Borderline Changes for DSM-5

I am often inspired (sometime it's "stuck") by what I see throughout the week.  I try to "Ride the Wave" as often as possible but there are think about something past it's expiration date in my head.  Case in point the term "Borderline Personality Disorder," which someone on Twitter had issue with.  As I begin writing this blog about the possible DSM-5 revision  and clicked on "personality disorder" I had the same thought- calling it a personality issue makes it sound minimal and like you have a bad personality.  

Back to the topic: What changes might be in the DSM-5?  First off, the DSM is the manual for which people are diagnosed   I had a college professor say it was like ordering lunch of a Chinese food menu; choose 2 of  5 choices of meat; 2 of 4 sides and 1 of 6 beverage choices and viola you have a diagnosis.  It's a little more complicated than that but you get the idea. Currently it's a 5 Axis system, where Personality Disorder is on Axis II (which insurance companies typically only cover Axis I.)

The DSM 5 proposed revision will make ALL diagnosis on one Axis, like it is done in most other countries. So for example Jane Doe's Diagnosis: Major Depressive Disorder Moderate, Borderline Personality Disorder, Disease of the eye, Problems with living environment, GAF 55.  

Currently the criteria for Borderline Personality Disorder is as follows:

A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as 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-injuring 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., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation).
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 anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

The proposed DSM-5 revision is as follows:

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.
AND
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.

Okay so following all that information, I am really interested in feedback from those currently diagnosed with Borderline Personality Disorder.  Please comment here and join the discussion or tweet #BPDDiagnosis.  As someone without the diagnosis here is my opinion- it's vague.  It is so vague that I am concerned that people will be over diagnosed with it, that insurance will not cover any care for those with the diagnosis. Or will it be diagnosed appropriate, as many people who don't have the diagnosis meet the criteria and more people will get the help they need?

The DSM-5 doesn't come out until May 2013 so don't fret.

Bipolar vs. Borderline?

One of the joys of my job is that I diagnosis clients with mental illness, I find it necessary for someone to have the right diagnosis in order to move forward with treatment.  I often explain Mental Health diagnosis's as looking like a Venn Diagram with much overlap and often very little differentiation.

The tricky part is the past diagnosis's the clients have had.  There have been multiple clients that when I asked for current diagnosis they listed 5 contradicting diagnosis and the more I probed and speak with them the more it looked like 1 or 2 total.   This all brings me to a point regarding Bipolar  Borderline.  Most of the women that I have meet whom are diagnosed as Bipolar are not.  When I ask for mania symptoms they tell me things such as "I yell at my teenage son," "I blow up at my husband," "I get so angry I...." or "Sometimes I just don't want to talk to people and hide."  All of these are normal reactions for people with little/no coping skills.  I don't know anyone (even without a mental health diagnosis) whom wouldn't have at some point said yes to all 4.  I think this over diagnosis happens for a few reasons:

• Women are not suppose to get angry
• Anger in women sometimes feels like anxiety and a loss of control
• Psychiatrists don't know what Bipolar really is diagnostically
• Mood swings are viewed as "rapid cycling"
• It's easier to medicate a disorder than help someone with coping skills

For these reasons I take a lot of time and consideration into diagnosing women with Bipolar, especially those with trauma and abuse in their history.  Many of these women more likely have Borderline Personality Disorder (I am unable to "officially" diagnosis Axis II because of other reasons) and Post Traumatic Stress Disorder.  

Here are the difference between Bipolar and Borderline Personality Disorder (via Psychology Today article )

1. People with BPD cycle much more quickly, often several times a day.

2. The moods in people with BPD are more dependent, either positively or negatively, on what's going on in their life at the moment. Anything that might smack of abandonment (however far fetched) is a major trigger.

3. In people with BPD, the mood swings are more distinct. Marsha M. Linehan, professor of psychology at the University of Washington, says that while people with bipolar disorder swing between all-¬encompassing periods of mania and major depression, the mood swings typical in BPD are more specific. She says, "You have fear going up and down, sadness going up and down, anger up and down, disgust up and down, and love up and down."

*Do not diagnosis yourself-leave it up to the professionals*