A newer version of the platform is available. Please refresh the page.
Sign Up to Get information about Sales & Events Click Here
A newer version of the platform is available. Please refresh the page.
By: Garry Cooper, LCSW
The DSM-5 defines borderline personality disorder primarily by a symptom checklist:
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:
But in extensive interviews with practicing clinicians, psychologists Drew Westen and Jonathan Shedler found that most clinicians used criteria for diagnosing borderline personality disorder (BPD) that were considerably different from the DSM checklists. Westen and Shedler found that clinicians tend to pay more attention to their clients’ subjective experiences and to their own feelings. Rather than diagnosing by tabulating symptoms against a checklist, in real-world practice, most clinicians have mental templates of a disorder and they gauge how the person sitting in front of them matches that template. Then they use causal theories to make sense of how the symptoms relate to each other. In other words, clinicians aren’t accountants; they deal with gestalts. As part of the Psychodynamic Diagnostic Manual (PDM) Conceptual and Research Foundation Task Force, Shedler and Westen had considerable input into the PDM‘s BPD sections.
Shedler and Westen point to several problems with how the DSM conceptualizes and presents Axis II personality disorders. Fundamentally, they feel that the DSM substitutes symptom checklists for clinical judgment. Among the problems they point out with the DSM‘s Axis II approach:
In keeping with its overview of seeing people on a continuum that runs from healthy to disordered, rather than existing in discrete categories, the PDM posits three levels of personality patterns. Healthy personalities may have their characteristic, individual ways of coping with stressors, but they have sufficient flexibility. “It is clinically valuable, however,” it says, “to understand the general personality of a patient, whether or not a personality disorder exists [their italics].” Neurotic-level personality disorders are more rigid in how they react to stressors, with a more limited range of defenses and coping mechanisms. They tend to have some perspective on their difficulties and can imagine how they’d like to change. They often come into therapy with a plausible idea of the sources of their problem, they can establish a good working alliance with their therapists, and therapists tend to feel comfortable and sympathetic working with them.
Borderline personality disorders, on the other hand, have “recurrent relational difficulties, an incapacity for emotional intimacy, problems with work, periods of marked depression and anxiety, and vulnerability to substance abuse and other addictive behaviors such as gambling, shoplifting, binge-eating, sexual compulsion and addiction to video games or the internet. They are also at greater risk for self-harm via reckless behavior, including self-mutilation, sexual risk-taking, the acquisition of inordinate debt, and similar self-destructive activities.”
It’s important to note that many of these characteristics can also indicate other disorders, such as ADHD and obsessive compulsiveness. Behaviors, in other words, are not sufficient to make a diagnosis.
The PDM stresses that, although it’s easier to identify extroverted borderline patients, many are more introverted. These “quiet borderlines”—people who have inhibited, schizoid or depressive personalities—don’t behave in the “dramatically self-destructive ways described in the DSM,” but they “suffer chronic despair, feel little pleasure in love and work, and have serious problems with their sense of identity, relationships, affect tolerance and regulation, resilience, and moral consistency.”
The most common defenses are splitting and projective identification. In splitting, they see themselves and others in either all-good or all-bad categories; people who split are metaphorically color-blind to grey. Their interior and external world is populated with saints, heroes and rescuers on one end and villains and abusers on the other. In projective identification, they can’t see the troubling aspects of their own personalities but feel “absolutely certain that another person (e.g., the therapist) has those undesirable qualities and treats that person accordingly—eventually evoking from the other person the attitudes that have been projected with such conviction.”
This explains why therapists often find themselves struggling to contain their own negative feelings—hostility, fear, confusion, helplessness, or boredom–when working with people with BPD. The opposite is also true. People with BPD project their idealized rescue fantasies, and therapists may find themselves loving their patients and desperately wanting to cure them. “Patients with severe personality disorders tend to evoke strong tendencies in the therapist to act, not just ‘sit there.’ To put it more bluntly, clinicians may find themselves wanting to kill these patients, or else to cross professional boundaries to ‘save’ them.”
The PDM cautions that patients at the severe end of the continuum can be misdiagnosed as psychotic because of transient psychotic features such as excessively concrete or over-generalized thinking, pervasive, severe annihilation anxiety, and the “unshakeable conviction” that their own attributions about the other person are correct. One example: a stalker who is convinced that the person being stalked “loves” him or her.
Reference
PDM Task Force (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations