Hidden suffering of the Psychopath…

I saw this article and was intrigued. Especially as the Conlcuding paragraph is this:

It is extremely important to recognize hidden suffering, loneliness and lack of self-esteem as risk factors for violent, criminal behavior in psychopaths. Studying the statements of violent criminal psychopaths sheds light on their striking and specific vulnerability and emotional pain. More experimental psychopharmacological, neurofeedback and combined psychotherapeutic research is needed to prevent and treat psychopathic behavior.

The current picture of the psychopath, which is reflected in the leading diagnostic criteria of psychopathy offered by Cleckley (1982) and Hare et al. (1990), is incomplete because emotional suffering and loneliness are ignored. When these aspects are considered, our conception of the psychopath goes beyond the heartless and becomes more human.

It’s not an incredibly recent article but it does take a look at psychopathy from a perspective other than witch burning and untreatable. I wonder if clinicians generally ignore research like this on purpose or discount it automatically in favor of perpetuating the stigma.

Bordering on Sociopathy?

A reader from another blogged asked me a question that roused my curiosity: Are people with BPD always sociopaths, never sociopaths, or some of each?”

 

My immediate response was never. I don’t think I’ve ever heard anyone say that someone with BPD is sociopathic. Though clearly we’re grouped together in the spectrum of Personality Disorders. Sociopathy is classified under Anti-Social Personality Disorder which is Axis II, Cluster B along with Borderline Personality Disorder.

There are reasons as to why we are grouped alongside one another.

So, after a few seconds contemplation my response changed from ‘never’ to; there are some shared characteristics, but still no.

Dictionary Definition of a Sociopath: “Someone whose social behavior is extremely abnormal. Sociopaths are interested only in their personal needs and desires, acting without empathy, without concern for the effects of their behavior on others”. I’m not even going to bother explaining how inadequate of a definition this is for describing sociopathy. It’s the same thing as grabbing a two sentence definition of Borderline. Let’s run with this though shall we…

A case could be made that BPD has sociopathic traits: Our behavior is extremely abnormal, we have a skewed sense of empathy, we act with regards to our immediate needs without concern for how it will affect others (most notably with Low Functioning BPD; High Functioning BPD we may want to act this way but we can often restrain the impulse), we’re impulsive, manipulative, etc.

But seriously, welcome to the world of personality disorders. There’s bound to be some overlap between a great deal of these traits. While both disorders may display many common traits, our motivations, intentions, reactions, perceptions, and presentations are very different. For someone with a Borderline Personality Disorder we are often moved to do the things we do out of a need for attention, sympathy, closeness, reassurance… while the sociopath is not going to have these things as their driving force.

Where the sociopath will have a very limited sense of empathy and low emotive threshold, the borderline is almost the complete opposite. We have a heightened sense of emotional response. Responding to things too quickly in a way that is out of proportion to the situation that has provoked the response.

This reader also had questions regarding our potential penchant for sadism (masochism), and being able to empathize or take pleasure in the injury and suffering of others. I don’t believe this is generally the case. Personally, unless it’s someone I care for, I rarely feel anything for strangers and therefore have a neutral, uninterested view of such things. I may not be interested in their suffering but I don’t’ relish in it either. Now, if it’s someone I’ve split into an all Bad category because of how they’ve treated me poorly in the past; I may take a certain amount of satisfaction in their pain. I’m willing to bet that this crosses the line to how many normally empathic people feel though. No one’s perfect, and most people have some small vindictive streak.

Not happy to go off of my own guesses and assessments I tried to find something already written about this. I found a LoveFraud article (don’t get me started on her bullshit) but as it was submitted by a private psychotherapist names Steve Becker I gave it a read. The title of the article is: The Borderline Personality as Transient Sociopath.

 “It is not unusual in my clinical experience to see, sometimes, some quite chilling sociopathic activity from my “borderline personality-disordered” clients. When someone has a “borderline personality,” it’s quite likely, among other things, that he or she will present with a history of emotional instability; a pattern of chaotic interpersonal relationships; and poor coping skills under stress, reflected in self-destructive/ destructive acting-out and a tendency to suicidal behaving.”

Quite likely, huh? I’m fair certain by definition we are likely, nay expected, to present with a history of emotional instability. Of all the criteria we may present with, this is the one overarching issue we share in common. How do you diagnose someone with BPD without this?

“A question I’ve found myself considering is: When the borderline personality is acting, and looking, like a sociopath, is it the case that he or she, in these states, effectively is a sociopath?

It should be noted that behaviors per se are never sociopathic, only the individuals perpetrating them. Sociopathy is a mentality from which antisocial, exploitative behaviors gestate and emanate with a destructive, historical chronicity. But one can infer the presence of the sociopathic mentality from a telling pattern of behaviors.

Clearly there are fundamental differences between borderline personalities and sociopaths, differences which I appreciate. At the same time, when the borderline personality’s rage or desperation is evoked, one sees (and not rarely) responses that can closely correspond to the sociopath’s calculating, destructive mentality.”

I’m not saying I can’t be calculating and destructive, but this combination doesn’t take over in the moment of provocation. Destructive, quite likely. Calculating comes when the storm has subsided and I can think clearly. I also won’t say this is all borderlines. We are obviously all different, but I’m not immune to barbing and hurting those that I care about. I talked about Alienation the other day and this certainly comes into play there. It’s one of the things I know beyond most others that I’m trying to stop.

