Tuesday, October 30, 2007

Borderline Personality Disorder and the DSM

Almost 30 years ago, when I started my master's degree program, if we discussed borderline, that meant we were discussing psychosis. A "borderline" was a person on the "border" of psychosis.

In those days we were taught that psychopathology either manifested as

(1) a neurotic disorder, people were depressed or they worried endlessly over problems stemming from unresolved childhood guilt; we called them the Woody Allens;

(2) a psychotic disorder, accompanied with hallucinations and/or delusions; the patient being out of touch "times three," meaning he didn't know his name (person), where he lived (place) or the day of the week (time) ;


(3) a borderline disorder, essentially No-Man's Land, neither neurotic or psychotic, but definitely leaning towards the latter.

Borderline meant having such poor boundaries that the patient felt blended with others psychologically, did not see where his or her perception of others' thoughts or intentions could be wrong. The condition would manifest as severe abandonment anxiety, anger or depression, and certainly suicidality, ala that movie, Girl Interrupted. Perhaps the behavior was manipulative, but who knew for sure?

Disturbed, that we recognized. Depression didn't have to enter the equation (but it usually did).

Merging was thought the natural consequence of not having separated properly from parents, not having individuated or developed into an independent person, secure all on one's own. And to individuate well, one needed psychologically healthy parents who encouraged that differentiation and confidence.

You see why I push it, some thirty years later.

The first Diagnostic Statistical Manual (DSM, 1952), the Big Book of psychiatric diagnosis, included an etiological component that subsequent versions for the most part phased out in favor of statistics. Empirically-based medicine had evolved.

But ideas of merging and family dysfunction had a place in the first manual, as did other etiological explanations of pathology, such as the stress of combat contributing to substance abuse in the military. Not surprisingly, the American Psychiatric Association (APA) released the first DSM to meet the needs of the military— soldiers had returned from war alcoholic and traumatized.

This was also about the time that psychiatrists recognized the association between self-medicating with alcohol, and the manic component of bi-polar disorder.

The need to mesh psychiatric diagnosis with numeric coding consistent with the International Statistical Classification of Diseases and Related Health Problems [(ICD), the World Health Organization] followed soon thereafter. Then the mission of the DSM officially shifted from the explanation of psychiatric disorders to descriptions.

And as clusters of features and symptoms emerged for each new edition, psychological disorders became medical disorders, handily recognizable sets of features and symptomatology.

Our latest edition, the DSM IV-TR has refined the process, adding cultural diversity to the mix and some general psycho-social history that is associated with certain disorders. There is also an occasional reference to how genetics steer the course for others.

But to diagnose, we focus upon what we see and hear in our offices.

And borderline no longer necessarily implies having "poor boundaries." The disorder is now neatly cataloged as an Axis II personality disorder with easy to recognize socially dysfunctional features (see below). But those of us who remember what it means to people to feel less than whole, to have a need to own or merge with someone else's ego, body, or personality, are more likely to empathize with that particular pain, even though it isn't on the list.

Lucky for us, the DSM modifies, adds, and removes diagnoses with each edition.* So I look forward to seeing what the next one (2012) will do with borderline.

As it stands, anyone with or without a college vocabulary can take a stab at reading and understanding the DSM IV-TR to diagnose family and friends. Anyone can look up a diagnosis like "Borderline Personality Disorder," find the features, and label others. I started this post because a patient wanted me to list the features so that she could do that. You, too, might become rather good at psychiatric diagnosis with a working knowledge of the DSM IV-TR, assuming memory and retention serve.

It is a free country. Go buy a copy. (But pop for the full edition if you do, not the condensed spiral). It will teach you little about how a person develops a disorder or what to do about it, but at least you won't be caught using terms like "split personality" or "multiple personality disorder" anymore.

We'll get to the Dissociative Disorders another day.

But you wanted to know about Borderline Personality Disorder. So here you go. Here's what it says in the book:

Diagnostic criteria for 301.83 Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization or devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(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)

(7) chronic feelings of emptiness

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

(9) transient, stress-related paranoid ideation or severe dissociative symptoms
Well, on the re-read, perhaps one might need a dictionary, if not a graduate school education, to really get this.

You can see why it's considered a VERY painful condition. Painful to have, painful to treat, painful to live with, all around painful. The disorder always calls me to task, forces my patience, and ultimately brings out my compassion. It's difficult, emotional work and I've heard time and again from peers that working with too many patients suffering from borderline personality disorder contributes significantly to burn-out.

But there are those who burn-out working with people who suffer from depression, too.

Notice my use of language. SUFFER FROM. You'll read on the Web that people think of themselves as borderlines, or bi-polars, obsessive-compulsives, depressives, or schizophrenics.

The better way to refer to someone with a disorder is:

a person who suffers from schizophrenia

or a person suffering from borderline personality disorder.

And so on. We don't say, "She's schizophrenic." Or, "He's bi-polar."

That minimizes a person. The process does that already. We don't need to add to it.

Copyright 2007, therapydoc

*Homosexuality, for example, is no longer considered a disorder, and it is likely that in the fifth edition of the DSM we will see Adult Asperger's and Adult Attention Deficit Disorder, currently two disorders of childhood.


Anonymous said...

I know someone who fits this description almost exactly. She has recurring patterns, but hides her more extreme personality disorders very very well, but when I was exposed to that side of her, I have to say it was the scariest experience of my life. She is a truly toxic individual who can ruin the lives of others. How much of her behavior is her fault? Doesn't an adult have to take responsibility for their own actions at a certain point? How much can you blame on a psychological disorder and is there any way to really help someone like this? The person I'm speaking about has been in therapy for years, and is on anti-anxiety drugs (for over a year) and still her behavior persists. It seems helpless.

therapydoc said...

