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) ;
or
(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 DisorderWell, on the re-read, perhaps one might need a dictionary, if not a graduate school education, to really get this.
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
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.
Labels: borderline personality disorder, DSM IV, evidence-based medicine, Girl Interrupted, ICD codes, identity disorder, Woody Allen
posted by therapydoc at 6:10 PM
44 Comments:
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.
Everyone can change. I never said it was easy.
Welcome to my life. Got pain?
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.
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.
that means we're on the same page, that she posted this. we've talked.
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.
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.
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.
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.
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.
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
effects."
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.
Thanks Julie. You're going to be great at this job.
wow. great post. very interesting. i am going to have to link to you.
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. :)
Gisele, thanks for a beautiful comment. Just beautiful. I might post it as a post, if it's okay with you. We'll talk :)
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. :)
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.
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.
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.
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"?
Thanks.
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.
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.
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.
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.
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.
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.
Phingari-
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.
"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.
Benefit of the doubt is useful here.
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.
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.
I am borderline. Check out my blog at http://bpdokc.blogspot.com
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?
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.
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. :-(
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.
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.
Amen, Anon. Thanks for writing.
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.
You're wonderful, for sure, much more than a diagnosis. So willingness on, right? Thanks so much for writing.
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.
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.
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