“Once inside this mentality, I’m suggesting that borderline personality-disordered individuals can lapse into a kind oftransient sociopathy. Commonly, victims of the “borderline’s” aberrant, vicious behaviors will sometimes react along the lines of, “What is wrong with you? Are you some freaking psychopath?” They will say this from the experience of someone who really has just been exploited as if by a psychopath.”

Just because someone doesn’t understand the reaction someone with BPD has, does not mean we’re actually psychopaths. Especially considering the base motivator is emotive and therefore not anything resembling the emotionless drive of a psychopath. Also, just because some person mentions the world psychopath, does not make for an actual diagnosis.   

“Because this isn’t the borderline personality’s default mentality (it is the sociopath’s), several psychological phenomena must occur, I think, to enable his temporary descent into sociopathy. He or she must regress in some way; dissociate in some fashion; and experience a form of self-fragmentation, for instance in response to a perceived threat—say, of abandonment.”

Our ‘vicious’ aberrant behavior is not someone with BPDs default mentality. I do agree with this. For the entire stigma and the accusation that a borderline is labeled with, our bouts of anger, impulsive lashing out and frenetic behavior are rare compared to our day to day state. However, that these things do occur is a hallmark of our disorder. This is part of what classifies us as Borderline. I’m willing to bet that most Sociopaths aren’t on the constant prowl to manipulate and victimize everyone around them. Day to day they probably just live their lives. The make up our personalities are predisposed to acting the way we do and those actions are what define our different disorders. That there is cross over does not mean that we slip into the mental state of the other. It is becoming increasingly more clear to me that this guy knows practically nothing about Borderline Personality Disorder and is simply trying to fit a square peg into a Sociopath shaped hole.

Several psychological phenomena must occur… if these are really the criteria that define slipping into a transient sociopathic state, than I might as well embrace the title. I live a good majority of my life in this comorbid ‘regression’; dissociation, unstable sense of identity, fear of abandonment… how do these characterize sociopathy?

“These preconditions, I suggest, seed the borderline personality’s collapse into the primitive, altered states of self that can explain, among other phenomena, his or her chilling (and necessary) suspension of empathy. This gross suspension of empathy supports his or her “evening the score” against the “victimizer” with the sociopath’s remorseless sense of entitlement.”

Now this does peak my interest. I do relate to these periods of suspended empathy. This is a product of my dissociation and detachment though. When I’m feeling like this, or more accurately not feeling like anything, ‘evening the score’ is not on my mind, because in not feeling anything for myself or for anyone else, I can’t care. I may not empathize; not feel for someone else; not care about what they’re going through… but I also don’t feel for myself, and I certainly am not thinking to plot some revenge. I can see where this ill formed train of thought may come from though. As is especially the case in Low Functioning BPD, when something triggers a borderline and they do rage, and lash out, unable to control their emotional state, they will focus that hurt and aggression on those they love. I don’t think this is due to a lack of empathy though. No, they’re not thinking about the other person’s needs or well-being, this is true, but it’s not for lack of wanting to. Their own emotions are so heightened and out of control that they can’t see beyond their own scope. I’m not saying it can never happen, but the detachment of empathy and the lashing out against the victimizer are often separate feeling states, not maliciously aligned.

In my states of detached emotion and lack of empathy, my mind may roam to places that I don’t care what happens to another person/people, but at the same time, since I am not clouded by emotional responses I am at my most rational and don’t think to act on my lack of empathy. My motivation to lash out is void because the emotional drive is absent. However, my responses to people may be more callous, less guarded. This is almost always how I think though. It’s not some transient state I’ve slipped into, but a removal of the veil I no longer care to hold up. Normally, instead of acting out on my impulsive thoughts, I hold them in. Where someone more low functioning would act out and then need to apologize profusely to regain the favor of those around them, I generally manage to tame my temper outwardly. It’s my understanding of social interaction that stays my responses so I don’t alienate the people I desperately need in my life. This doesn’t mean the feelings aren’t always there, but my awareness of my actions guides my behavior.

This article is just one more way of demonizing someone with Borderline Personality Disorder under the guise of gleaning a better understanding of what BPD is. Personality disorders are demonized enough; do we really need the mutant hybrid versions too?  

In conclusion, do I think someone with Borderline Personality Disorder is Sociopathic? No. I do not.

Do I think this psychotherapist is an idiot? Yes, yes I do.

There’s a lot of bullshit out there about all the PDs. It’s no wonder people are so quick to judge. 

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.

Characterization:————————————————————————————————————-

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

Schizoid Personality Disorder – A 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.)

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. 

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::

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.

Debate:

[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.

Through a Looking Glass, Shattered.

Hello. I am Haven. My hopes for this blog is to reach out, to connect, to touch you in some way that will increase awareness of what it means to have a Borderline Personality Disorder.

I promise nothing but an attempt, an honest look into the experience and insights of someone that walks through this world in a way other than you may do so yourself.

I do not claim to be representative of BPD. In fact, I don’t believe there is such a thing as a general representation. As one of the predominant features of my disorder is my dissociative condition, I feel almost no attachment to a group of individuals whatsoever. I hope to convey just how separate, other, this worldly experience is. Raise awareness, increase understanding, and challenge the perception of what is commonly held as the social norm of being.

Let us begin, shall we? Through a Looking Glass, Shattered.