Everyone can change. I never said it was easy.

Anonymous said...

Welcome to my life. Got pain?

therapydoc said...

Another Anon:

Right. I know, and nobody wants to hear about it.

Once I wrote a musical about child abuse (true story). My s-i-l said, Nobody's interested, music, no music.

Anonymous said...

Notice my use of language. SUFFER FROM. You'll read on the Web that people think of themselves as borderlines, or bi-polars, obsessive-compulsives, depressives, or schizophrenics.

The better way to refer to someone with a disorder is:

a person who suffers from schizophrenia

or a person suffering from borderline personality disorder.

And so on. We don't say, "She's schizophrenic." Or, "He's bi-polar."

That minimizes a person. The process does that already. We don't need to add to it.

therapydoc said...

that means we're on the same page, that she posted this. we've talked.

So, what IS in a heart? said...

I remember forum goers over at Portal of Evil.com talking about Borderline Personality Disorder, and one of the members said this: "If you think it's hell dealing with a Borderline, try BEING one."

However, it's hard to sympathize with those who've caused lots of misery, and you simply can't accept ANY excuses for crappy/abusive behavior.

therapydoc said...

I like to think of it as not so much looking for an excuse to behave in a sociopathic way, but as behavior that begs the question. As in, Why are you doing this? Is this going to make other people like you more?

That sort of thing.

Fallen said...

I remember when I was doing my undergrad in psychology they pretty much took on the view that Borderline Personality Disorder was basically a catch-all. If they couldn't find another diagnosis then that was what to go with. I couldn't believe that the professors were actually advocating that. As someone who used to engage in self-injury I've also heard that it's common to be labelled as Borderline just for engaging in that behaviour. So I really do hope that some changes are made in the next edition of the DSM.

Fallen said...

If people want the disorder and criteria from the DSM-IV they can go to http://www.behavenet.com/capsules/ but it doesn't give the backstory and etiology of the disorder. More of a quick and dirty reference guide... Just in case you want to diagnose (or at least label) all the people in your life.

therapydoc said...

So I see I have my work cut out for me in moving you all AWAY from diagnosis.

I'll post on it, I guess.

Anonymous said...

Has anyone read "The Heroic Client" by Duncan, Miller, and Sparks? Chapter is is titled The Myth of the Medical Model and includes a discussion with numerous citations about the lack of reliability of validity of DSM diagnoses. I found it thought-provoking. Here's a brief excerpt: "Consider borderline personality disorder (BPD), the mental health equivalent of "the thing" in horror movies. The prevailing diagnostic guide provides 126 possible ways to arrive at a diagnosis. All it take is to meet five out of nine criteria. If one can be diagnosed as BPD in 126 possible ways, how distinctive of valuable can such a diagnosis be?" And from a recent post to a listserv I'm a member of: "It is my feeling that the use of this diagnosis is analogous to the old use
of the resistance tag. In other words, it strikes me as a way to blame the
client. In this case, it is giving the client a label that is supposed to
be permanent. After all, it is their "personality". I have found this label most frequently given to women who do not fit the old stereotype of compliance and femininity. If a woman is upset, anger, or devastate by horrific life events (such as a history of molestation or rape) she will get this diagnosis. If she complies with the cultural demands that have been eternal in almost all societies for dependence, she will get the diagnosis
when her dependence is threatened. I have found that if I debunk the diagnosis with women who have already gotten it, they immediately improve. The label can have devastating

Anonymous said...

Great post. I've just spent many class hours discussing the borderline client and everything that comes with him/her. We talked extensively about the object relations theory, and Klein's concepts of the paranoid schizoid and depressive positions. It's also interesting that bipolar diagnoses are often mistaken for borderline and vice versa. It's fascinating that a seemingly unimportant and small part of infanthood can have such tremendous affects on the child's life and personality.

therapydoc said...

Thanks Julie. You're going to be great at this job.

Suni said...

wow. great post. very interesting. i am going to have to link to you.

Anonymous said...

What an interesting post that hopefully enlightens people. When you wrote: "You can see why it's considered a VERY painful condition. Painful to have, painful to treat, painful to live with, all around painful. The disorder always calls me to task, forces my patience, and ultimately brings out my compassion." I said to myself, Thank You. Thank you for that compassion and that willingness to understand.

Yeah, I was diagnosed with BPD. And that has made a huge difference in my life, because now I have a better explanation for my impulses and behaviors, and now I can see that this all is manageable.
While I have no problem calling myself a borderline, sometimes I don't like if someone says I "suffer from" BPD. Because while it is an extremely complex and painful condition, I refuse to "suffer" from it. With A LOT of hard work, the right therapy, and sometimes the right meds, Borderline Personality Disorder is, in fact, treatable.

The worst misconception about BPD is that those of us who have it are toxic (as in comment above) and difficult and manipulative, and it's b/c we like it, we do it on purpose! As if anyone would choose to have BPD. We're actually individuals, and we're not awful and toxic. We can be very sensitive and intense. But we are still unique human beings, and often people forget that. Don't dismiss me b/c of my condition. And don't insult me or label me b/c of it. I'm just like everyone else in the sense that we all have something to work on...mine just might be a little more difficult to manage.

I have BPD. Every day I am conscious of it and monitor myself accordingly, best as I can. I move forward. I participate in my recovery process. I'll always "have" this condition, but I'm finally learning about myself. My BPD self, my core self, and the ME that exists as a combination of both.

Thanks for listening. (I tend to write a lot.) And thanks suni for leading me to this post. :)

therapydoc said...

Gisele, thanks for a beautiful comment. Just beautiful. I might post it as a post, if it's okay with you. We'll talk :)

Anonymous said...

