterological problem and merely a learned response to environmental factors. This thought process leads to an inability to treat patients properly. To believe that someone with BPD is just acting our or trying to get attention. Tragically it is often believed that these environmental factors are the parents fault (though in many cases this may absolutely be a contributing factor: Nature vs. Nurture). What’s truly horrible about this is that parents may be afraid to get their children help or may alienate their children once diagnosed for fear of being judged themselves.
All Borderlines are ‘angry, violent, and explosive’, in other words, very hard to cope with. All of us. Instead of getting to know a patient individually we are judged on the behavior of a few. Clinicians will discriminate against someone with BPD because of what others have said, not what they have experienced. Yes, the moods of someone with BPD can be all of these things. Hell, my behavior can be all of these things at time, but I’ve never brought it to therapy. However this is not the most predominant mood. These occurrences are much more rare (if they occur at all) compared to the day to day operating mode of someone with BPD.
“People take a couple of bad examples then deems everyone else with the same disorder through one very narrow perspective and then tells all of their friends of this belief who continue to pass it along but it seems like no one stops this communication to actually take the time to understand the disorder so all of this false information is allowed to saturate through society until everyone takes it as common knowledge and then uses it to judge others”
Extension to above: Borderline Personality Disorder IS characterized by mood swings between anger, anxiety, depression, and temperamental sensitivity to emotional stimulus. We can be destructive and prone to self-destructive behavior. Because of this, it is one of four related pathologies classified as Cluster B (“dramatic-erratic”) in the DSM IV. This is hallmarked by disturbances in impulse control and emotional dysregulation. Someone with BPD is often very sensitive and reacts strongly. They may have love/hate relationships with everyone and themselves, substance abuse, and impulsive behavior, or a multitude of other problems. Because of these potential qualities many professionals will not treat someone with BPD as they may not be comfortable doing so, and this is their prerogative. So while it is not as severe a stigma as the last one, it is still a problem. It does not make them bad doctors or therapists, it just makes them not right for the person suffering with a personality disorder. I can understand this. We do have a lot of things to deal with and some people simply are not equipped to handle as much as we tend to bring with us.Extension to above: Borderline Personality Disorder IS characterized by fluctuations between anger, anxiety, depression, and temperamental sensitivity to emotional stimulus. We can be destructive and prone to self-destructive behavior. Because of this, it is one of four related pathologies classified as Cluster B (“dramatic-erratic”) in the DSM IV. This is hallmarked by disturbances in impulse control and emotional dysregulation. Someone with BPD is often very sensitive and reacts strongly. They may have love/hate relationships with everyone and themselves, substance abuse, and impulsive behavior, or a multitude of other problems. Because of these potential qualities many professionals will not treat someone with BPD as they may not be comfortable doing so, and this is their prerogative. So while it is not as severe a stigma as the last one, it is still a problem. It does not make them bad doctors or therapists, it just makes them not right for the person suffering with a personality disorder. I can understand this. We do have a lot of things to deal with and some people simply are not equipped to handle as much as we tend to bring with us.
Since there is no medical treatment professionals think there is no hope. I hate this. I think it’s a lazy attitude because especially with recent development in therapy it has been clearly shown that there IS hope. Medication may not work to cure all of our problems, but that does not mean we can’t learn to cope and recover from our problems. We just need a different approach than throwing drugs at it.
Those with BPD are treatment resistant. This is often a problem in the therapeutic technique, not that someone with BPD is resistant. Some styles of therapy are not conducive to treating Borderline Personality Disorder or one technique is simply not enough. It’s often difficult for us to internalize some concepts because the nature of BPD is so transient. What may work for someone without BPD probably won’t work the same for us. Or what does work for us one minute, may not work for us in another because our moods shift so rapidly. All this means though, is that we need to focus on changing our overall mentality, not just on techniques to get us through a situational development (though these can be helpful!). We can’t just record, talk through, and repeat new behaviors and expect them to work right away because these are things that are ingrained in our character, not a learned behavior that we’re just trying to reverse. It might take a variety of integrated techniques, not just one, but treatment is absolutely possible!
Someone with BPD will never get better. With this attitude many clinicians adopt an attitude of hopelessness for someone with a Borderline Personality Disorder. They won’t even bother to treat someone with BPD because they don’t have the knowledge of current treatments and options for the patient. Because it requires more effort to change characterological problems many won’t read updated information and therfore remain stuck in outdated modes of thinking.
Someone with a Borderline Personality Disorder is intentionally manipulative. This is one of the worse stigmas in my opinion. Borderlines are just manipulative, “bad” and hurt other people on purpose. The truth is we don’t always know that we do these things. We don’t know what the behavior itself is that comes to this conclusion, let alone know how to change these behaviors (more on this in a separate post).
Everyone with BPD is a self-injurer.
1.) All people with Borderline Personality disorders engage in self-harm practices, and
2.) That it is merely a cry for attention so it should be ignored and the person will stop doing it.
First, I know of quite a few people with BPD that do not cut, burn, bang, or engage in these kind of tendencies. BPD presents in a huge variety of ways and this is only one potential aspect. Second, many of us that do have these self-harm/cutting tendencies do not tell people about it at all. It is a way to take control of our lives, emotions, stress, or a dozen other things. Yes, some people may do it for attention, but ignoring it is never a good answer because this is harmful and in some cases could lead to death.
Because of all of these things someone with BPD may not even consider finding treatment. If they’re pre-judged by the mental health industry, if their attitudes are already set, what hope is there of getting effective help? It’s a defeatist attitude that bleeds into the thoughts of the patients themselves. If the psychiatrist, the psychologist, the therapist have no hope, what hope can we have for ourselves? I was aware of most of these stigmas when I was diagnosed. I was already seeing my therapist when my psychiatrist diagnosed me with BPD. I was actually very reluctant to tell my therapist about the diagnosis because I was afraid she’d drop me as a patient. This fear is not okay. Especially for someone that is so afraid of rejection! Without the ability to be open and honest with the person that is trying to help you it makes it almost impossible, at least very difficult, to get effective treatment. This is a very sad thing to me. Hopefully with understanding and new therapeutic developments this mentality will begin to change. Pulling these things together and taking a good look at them will be beneficial. That’s the goal at least. 

