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’.

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. 

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.