Wow. Thanks. A lot. You can post it, excerpt it, quote it, as you like as long as it has my first name on it. :) So people knows where it comes from. From someone with BPD who refuses to be labeled as difficult, called toxic, blamed for my behavior, called manipulative . . . instead of someone trying to cope with her disorder... Ultimately I will recover. I will always have to keep tabs, but I've already seen incredible changes and I now know that I can do this. Because now I know why, and I know there is a reason for my past behaviors and actions. Huge difference! I am not toxic. I am a human individual discovering that she can be valuable and discovering who she is and amazed that she's not all that bad. :)

Just Me said...

Funny, I prefer to avoid the "person with bipolar" stuff when talking about myself. It feels so awkward. I am bipolar. I am also many, many other things. I just consider it another characteristic. Sort of like I wouldn't call myself "a person who is intelligent" rather than just saying "I am intelligent". (Not that this is the main way I think of myself, I'm not that self-centered, it was just an easy example).

I also don't like the whole "consumer"/"client" thing. This is a medical condition I'm being treated for, by medical professionals. I'm not sure why that keeps me from being a "patient".

I did a post about this sometime but have no idea when. I remember nobody agreed with me. Maybe I'm just weird.

therapydoc said...

Thanks for your thoughtful comments. I think it's one thing for you to say, "I'm bi-polar," and for another person to say, "You're bi-polar."

It's not the same as saying, I can say whatever I want to about FD, my mother, my kids, but you better the hell NOT.

Anonymous said...

There are currently 256 ways to be diagnosed with Borderline Personality Disorder through the DSM-IV-TR.
Saying someone is borderline is not the same as saying someone is bipolar, precisely, but not only, because the diagnosis of the first is so imprecise.
Unfortunately moral judgements still contaminate how we see all personality disorders. Saying that someone "has" a personality disorder is not the same as saying someone "is" plus an adjective (narcissistic, histrionic, etc.) derived from the PD list.

I see Borderline Personality Disorder as foremost an emotional dysregulation disorder. Impulsivity in various degrees comes next, but in individuals with strictly internalizing strategies of coping with their pain and depressions, it may be missing altogether. Insecure attachements of one sort or another make it very difficult for these individuals to find socially accetable ways to state their needs and ask for help. However while caracterological manifestations such as lying, trickery, "real" manipulation (with planning and foresight), blackmail and other "toxic" behaviors might have everything to do with a person's individual biography, they have nothing to do with a responsible diagnosis of Borderline Personality Disorder.

process said...

Hi, just found your blog recently and am reading the archives.

I wanted to email you but couldn't find an address.

Could you please explain what you mean by "This was also about the time that psychiatrists recognized the association between self-medicating with alcohol, and the manic component of bi-polar disorder"?


therapydoc said...

Yes, PROCESS. The Vets came home from WWII (as from any other war)addicted to alcohol and drugs. The VA dried them out and did follow-up, found that a significant number couldn't sleep, had bi-polar or uni-polar mania. They had been using alcohol (and other drugs) to sleep.

Unknown said...

The blog is well written and it is interesting to see someone perspective from the other side of mental illness. Unfortunately having the BPD diagnosis is viewed in the same way as leprosy both inside and outside of the therapeutic community. When you are diagnosed the stigma that follows this disorder is almost more difficult to deal with then the actual diagnosis.

Anonymous said...

My mother is BPD. I lived my whole life with her issues. Went into mental health as a profession (maybe as an unconcious way of helping MYSELF). Out of my 50 years, I had almost 5 normal years with her. I thought she had finally turned a corner. WRONG. My father passed away one month ago. He had remarried and had 16 years with his wife who loved and respected him and gave him what he deserved in life. My mother began her rampage months before he died of cancer. The extreme pain & suffering she has thrown in our path as a family has been pure unadulterated hell. The lies, manipulation, greediness, and total disregard for her children's grief is so extreme it blows my mind. As a mental health person, I understand, BUT, I am human and it just seems incomprehensible that another human being can be so mean, cruel and nasty to her own grieving children. All she seems to care about is what money she is entiltled to. Her behavior at his funeral was horrible for all of us as well. Has she no heart? I can't wrap my self around this.

therapydoc said...

Man, it can hurt. I'm not going to address this specifically to you, since I don't do that on this blog (it's just for teaching). But in general, we look at that kind of insensitivity to others as a reflection of her own personal pain, sort of a look out for Number One thing. Except it becomes only Number One, and people get pretty good at it, and it's self-reinforcing.

That's only one way of looking at it, but I think it makes sense.

Anonymous said...

I am happily introverted, I like to be alone, I love to read, I tend to hide my feelings. My work is creative. I'm not impulsive, only very subtly self-destructive if at all (with the exception of a serious suicide attempt when I was only thirteen), and I can not relate to "frantic efforts to avoid abandonment" - I suffer my abandonment depressions in shameful silence. But something is very wrong. There are almost always four to six consecutive days out of every month where I am assailed by horrendous feelings of frustration, irritation, and despair. Obsessive mutterings fill my head pushing out all the productive ideas I might have had only twelve hours ago. Tremendous anxiety dreams take over at night. I'm not sure this is reactive; although I can often point to triggers, the same events or frustrations on another day will lead to no reaction at all. Not only is existence unbearably painful during these days, even if I succeed (and I most often do) in hiding my feelings from the world (including husband and friends), this is time lost in every sense.

I reluctantly accepted a diagnosis of BPD several years ago because of these terrible dysphoric states I fall into. Dysthymic (I was told), I also startle too easily and strongly coercive situations provoke anguish and sometimes, but rarely, aggressive behavior. I always feel terribly guilty afterwards. Also I was told that if major depression reoccurs there's a reason, i.e. BPD. I've been told that this is the "closest category" for me.
At the end of my second three years of therapy last fall I was assured that I could now consider myself "borderline normal". This has left me still further without words, to say the least.

I've read all kinds of horrible things that people have to say about "borderlines" such as the entry above that starts "My mother is BPD..." I cannot face having others associate me with this diagnosis. I have hid this dx from husband, family and friends for over 10 years now. I get by with meds for insomnia. It helps that I work alone, and the depression usually lifts in the afternoon. I can be quite cheerful in the evening. Still I live in fear of what would happen to my world if "they" only knew. I am afraid that some day an inappropriate response in a stressful situation will give me away. The only solution I've found: I isolate more and more as time goes by. I greatly admire all those who have had the courage to say - in one way or another - that "borderline personality disorder" means them.

therapydoc said...

THAT takes courage, posting that comment, and it gives others hope. Thanks so much for sharing it. I think diagnosis is only a means to an end. Indeed, most people, if pressed, will admit that they have a bunch of days in a month that are real tests emotionally. Is everyone borderline? Not to minimize, but the lables can throw us off, lower self-esteem.

Just Me said...


I work in healthcare and over time it's become quite clear that diagnoses are quite often random, esp. psych dx. Psych. diagnoses seem to often be bizarre because there are too many cooks with one pot. I had a few ladies a couple years ago who had apparently been multiple diagnosed to the point someone finally wrote in their charts "mentally ill". Not a useful set of words.

But...I understand why you try so hard to function without people knowing your label. I don't let too many in on mine either. (I have severe bipolar I with mixed states. Until a few months ago I've been totally unstable and impossible to deal with for years).

But honestly? You sound much like me. I accept the pathology in myself, and I do have more interpersonal issues than most bipolars; my problems are different than standard. I have irrational loss of temper and impulsiveness at times, but mainly I have paranoia. Trusting people sometimes feels impossible to me. However I also grew up in a very abusive family and this makes it a bit understandable, although still frustrating.

I don't know what I'm trying to say exactly, just you're not alone. Come visit my blog sometime if you want to see more.

So, what IS in a heart? said...

"I've read all kinds of horrible things that people have to say about "borderlines" such as the entry above that starts "My mother is BPD..." I cannot face having others associate me with this diagnosis."

It's because people don't seem to realize that one might not choose to have BPD(some say you do, others not), but they choose to be evil. Evil is based on a belief system, and it can stem from everything from having a depressed spirit, corruption, to outright hatred and anger of self and everyone else. Or for one's own amusement. BPD has nothing to do with it, but it sure doesn't help any.

therapydoc said...

Benefit of the doubt is useful here.

Anonymous said...

What a great find. I was just looking up more info on BPD for a group I'll be running at the clinic I work at. I find much of the stigma around BPD comes from the system itself "she's so borderline" type comments, etc. (From therapists none the less). I hope and continue to advocate for proper diagnosis and treatment of individuals who have been diagnosed. However, I find part of the problem also falls into not being diagnosed properly (sometimes from confusion of bipolar vs. bpd). I think a lot of therapists avoid making the diagnosis of BPD (if i make the diagnosis then it must be true?) and end up diagnosing Mood Disorder NOS (not otherwise specified) or Personality Disorder NOS. I don't think many clinicians ask the right kinds of questions about whats going on which is so unfortunate. Hopefully since the disorder seems to be getting more press/more awareness things will change.

therapydoc said...

So true. And the insurance payor system complicates it, too.

I tried my best to leave off Axis II diagnoses. I didn't see why it was necessary, as long as I could code for an Axis I and insurance paid.

There was a time, and it's probably still true for some HMO's, that an insurer wouldn't pay for an Axis II dx.

jennifer said...

I am borderline. Check out my blog at http://bpdokc.blogspot.com

Anonymous said...

But should this be called a "personality disorder"?
Would it be better off renamed and on Axis I?
Is it possible that it really is an affective disorder on the level of Bipolar but distinct and perhaps there's an added ingredient of trauma or shame, etc. that is driving all other manifestations, including the desire for therapy and/or meds to stop the pain?

therapydoc said...

I've rarely treated someone who presented with the personality disorder who didn't have a co-existing Axis I disorder such as a type of affective (depression/bi-polar) or anxiety disorder.

Therapists have a 5-axis coding system and should really be looking at a patient in all five ways.

Anonymous said...

I've been diagnosed as "Personality Disorder Not Otherwise Specified."

To me it just means I have a bad personality, as there are no specifics I can work on or fix.

It makes me want to never socialize again for fear that others will also recognize my awful personality.

Funny thing is, I don't know what it is I'm trying to hide--just that there is something wrong with my personality. I've never had anyone tell me my personality was bad before... but I guess it is.

I'm trying to get over the stigma of it, but it ain't working. :-(

therapydoc said...

It's simply unconscionable that someone gave you a diagnosis and then didn't help you treat the problem. There's therapy for this, not so difficult, either, and I'm sure you'd do fine. Find out if anyone out there in your hood treats this disorder and try again with the therapy. If it's really borderline, then there are specific therapies that can help.

And don't get discouraged.

Anonymous said...

I also have BPD and am currently in treatment, specifically with Dialectic Behavioural Therapy. I think I'm lucky in may ways to have BPD instead of one of the myriad other conditions I could've had.

BPD is not a life sentence. There are people who no longer fulfill any of the diagnostic criteria for the disorder. This is a rare and wonderful thing in the world of psychiatry, to have a condition that can be 'cured'.

I'm not saying it doesn't suck to have BPD, after all I lived untreated for 26 years, and I'm one of the lucky ones having gotten into treatment so young. And certainly the stigma associated with this particular illness as well as mental illness in general is very great. We are loofed upon to be some of the hardest patients to treat. But the rewards of getting back a life worth living is so great.

therapydoc said...

Amen, Anon. Thanks for writing.

Anonymous said...

Thanks for reading.

For me the diagnosis was simultaneously freeing and saddening. I realised what it meant while I was in treatment for Social Anxiety Disorder. Ihad been diagnosed some time previously, but didn't know what it was, I thought it meant I was on the border of having a personality disorder, but that I didn't quite qualify.

At the time of my diagnosis I qualified under all of the diagnostic criteria stated above. When I read the description of the illness I knew instantly that it described my life. These were long-term problems that started when I was very young and culminated in a nervous breakdown at 24 years old.

I had previously known that something was wrong, but when I seeked help I fooled the professionals into believing that I was okay. I am very good at appearing confident, capable and whole, and I wasn't yet ready to accept the reality of my issues.

Dealing with this diagnosis was difficult, I did come across a lot of the negative talk about people with BPD. It really shed light on some of my more extreme behaviours. I've never been an evil person, but when I lose control of my reactions to my emotions I can say things that I regret as they come out of my mouth. I alwys apologize, and there are things I've never said that have occurred to me at those times, but still.

My mother found my diagnosis enlightening. She had always blamed herself for my issues, even now she tends to do that. The diagnosis served as a catalyst for the realisation that she is not responsible for my illness.

It is an illness. There is no question of that. It's something I didn't ask for, something I suffer from and through, and it sucks.

But that's life and I'm all about the radical acceptance. Willingness oover willfulness and all that.

therapydoc said...

You're wonderful, for sure, much more than a diagnosis. So willingness on, right? Thanks so much for writing.

Anonymous said...

My wife suffers from BPD. Diagnosed by her last psychiatrist, which is why she stopped seeing him. Followed by five years of counseling, waiting for her to accept the diagnosis and accept treatment.
Our marraige is a wreck, she self medicated with alchohol, lies constantly, lost her job over it, berates our children, and all beucase she believes we are all against her.
How can I help her get to the point where she can accept the diagnosis? Our marriage counselor has quietly agreed with me and the psychiatrist, but won't push the matter. She is still working on winning the confidence of my BP wife, but I am losing my patience.

therapydoc said...

Anon, I can't speak to your particular situation, that's not what I do here, but I can give you a hint about how I'd handle that kind of situation in general, which is to not stress about a diagnosis, find out what hurts her, and try to get help for that. But with most personality disorders, the disorder itself (and alcohol) tends to defend the person, so it's the family that feels the pain. Again, just a general spin on these kinds of situations.

Anonymous said...

"Find out what hurts her...." Yes for sure. Try anyway. Because she's drowning in emotional pain.

But meanwhile get her to a good psychiatrist. Because it's sheer hell that she is in. She needs to have her depression taken seriously - we jump to medication when confronted by "irritable-hostile depression" in bipolar disorder, why do we not it medicate in BPD? I suspect it is because there is a prejudice out there blind to the immense pain - once someone has been labeled BPD, they are only seen as "irritable-hostile" - we ignore their depression. Why? Because there is a belief that all personality disorders are actually defenses that only make everyone else suffer. But NO - BPD is a breakdown in defenses. Why is the world so blind to this? There's a big difference here from many other "personality disorders" that is not getting enough press.
There is a moment when the acute symptoms of BPD emerge under an onslaught of emotional stress/trauma - they are kindled by something. So okay, there's a cause and effect. There often is in Axis I disorders too - we just don't look for them. But there were good times before, weren't there? She/he wasn't always this way? Wonders never cease...

BPD for me is awfully suspect as a "personality disorder". The first reason: It waxes and wanes just like many "axis I" disorders, no one is BPD all the time. The second and most important as I see it: It's more and more clear that so many different kinds of people are getting dx'd BPD - a DSM dx that is a bizarre mix of traits and states that does not even bother to shortlist the most notable feature i.e.the intense inner pain - that there is no way we are defining one type of personality here - the number of subtypes created to date so as to include everyone with this dx speak eloquently for themselves.

Every time there is a study done on subtypes, you get people who do not fit into the stereotypes - studies on attachment? Surprise a small group of patients seem "securely attached" and the rest have to be divided up between avoidant and ambivalent, two variants that play out totally differently. Studies of emotional dysregulation? Surprise, a large group do not know how to express their anger openly - this subtype has been dubbed "internalizing dysregulated" and the comment has been made that they do not even fulfill the criteria for the DSM. Studies on impulsivity - surprise a small group of BPD patients are not impulsive at all...

What do they have in common then? An overwhelming subjective sense of emotional pain. They are sinking in a quicksand of negativity and they do not see a way out. At the baseline they were probably born hypersensitive to other's feelings - but that could have been a plus in a more caring and sensitive world than the one they were born into - negative schemas emerge from interpersonal trauma. That's acquired through real life experiences.

Everyone is barking up the wrong tree thinking that this disorder is about behaviour. That fact is that when the anguish level goes down, when the depression lifts, when the ground stops moving from under their feet, the behaviours go away. What you often have left is a deep underlying sadness and a true vulnerability to painfully dysphoric states (intense shame, guilt, fear, self-hate and anger) that can undermine one's very feelings of existence. This is why DBT is only successful up to a point. It raises the guilt level and the self consciousness of individuals to the point where they learn to behave - so as to stop bothering others, but it doesn't get at the source of the emotional pain. Since the whole DSM description is nothing but "objective" i.e. it only describes what one can see, we say that they no longer "fit" this dx. BPD sufferers need reasons to live - their depression is often existential in nature - they would probably benefit from an existential approach in therapy, but who takes the time to learn how to think existentially any more?