Axis I vs. Axis II: Controversy in BPD- Part 4

Where does Borderline Personality Disorder belong?
I’m referring to the DSM criteria for Axis I and Axis II designation. Let’s start off with, what’s the difference between Axis I and Axis II.
* Axis I: major mental disorders, developmental disorders and learning disabilities. Axis I disorders are predominantly mood disorders.
 * Axis II: underlying pervasive or personality conditions, as well as mental retardation. Axis II disorders are personality disorders.

For or Against?
[For Axis 2] Personality disorders are classified as Axis II disorders.
Personality disorders in general have their own list of general criteria that must be satisfied. They’re a class of personality types and behaviors that the American Psychiatric Association (APA) defines as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it”.
“These behavioral patterns in personality disorders are typically associated with severe disturbances in the behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior is ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in the client adopting maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress and depression in clients.”
The behaviors cause serious interpersonal and social difficulties as well as general functional impairment. I don’t think anyone can argue that BPD fits this criteria, which is a large part of why it is considered Axis II. It also has a sub-designation as Axis II, Cluster B which is characterized by dramatic, emotional or erratic behavior. No argument there either.
[For Axis 1] Both Axis I and Axis II are psychiatric disorders. Only personality disorders and mental retardation are segregated onto Axis II. All other psychiatric disorders are Axis I. Does it really make sense to segregate these if they are essentially the same type of thing?
[For Axis 2] However Axis I disorders are generally treatable with medication. While some presenting symptoms of Axis II disorders may be treatable with medication, it’s not shown that medication can ‘cure’ a personality disorder and correct all presenting symptoms.
 [For Axis 1] Moving BPD to Axis I would have economic benefits. Many insurance companies don’t recognize BPD as a treatable condition and use it as an excuse to withhold payments. I know for a fact that my therapist classifies me as Major Depressive when billing my insurance company. I am pretty certain my psychiatrist does as well. This is certainly true, but not completely accurate.  I’m not going to complain though.
I think the major debate lies here:
[For Axis 2] Axis II BPD is pervasive to a person identity, characterlogical in nature.
[For Axis 1]: But…There’s some debate about whether BPD should be considered a ‘personality disorder’ at all because it has such a high rate of co-morbid symptoms that fall into the Axis I designation.
Axis I disorders are primarily for mood disorders that are reactions to atypical situations which are not part of a person’s character. “Mood disorder is the term designating a group of diagnoses in the DSM IV TR classification system where a disturbance in the person’s mood {not their character} is hypothesized to be the main underlying feature. The classification is known as mood (affective) disorders in ICD 10.”

