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A Diagnosis with a Bad Rap

Borderline Personality Disorder


Updated June 02, 2010

A Diagnosis with a Bad Rap

Most of us have heard of Borderline Personality Disorder. Much of what we hear seems to be negative. Patients with this disorder have gotten a bad reputation. Remember the movie Fatal Attraction?

Mental health professionals are partly responsible for the bad rap that patients with this diagnosis have received. Some mental health professionals use this diagnosis for their female patients who are a "pain in the ass." If you are female and are seen as a "difficult patient" you may be at risk for getting this diagnosis.

The only responsible way to apply this diagnosis to someone is to use DSM-IV criteria established by the American Psychiatric Association (or the international ICD diagnosis system). The DSM-IV defines Borderline Personality disorder in the following way:

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 and devaluation

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

4. impulsivity in at least two 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(American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, 1994)

This covers a lot of ground. Is a borderline patient who meets the criteria for 1,3,5,7 & 9 anything like another patient who meets 2,4,6,8 & 9? Mental health diagnosis is often not an exact science. The Chinese restaurant menu nature of diagnosis ("one from column a and one from column b") was developed as a way to make diagnostic categories more objective, but it has its limitations.

Still, any label should be based on the best science available. Not all "pain in the ass" patients are truly borderline; and some borderline patients are actually easy to get along with.

Recent research has shown that many borderline persons are trauma survivors. The emerging concept of "Complex Post-Traumatic Stress Disorder" includes both traditional PTSD symptoms and some symptoms of Borderline Personality Disorder. The tenuous hot and cold attachments often made by these persons make sense in this context.

Another quirk of this diagnosis is the fact that women tend to get this label much more often than men. It is telling that men with this disorder are often referred to as "male borderlines." You never hear the term "female borderlines." It is not clear whether this reflects the prejudices of those making the diagnosis or a true finding reflecting base rates in the underlying population.

There are several psychotherapy approaches that have been proven to be helpful in borderline personality disorder. One of these, Dialectical Behavior Therapy (DBT) is an approach that combines techniques from several approaches, and takes advantage of a combination of group and individual therapy.

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