Personality disorders are supposed to be syntonic - this is not the case in BPD. Although they can no express themselves, BPD sufferer's feel extremely guilty about their outbursts and their incapacity to feel okay.

Just suppose for the sake of argument why not consider that BPD instead of being about one's personality is about having one's personality submerged under an immense tsunami of emotional pain - it's a breakdown of defenses, it's
a psyche skinned alive, it's being assailed by suicidal thoughts, because it is the only fantasy that offers a way out. It is about desperately flailing about with sand in one's eyes, hoping that someone will throw you a branch to cling to, as the quicksand just gets deeper, but knowing that even if they do it'll probably break, because you're just lucky that way.
Mary C. Zanarini has recently come to the conclusion that the only distinguishing trait of this disorder that applies to all is the enormity of the emotional pain that they feel.

Nothing like telling someone their very own personality is the sole cause of their pain and expecting them to put their trust in you in return. Though I suppose it's better than belittling their suffering by convincing them that it's nothing but a defense so as to make other's suffer instead. But remember - their own negativity and despair is so great they can not handle another drop of criticism. No one is going to gain their trust by jumping in and calling them "borderline". Try caring - really caring - about how they feel first. The results could surprise you.

The above is mostly just my opinion of course, but there are a few facts thrown in, I assure you. We are in need of professionals with the courage to rethink this disorder now - from the inside out this time around.

therapydoc said...

Zephyr, this is brilliant and I thank you sincerely for taking the time to write it and post it here. The only way to work with anyone is to feel their pain. You obviously get it.

Anonymous said...

I have not been diagnosed with BPD, just recently discovered that it existed due to the movie Girl, Interupted. After reading the symptoms I can honestly say that I have experienced each one several times in my life. As a child I always felt different and couldn't quite understand why. In my early childhood years I never spoke a word and was never able to express myself due to my feelings. Being told on a daily basis that I was beautiful, but never beleiving it and developing low self-esteem. I have always been a nurturing person and have always put others before myself. I grew up in a two parent home, very loving christian family. My parents love me dearly, and raised me to be what I should. As a child I remember being molested by a neighbor but being that I never talked, no one ever knew. Adolescense was filled with sex, lying, and stealing. Not th6at I wanted to but I felt I needed to for the attention to know that someone cared and loved me bc i didnt myself. Attending my first college and being suspended for stealing was the first time that I knew there was seriously a problem. I fully take responsibility for the things that I have done. And would never blame this on a personality disorder but I knew I'd steal to get money to spend, spend and spend. Spending made me feel better. It made me hurt less because I had things and those things would not make me feel so strange and lonely and keep my attention. I've had relationships where i would be the "perfect girlfriend" and wonder why guys would not want to be around me all the time if i did whatever would make them happy. Always with guys that I would alter my teachings and better well-knowing for. More times in often being treated unfairly, but accepting because I thought they cared. Never turned out to be true. How come they would leave me alone. When they'd make attempts to leave that I didn't agree with I would break down throw tantrums and cry my heart and soul out, literally beg. Often times arguments with them would lead to fist fights that i sometimes initiated due to my anger. Being called crazy many times for this I never agreed. Just figured all girls did these things. But I convinced myself that I needed them around in order to feel sane, and reassure myself that I was loved. Break-ups led to days of not eating, stress, suicidal thoughts and weight loss, the list goes on. No one knew what I ever went through bc being a multi-sport athlete, member of a prestigous sorority, and confidant to friends, teammates, family, and others I would get myself together and smile, carry on as if things were fine. To this day many think that I have lived one of the best lives there is to live. But through this all I've always felt a deep dark sense of pain for myself and others. I would go days crying, depressed and sad but never knowing why. Some days would be fine and I normal, but still that deep sense of hurt. I have several traffic tickets that I haven't been paid due to the fact that I would make myself beleive they didn't matter and at times that I didn't exist and blocked them out like they would just disappear. Now at the age of 24, I guess I have learned to self treat myself. I am no longer in a relationship due to the emmotional stress I tend to suffer. I am working on building myself and getting over the hours and days of anxienty attacks, depression. Some days I am fine but sometimes I just go into the deep feelings that there is no hope. Thanks to God I have seen and realized what may be wrong and am ready to control the issues I have delt with for so long. So many things I have left out but this is a generalization to say that if asked of any of my peers they would say that I am the most giving and wonderful person to be around. But the struggles that I have faced have left me at a point where if I didn't have a personal relationship with God, I would no longer be here to even express the pains and struggles I have encountered. I do not believe it is fair to say that I did the things I did bc of a undiagnosed disorder but because my hurt,stress, pain, and sensitivity to my surroundings, and what i felt like was neverending failure. Especially when I deeply wanted to do good, and knew I knew better. Talk about emmotions taking over? I have not been able to clearly make stable decisions. Please don't label me as a bad person or crazy because I want for more, I dont want an exs=cuse, I just want to feel whole and understand what I have struggled with for so long. I now have a degree and and am willing to do what it takes to control my emmotions so that I can live a stable life and have the continous happiness that I don't have to fake. Please pray for me and don't forget not to label those with BPD because some may never know the internal struggles and deep sense of being lost, left out and insecurity that they face throughout each day of their lives.

*Sorry so long but my first time, admiting, and even accepting all the pain I've endured for so long, only an excerpt that I pray will help others to understand*

therapydoc said...

There's a book by William Burroughs, Been Down So Long it Looks Like Up to Me. This acceptance, I think, is the beginning of healing. Best of luck, and of course, blessings.

Anonymous said...

I think that's what my ex-wife had. And why she's my ex now. Such a brilliant con artist, using poise, sparkle, accomplishment and beauty to seduce and capture authority figures (including her psychologist and psychiatrist - counter-transference issues up to and maybe crossing the ethical borders) and others to always see her viewpoint, never mine. Always blaming me for her abusiveness. I look back on it and can't beleive I put up with it for five years.

Then, a corporate attorney and not a stripper, she got enormous fake tits for her 5'1" frame. Thank god she did, because it broke the spell and now I'm free. And I just recently broke free of the secondary spell the fake tits had cast on me.

Now I'm, as they say, "ready to love again."

What a relief.

therapydoc said...

This kind of stuff has people scratching their heads for years, no, Stone?

Colleen said...

I suffer from bpd, and INTERNAL PAIN is the most descriptive term I can find to describe it.

I'm sad to see all of the people that commented on here about how terrible the borderline that they know - is.

It shows they don't understand the disorder, and they aren't particularly compassionate.

Not all borderlines are evil horrible people! I hope others that read their comments don't base their understanding of this disorder on the awful things some of these people have said.

therapydoc said...

Me, too, Colleen.

Anonymous said...

Ok, so I completely realize that diagnosing someone with anything is wrong and unethical without a professional degree. That is why I haven't said anything to her (my girlfriend. However, being an observant, logical, sensible person, she fits the BPD description from beginninng to end. Now I love her so much, but how do you help? Some say a diagnosis makes things worse for the person suffering, some say it helps so as to moderate themselves and feel good about controlling it somewhat. Then others talk about the people around them lacking empathy. The thing about BPD is that it practically makes the people around the person take on the charecteristics as well! How can you empathize when your defending yourself? Sometimes physically, sometimes, emotionaly, and sometimes just plain defending everyday actions. Now I understand that a person who suffers from BPD goes through a tremendous amount of pain, and I also understand that they dont want to lack control of their emotions and actions, but how are others supposed to deal with a person who suffers from this? It isn't a lack of empathy so much as sometimes a lack of infinite patience. You can only deal with someone you love putting you down for so long before you slip and act "unempathetic." All that being said, in order to help mitigate a loved ones pain under these conditions, what is the best course of action? My girlfriend is 20 years old and I would guess in the rising action stages of this disorder. (Yeah, I know. A "guess" with this issue sounds horrible, but talking about talking to someone with her becomes horrible too) There are still so many issues she hasnt dealt with for so long (her father basically abandoning her and her mother not protecting her from molestation). And BPD seems as though its the natural consequence of these happenings. Now I want to help her with everything I have, BUT HOW DO I DO THAT? I admit I do not have unending patience, and even sometimes I dont have unending empathy. What can I do? I feel that she has tried so hard for my sake to push her emotional situation away so as to function better with me. However, that is making things worth because it is hiding the real issues. How do I get her to look up from the hole i know she percieves shes in instead of digging further down into uncertainty? I care about her and want to do whats right for her instead of the other way around. I realize I was extremely long whinded here and might not have organized what I am trying to say effectively. I was looking to get as much info in the open about myself and her and hoping for any sort of advice in return. Perhaps if you can teach me something others can benefit as well?

therapydoc said...

I guess it's time to write some more on this one. Give me a little time, I'll get there. I'm working on it.

Anonymous said...

I am an MFT working with a Borderline client and wondering if you have any specific suggestions when someone says that nothing or no one can help them.

therapydoc said...

I'd start with empathy. "That must feel awful, thinking no one can help you," and work up from there.

Susan said...

My mother has been diagnosed with suffering from Borderline Personality Disorder. It was masked somewhat by a faulty diagnosis of Bi-polar disorder with high manias (depression, spending and high anger). My sisters and I continue to deal with the the PTSD from our childhoods. Recently, our mother (who has now stopped her SSRI's and Klonopin) dropped my father off at the front door following his colonoscopy, saying that she was going to take the car to the back and put it into the garage. Instead, she left him outside for hours while she went shopping. My father was frantic. Has her illness changed? She has not been cruel in the past, just angry, biting and manipulative.

therapydoc said...

And like you said, depressed. There's no generalizing. I love it when people say, It gets WORSE, symptoms are exaggerated, as people get older. But it isn't true, not at all, for so many others who learn to cope with their burdens and get a wider lens as they age.

Ms H said...

I am so glad I found this post.
I suffer BPD (diagnosed with it in March). I am on medication as well as just starting therapy.
My boyfriend broke up with me a few days ago. He said he couldn't handle it anymore and that he wasn't sure if I was a threat to him and his family. In the last few days leading up to the breakup, I had been sending millions of sms, countless emails with threats and abuse, ringing him 10 - 20 times a day. I know it is wrong, and yet I can't stop it. I wish I could. I am trying to make him understand but he doesn't want to know ... I told him ignoring me is the worst thing he could do to me, because it makes my mind go haywire. Because he is a student, his schooling is his priority and I am not. He labelled me obsessive, paranoid, demanding and manipulative. He also said I was threatening ...

The one thing I can never forgive him for, is telling his father I am BPD. That is not his call to make, that is my call to make. He told his father and his father told him to stay far away from me.

I am a very private person. I don't handle rejection well, nor do I handle being left alone for too long. I start thinking all kinds of things are going to go wrong, and my brain doesn't stop thinking ...

I do understand how hard it is for my boyfriend, to have to watch someone he loves mentally tortured. I understand why he ended our relationship. I don't like it, but I understand. I just don't like how he seems to think I have done this on purpose, I have done all these things with a motive. To be honest with you, I don't remember what exactly I did or said. A lot of people seem to think we love doing this to ourselves, I can safely say as a BPD sufferer, it's a living hell. I won't have to wonder what hell is like when I die, I am living it.

therapydoc said...

Ms. H, thanks for writing. This is a great example of the pain. And I hope when someone tells you that you are,

"obsessive, paranoid, demanding and manipulative"

that you smile and say, "I know, I know, I'm working on it, but you love me, right? I'm working on it. And it ain't easy!"

Anonymous said...

This is one of the most interesting diagnosed conditions because it is very hard to understand the underlying reasons for it. I saw Girl, Interrupted and it was obvious that Winona Ryder's character had something wrong with her. However, we didn't understand why or what. She had no specific symptoms or behavioral patterns. She was just "crazy." I would like to learn more about this disorder.

Anonymous said...

One blogger wrote that they "cannot express themselves but feel guilty afterwards." After confronting my mother on her behavior over the years, she'd often reply "I never said that or I never did that." For years I thought she had multiple personality disorder. Is she aware that she said and did these things or is she lying and if so, does she know that she's lying?

therapydoc said...

I wish I knew, honest. But I surely know people with this disorder who will admit they couldn't handle the truth so denied it immediately, effectively lied.

Anonymous said...

"I'm sad to see all of the people that commented on here about how terrible the borderline that they know - is."

Fair enough. But probably not as sad as they are for having suffered the borderline's impact on their life. Probably not by a long shot.

"It shows they don't understand the disorder, and they aren't particularly compassionate."

Possible. But it may also show that while they understand the disorder, the borderline creates so much pain and chaos that even understanding doesn't make it better. We are talking about years, often decades, of behavior so extremely chaotic and hurtful that the uninitiated often don't believe it when they hear about it.

In my experience, any demonstration 'understanding' and 'compassion' are interpreted by the borderline as a "green light" to continuing their chaotic, abusive and evil behavior. It's a shame, but it's true.

therapydoc said...

Anon, there's no generalizing here, I don't think, but there have to exceptions to the rule, and I think your rule is correct. All we can do is continuously confront inappropriate (horrible) behavior in a nice way and set up boundaries, find support from others, and if necessary, get out. Unfortunately, getting out means abandoning children, too, sometimes, which is not cool. It's interesting how often the word "evil" is associated with this disorder, but anyone familiar with it can certainly see why.

Amanda said...

Having read this blog post saddens me to see how I am perceived by others. I have BPD and have just completed Dialectical Behavior Therapy. It is one of the best things that has happened to me as I am now more aware of myself and aware of how I can regulate myself and deal with my day to day life more effectively.

I can honestly say that I understand why people have a hard time dealing with borderlines; but we have a hard time dealing with ourselves as well. The pain that I have been in my entire life is unimaginable to a person who has not experienced what I have. Every day I struggle carry on; every day. Every day I wonder why I cannot maintain lasting relationships other than my boyfriend (4 years together). Life is exhausting with this diagnoses.
What I do not understand is why everyone sees us as being so manipulative and unapologetic. If anything I am apologetic and try not to manipulate; although maybe I do without knowing it?

Anyway, thank you for this blog post because after being diagnosed with this six months ago I am obsessed with learning more about it.

therapydoc said...

Best of luck, Amanda. You're going to be fine.

kevin blumer said...

the thing that gets me with diagnosis especialy with me i was diagnosesd with so many things before i was sectioned and finaly diagnosed with borderline personality disorder and my doctor says i show some of the trats of BPD quite a bit but i want to know how come it has took them 18 years to diagnose me and how can i be certain that there diagnoses is correct since ive had some many diagnosis in the past

therapydoc said...

See, this is the thing about diagnosis. It's only good to help us treat people, and yet everyone has to know, has to worry about it, etc.

I have no idea why it would take anyone so long to diagnose a particular disorder, all I know is that even after the diagnosis, you have to treat it, generally, by treating the manifestations of the illness, get people symptom free. So it almost doesn't matter what the diagnosis is, assuming a person has a good therapist and relates well, works on change.

Anonymous said...

To all the BPD's who post their victim poor me attitudes and ponder who us NONs can deem you manipulative, evil liars...I say this: ONCE. JUST ONCE OWN YOUR BEHAVIOR and STOP acting the victim. then maybe we will stop seeing you this way.

Lisa said...

Such a great post...full of information. I have suffered from BPD for two years now and while it can be difficult to deal with, it can be dealt with. It does not have to control your life. I have participated in DBT with a lot of success. For those still trying to control your BPD, I recommend you check out http://onlineceucredit.com/edu/social-work-ceus-tdp for a lot of information about treating BPD. I hope this is helpful.

Lashh said...

Before reading the comments on here, I had no idea people such as myself were looked at so horribly. The way I see it, no person suffering BPD is the same. You seem to all think we have the complete same personality to each other, we mare share the same disorder, but no two are the same. I think people react differently to the emotions BPD makes them feel. I CAN be horrible, and i'll admit this any time of any day, I can be a head case, completely unavailable of being controlled, but I know behind my disorder how good of a person I am, I am honest, I am friendly, I am loyal. I am not the person you seen suffer from this, I am myself. If people COULD understand more, we wouldn't feel so lost and alone in our on minds. But they just can't, because it's never the same. We can seem content, happy even, and just seem to snap, but we aren't happy, ever, we have so many emotions, problems, things in our minds, so much pain, and that can make people irrational, lash out, everybody does it, not as much as me - as other people with this disorder, but they do. We aren't so different, honestly we aren't, we have just felt amounts of pain other people couldn't even imagine. That I don't think other people could handle. I am strong, for living through this disorder, just as anyone else going through it is. It may be so hard for people to live or even know people with BPD, but it's 10 times harder for the person with the disorder

therapydoc said...

Thanks for reminding us, Lashh. Well put.

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