[For Axis 1] There are many disorders that are just as pervasive as BPD such as bipolar, anxiety, and depression that are not caused by atypical situations, and are classified as Axis I disorders.
Two groups of mood disorders are broadly recognized (though not limited to these two); the division is based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, of which the best known and most researched is major depressive disorder (MDD) commonly called clinical depression or major depression, and bipolar disorder (BD), formerly known as manic depression and characterized by intermittent episodes of mania or hypomania, usually interlaced with depressive episodes.”

People with Borderline Personality Disorder almost always have a history of long term, pervasive depression.  I’ve never heard of anyone that didn’t, but I’m not a clinician. Hypomania is not always present. If you have manic phases though, that is the definition of Bipolar and while you can have bipolar disorder and BPD, I think you would then have both Axis I and Axis II designations, not just one or the other. From here it could be argued that the mood regulation disorders are the underlying cause for all the other disorder manifestations.
[For Axis 1] There’s also the stigma that a personality disorder just means that a person has a flawed personality that can’t be changed.  Except there has been plenty of research to support the idea that this is an emotional regulation disorder.  Which means it would technically be a mood disorder and qualify it for Axis I.
I can see how the mood disorder aspects can affect a lot of the behaviors and symptoms of BPD. I’m not sure it can explain all of them though. Things like a tendency towards impulsive behavior, identity disturbance, fear of abandonment, etc… these are not necessarily dependent on mood alone.
I certainly don’t believe that a personality disorder just means you have a flawed personality. Calling it a flaw implies that it’s a minor issue, easily corrected. BPD is not minor, nor is it easily treatable. You might not be able to change everything about who you are (or want to), but if there is an aspect of your life that you do not value; if you are willing to put in the effort; if you have hope of living a better life or just a life different from what you currently experience– it is absolutely possible to make changes in yourself. Without hope for change there can only be resignation to the inevitable. But people do have control over their lives, what choices they make, how they want to live. It may not be easy, maybe everything can’t be ‘fixed’, but it is possible to heal from those things that we are willing to work to change.

Brutal Ideation – Criteria 8 / Anger Part 2

The one thing I don’t do but I fantasize about constantly:
I grew up fighting. I was heavily involved in the martial arts ever since I was young. I had an outlet, a channel for my aggression in a safe, healthy, constructive environment. Because I’ve moved so often in the last few years I haven’t had the ability to find a new place to continue my study.
It’s come in handy a couple times in the real world when guys have tried to press their advantage with me only to have their wind knocked out and taken aback by someone half their size. I’ve never been in out right fights though, like bar room brawls, in the real world, though I fantasize about it constantly. Especially when I’m running. If I want to amp up my energy, creating a scenario in my mind where I’m rescuing a pretty girl from some drunken brute, or disarming someone that has me at gun point with less than honorable intentions… it sets my heart pounding, adrenaline pumping through my veins.
I’m not afraid of damaging myself. Some days I even welcome it. I know how much my body can take and I’ve survived the worst that can be done to it. Short of death I have no fear of injury because I already know I can survive anything that I’m dealt. And I do mean anything. I don’t fear pain. The thought of taking a blow to the face, the stomach, the chest, doesn’t deter me, it makes me gasp and come back stronger, attack more fiercely. My anger boiling and bubbling over until all I am is a fury of fists and feet.
In my visions I never escape unscathed, I take my hits, bruised and sometimes broken, but I’m never beat down, never relent. I always get back up and I always end up on top. Some day I’ll push this into reality and see just how well my fantasies match up to reality….

My Deadly Sin – Criteria 8 / Anger

Criteria 8: inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 

Anger. Wrath would be a better description. Not so long ago when I was a turbulent teen my wrath was explosive and violent. The smallest things would set me off. I’d scream and lash out at my family, my friends, put my fist through windows and walls, break down doors, at the smallest slight that most wouldn’t think twice about. Anything that didn’t go how I needed it to, was a loss of control and I railed against the loss. Fought to get it back. Violently.
I’ve developed greater control of my anger as I’ve grown older. Learned ways to redirect and channel my inner rage. Of course I didn’t know why at the time, everyone just thought I was a temperamental teenager. I hadn’t been diagnosed with my personality disorder yet but I knew something was wrong with me. Oh yes, I knew. I thought I could deal with it myself. I’d try to control myself, hold everything in, bottle it up until I couldn’t hold it in any longer and then I’d pop like warm champagne spraying blood and tears across the walls. Usually my own.
Now I’ve learned to face my problems directly. It doesn’t always stop the unjustifiable anger, but I can calmly approach a problem and work to devise a suitable solution. At some point my dissociation also intrudes, and instead of maintaining the rage that I would normally feel, I feel nothing. My ability to care or give importance to a situation slips away. On the one hand it’s good, because I no longer blow things out of proportion. In the grand scheme of things nothing really matters all that much so I can just let it go. This is one of the ways I’ve learned to use my dissociation to my advantage. It has taken a lot of time and effort to work on though. Some days I can’t stop the agitation and irritability, every small thing sets me off when all I want is to be left alone to do what I’m doing. To block out the noise and chatter. Unfortunately when you work in the real world with other people you don’t always get what you want and you have to adapt. Adjust. Suppress the mental urges just to get by….

Hollow – Criteria 7 / Emptiness and boredom

Criteria 7: Chronic feelings of emptiness or boredom.

Hollow. That’s often how I feel. Or don’t feel as the case may be. Like there’s a void where my internal receptors should be. There’s always a sense of seperateness, being removed from the crowd with only a hollow center to fall in on. I can never quite cross that emotional bridge that binds people together, I’m left to drift along the same river but never quite reach the shore.
Bored. I don’t know what it’s like to be bored. I hate to be bored and thus, never am. I plan and plan and plan ahead so that I always have something to do in case there is even 5 minutes where I’ll have to be left alone with my own thoughts. If you were to turn out my shoulder bag you would find, multiple books, my journal, multiple sketchpads, art/drawing supplies and my Netbook in case I manage to be somewhere with free WiFi.

When I was in school this was easy. I chose the hardest courses, would create elaborate study schedules and obsess over getting perfect grades. The more effort I put into my schoolwork, the less effort I had to put into my real issues. After I moved to New York I discovered the whirlwind that would become my social life. For months and months ahead of time I would have almost every day, every weekend scheduled away to see people, attend events, not leaving even an hour when I wasn’t off getting ready to run to the next thing. For nearly two and a half years I lived like this. Eventually the pressure and exhaustion caught up with me though and I turned inward once again.

Without something to occupy me I’m left only to think. My brain never shuts off, never slows down. My thoughts race. Being left alone with my own thoughts is dangerous. In the space of free time my thoughts can wander and roam. Often not to happy productive places. Feeling hollow it’s hard to hold onto the thought that there is anything good in me, when I feel there is nothing in me. What can there be to look forward to with nothing good inside? My thoughts are often ruminating and destructive, taking me down paths that will never actually be, except in my own mind. In this journey deep where those harmful thoughts dwell I have the power to destroy myself. I’m more a danger to myself than anyone else in this world could be. It’s no wonder I spend every spare moment trying to fill unused time with things that will allow me to escape the trappings of my own mind.
Maybe if I can make everyone see all the Stuff I do, I have, on the outside, they won’t notice how empty I am on the inside.

