Monday, December 3, 2012

Mental Illness and Self Identity

Since the book contest has been going on for a week (congrats winners!) I have not been blogging, but now my ideas are running amok so it's time to put down on paper what's swirling around my mind.

I have been getting a lot of questions about the new changes to the BPD diagnosis in the DSM5 coming out in May 2013, which was just finalized this weekend.  The new diagnostic criteria for BPD in my opinion is vague and covers too many people.   But what if looking at the current criteria, and after years of therapy, DBT, CBT, therapy, heck even EMDR therapy you now meet 1 or 2 of the criteria when 5 or more criteria equals a Borderline Personality Diagnosis?  Well, first off you no longer have a BPD diagnosis (per the DSM IV-r) but does this make you "cured?"

"Recovery may seem like an illusory concept. We still know very little about what this process is like for people with severe mental illness. Yet many recent intervention studies have in fact measured elements of recovery, even though the recovery process went unmentioned. Recovery is a multidimensional concept: there is no single measure of recovery, but many different measures that estimate various aspects of it. The recovery vision expands our concept of service outcome to include such dimensions as self-esteem, adjustment to disability, empowerment, and self-determination. However, it is the concept of recovery, and not the many ways to measure it, that ties the various components of the field into a single vision. For service providers, recovery from mental illness is a vision commensurate with researchers’ vision of curing and preventing mental illness. Recovery is a simple yet powerful vision  (Anthony, 1991.)"

I have worked with many people whom were diagnosed with a mental illness, and though therapy, groups and sometimes medications, were doing better; holding down jobs, attending college, making friends and felt like they were lost for a while, "I have been Bipolar for so long who am I now?"  I think this mindset can be especially true for some with BPD, since the therapy is so intensive and the community is so tight-knit.

Take for instance a client I worked with whom had Bipolar disorder with psychotic symptoms; he had been attending NAMI groups for years, most of his friends were from the mental health clinic I worked at, his calendar was filled with Bipolar workshops, meetings, and events he had been attending for years.  After years of therapy and medication he was still attending these events and at some point I told him he was the poster child for "Bipolar Success."  He was confused by this term "success," he asked, "am I cured?"  I opened the DSM IV-r and read through the criteria for his current diagnosis- he meet 2, when 5 was needed.  After I assured him that he was not going to be dropped from services due to this (oh, insurance woes,) we spoke about if he should continue to spend 20 hours a week surrounded by those with a mental illness he no longer has? Should he drop all his friends? Was it appropriate to discuss at NAMI meetings issues surrounding a mental illness he no longer has? Should he tell people?

After a 50 minute session and a follow up phone call (he was "freaking out!") we decided his plan of action; it is okay to continue the relationships he has created, he can be a role model for others regarding what recovery looks like; attending NAMI meetings-okay BUT new doors are now open he didn't think were when he was diagnosed before; college classes, a healthy relationship (he was too embarrassed prior to have one,) and  full-time employment over collecting disability.  He was (understandably) so attached to his identity that he didn't know who he was without it.

I understand this isn't the case for all people with Mental Illness, as some hide their mental illness from others, are not properly diagnosed and some even avoid the reality of their illness.

Here is a great list of people's stories regarding their mental illness recovery Connections: Stories of Recovery from Mental Illness:

"Today, LeRoy doesn't see any doctor for therapy. He sees his doctor simply to refill his prescription when needed. His treated Delusional Schizophrenia affects him as much as treated diabetes or high blood pressure would. He takes responsibility for it, and life goes on.  "I take my pill at bedtime. I haven't really had any side effects," he says.  But perhaps there has been a side effect his job. As a survivor of a mental illness, LeRoy realized he now has a responsibility not only for his own recovery, but for the healing of others. So he's made a career of it. LeRoy helps other people with mental illnesses, called clients, as they walk their own road to recovery.  He says he may be making less money than he set out to earn, but he's helping more people than he ever thought he could.   In addition to mentoring and supporting people with mental illnesses, LeRoy tries to teach the public about mental health issues. He speaks to churches, schools, and practically any group or individual who wants to hear about the bravery of those who battle mental illness.  It's easy for LeRoy to talk about bravery, because it's bravery that helps him accept himself, accept his diagnosis, and go forward.  "You can't deal with your mental illness until you can agree with yourself that, 'Hey, I have a mental illness so I need to be responsible and take care of it.' "  He's brave. He's responsible. He's taken care of it. LeRoy Simmons is a survivor, (pg. 13.)"
 I would love feedback from anyone who no longer meets the criteria for BPD regarding how they got recovery and how (if at all) their identify was wrapped up in their diagnosis.