Mood Swings – Criteria 6 / Instability of mood

Criteria 6: affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Duh. That’s really all I want to say to this one but that wouldn’t be very informative now would it. The important thing here is to understand WHY the moods of a borderline are so unstable. The problem is, it’s going to be different for everyone so I’ll just have to stick with why they’re so difficult for me.
I’m major depressive so my base set mood is mildly depressed. The best I can hope for on an average day is to just feel nothing; not happy, not sad, just a sort of blankness that doesn’t swing me in either direction. Of course it’s wonderful to feel happy. Merely talking to a friend, connecting with a loved one, will do this. This feeling rarely stays though because eventually people have to have their own lives or return to work. Resume normal everyday behavior. But to me it’s like I lose my hold, my connection to them. Having been happy while talking to them, now I slip from being happy to being left with only the thoughts in my own head and not knowing when I’ll be able to have that connection again; alone. I slip from happy, to alone, empty, spiraling down. In the space that was filled with that connection to a loved one, I’m now left with a hollow void where they’re gone and my thoughts can race and ruminate. This bleeds back to being alone, abandoned. It’s not rational, but it feels like something that was there is now gone. Being a thinking creature I can’t know for sure when it will be back. That uncertainty is maddening.
Anxiety is a big one. The smallest things seem to set me off, spike my anxiety and it feels like my world will crash in on itself. Especially if it’s something I’ve planned just so. I try to arrange things to bring about the most comfortable, stable environment for me. Calm. To feel secure in my surroundings I plan every detail to create the perfect scenerio. That house of comfort is built on a foundation of cards that even the smallest suggestion of change adds a weight, a pressure to, that can send it toppling to the ground. I have an incredibly difficult time getting through the fact that any change will not rock my foundation and will not wreak havoc on my plans because it feels like it does.
Lack of control of my environment means a lack of control of myself, my life. If I can’t even control my own life than what control can I possibly have in an ever changing world.
When a change attacks my plans it’s like an attack on my character. My plans weren’t good enough, that they had to be changed, an attack on me, my judgement when someone suggests I do something differently. They don’t want to accept my idea and therefore don’t accept me by extension. Of course this is not true, but that’s how it feels. Understanding how to make the emotional connection to the logical occurrence of this being not true is what’s difficult. For me there is a complete disconnect between what I logically know to be true and what I feel, if I feel at all.

Disappointment. I read disappointment into your reaction/suggestion because you wanted more than I thought to provide which translates to disappointment in myself because I couldn’t guess what it was that you would have wanted best. Or worse, that you don’t want what I want and I begin to fear that this one instance extends into the entire friendship, relationship, etc. What I’ve done isn’t good enough, I wasn’t good enough, it’s only a matter of time before you realize I’ll never be perfect and you’ll seek company elsewhere. Leave…  

On the other hand, if things go well, if I can do something that makes someone happy this also validates who I am. That I am someone good and worthy of being loved or cared for. If I can do something to show I care, and it’s appreciated, I can physically represent that I am an important aspect of someone’s life. Knowing this, in the moment, it’s euphoric. My simply being there isn’t enough, I must be able to SHOW it. If I can’t show it, how could they SEE it. I have a very difficult time believing that if I’m not immediately in someone’s presence that they can remember the care I hold for them (more on this later). Contrariwise, if it’s something I do isn’t appreciated I’m left with

Nevermore – Criteria 5 / Suicidal Ideation & Gestures

Why did I finally give up the ideation of suicide?
I’ve tried to end it mostly by slashing my wrists and overdosing. I’ve thought about it in a hundred different ways, in a hundred different places though; while I’m driving, just keep going right off the road/cliff, or pull in front of a semi, walk in front of a moving vehicle, take all my anti-psychs, stab myself through a major vein, etc. All ways I have easy access to. So why don’t I?
In a nutshell: 2 reasons.
To fight back. Just before graduating high school a ‘friend’ of mine worked to break up my friendship with my closest friend. He succeeded and later in a drunken confession admitted he’d done it to see if I would kill myself. He’d known how depressed I’d been for so long and thought it would push me over the edge. He had no reason other than his own god complex. The problem with this scenario is; I rail against adversary. If someone expects me to be one way, I am another (as long as it suits me). I don’t just go with the flow of a situation. I fight back. This act actually made me less inclined to kill myself and made me more determined to not let people close to me so that I could protect myself, my self worth, and my life. I don’t just roll over and die, I come back swinging, fighting tooth and nail. If you expect something negative from me, I will prove you wrong. If you try to push me one way, I’ll push right back. The less someone believes in me, the more reason I’ll give them that they should.
But more importantly, I lost faith. I was raised without religion but even from a young age I held to the old Earth Religions, believed in Reincarnation and an afterlife of sorts. There was an ‘ever after’ that I didn’t fear. After so many tumultuous problems in my life I lost faith in the belief that there was anything better, anything beyond what I was currently living through. I adopted atheism (Well, technically I’m agnostic but a practicing atheist). No longer believing in an afterlife made me believe that this was my only chance at this life. Death is the end of my only chance. As long as I am alive, there is a chance to change things. I never considered suicide an option after this. I’ve always done whatever I could to hold to that potential for change.
Amusingly if anyone knows anything about the Tarot: Death is my card. Death is a card of change. Endings as a doorway for the potential of a new beginning. As long as I live there will be death, and change.