  1. I have to be honest that, presently, a lot of my identity - but not all of it - is wrapped up in my BPD diagnosis. I clearly meet the criteria based on the current DSM criteria.

    As far as the new criteria, under A, I meet:
    1a and 2b

    Under B, I meet (do you have to meet 1a-1d?!):
    1a (though far less frequently than when first diagnosed-Pre-DBT)
    1d (though not as intense or frequently as when first diagnosed/Pre-DBT)
    Do you have to meet 2a & 2b?!
    2a (FAR less frequently than when first diagnosed/pre-DBT)

    I'm thinking I must continue to meet the diagnosis. I can relate to your bipolar patient in the sense that OCD used to control my life. My world had gotten quite small because I didn't know how to manage it. From time to time, the symptoms manifest, but they've been mostly dormant for about 4 years. I went through years of CBT and was showing up to groups coaching other patients and no longer really suffering from the condition. My therapist and I decided it was time for me to move on from the group.

    I hope to continue to get well from BPD and eventually no longer meet the criteria. I am not sure what will happen to my sense of self when the DX is no longer a present part of me, but I suppose I will be in a much better place to discover and process that when the time comes.

    Great post, Alicia.

    1. Thanks Debbie,

      I think " I will be in a much better place to discover and process that when the time comes," sums things up beautifully. Just kind of thinking while I type; if it wasn't for your BPD diagnosis what would you be doing with your life?

      Also as of now for the DSM5 diagnosis of BPD there is no 5 out of 9 criteria, no minimal at all. There is a justification for why that is...although the DSM5 site is now locked due to the end of revisions. If I find it I will let you know.

      I also think it's good to chart your progress; good and bad. I have my clients make a monthly goal list- just 1 goal (they have tx plans too,) and at the beginning of each month I read last months to ask for their opinion of how they feel they are doing on it and then we read the new months goal. It also adds a level of accountability, so if someone who stated on Nov 1st wants to work on boundaries then on Nov 20th is complaining about someone taking advantage of them, a group member will grab the sheet and remind them of their past goal. I truly love group dynamic.

  2. The proposed DSM-V (2013) diagnostic criteria for Borderline Personality Disorder:

    Borderline Personality Disorder

    The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
    Here's the new criteria for others interested:

    A. Significant impairments in personality functioning manifest by:

    1. Impairments in self functioning (a or b):

    a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.

    b. Self-direction: Instability in goals, aspirations, values, or career plans.


    2. Impairments in interpersonal functioning (a or b):

    a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

    b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

    B. Pathological personality traits in the following domains:

    1. Negative Affectivity, characterized by:

    a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

    b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

    c. Separation insecurity: Fears of rejection by - and/or separation from - significant others, associated with fears of excessive dependency and complete loss of autonomy.

    d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.

    2. Disinhibition, characterized by:

    a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

    b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger.

    3. Antagonism, characterized by:

    a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

    C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.

    D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.

    E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

  3. The answer to the issue of 'identity' uncertainty is that actually people's sense of self is based on falsity anyway as it is manufactured by the ego. My salvation has been in Mindfulness, Meditation whereby eventually you realise the REAL SELF is Eternal and in fact far more reliable and satisfying/functional than any psychologically created 'identity'. If you understand what I say here, you will be amazed at the significance of this.............

    1. Oh I agree, and I also believe that a sense of self (even in the example I listed above) is often in; who your friends are, where you go and where one's income comes from more than "who" someone really is.

      Great comment!