At what point do relatively “normal” and/or commonplace undesired personality traits become a “mental illness”? Specifically, this thread is about Borderline Personality Disorder.
I just finished reading the book Girl, Interrupted (and saw the movie a while ago). For the uninitiated, it’s the author’s memoir about her teenage years, when she was institutionalized following a suicide attempt and diagnosed with BPD. In the end, she is released and considered “recovered” and goes on to lead a (relatively) normal life. Her remarks near the end suggest that she felt uncertain about her diagnosis and that part of her “condition” might’ve merely been the effects of adolescence.
Reading through the Wikipedia entry for the disorder, the diagnosis criteria do seem to at least somewhat reflect generalized teenage angst.
So what’s the deal? Is BPD significantly different/worse? Are there actual physical causes? Is it just a made-up term used to describe difficult people, the way “hysteria” used to be?
It’s both. There are two reasonably robust clinical descriptions of “borderline.” In simple terms, the original: a person who is often on the edge of psychotic states; the contemporary: a person with pervasive life problems that include unstable relationships and unsafe behavior. Borderline Personality Disorder may be appropriately diagnosed, but is often used as a garbage can category, which is inappropriate. Some have argued that there is no BPD that is not caused by trauma and is thus better described as complex post-traumatic stress disorder; others think these are highly overlapping categories with distinct ends of their distributions. Someone will be along soon to say that all diagnosis is inappropriate and useless, so I will leave that side of the picture to them.
I don’t think Girl, Interrupted is a particularly well-written memoir. I feel strongly from the narrative Kaysen describes that she was not just being a normal angsty teen, but was also engaged in some problematic emotional and behavioral stuff. However, I don’t see her as meeting criteria for BPD, even at that time. It’s also true that in the mid-60’s-late 70’s in the U.S., psychiatric diagnosis and hospitalization were used as a tool of social control. I’d contend that that has decreased, but again, others see it differently.
For a memoir that gives more of a BPD vibe to me (not a diagnosis, just an impression), try Prozac Nation. She describes herself as depressed, but there appears to me to be a lot more going on than that, and a lot more problematic.
AHunter3 had some very good thoughts on mental illness here. Basically, most mental illness diagnosis are not much more than descriptions of sets of behavoir. We bump any behavoir into the “illness” catagory when it becomes overly disruptive to “living a normal life”, which obviously pretty culturally defined.
So in this sense they are inherently real, in the sense that they exist. But it’s not a black and white thing with a clear and understood cause and treatment.
That’s part of what I was asking (and it was indeed a good post!), but within the broad spectrum of mental illness, it seems that BPD in particular is even more vague than other conditions like schizophrenia or depression, both of which seem to have some basis in brain chemicals (and can be partially treated that way). Even other personality disorders seem to have more specific, isolated criteria, not a laundry list of disparate feelings that you have to mix-and-match to qualify for.
Does that make sense? It’s almost like BPD is their way of saying “Well, we don’t know what’s wrong with this person, but she’s a PITA who can’t function too well in the world, so let’s just call her this until we can figure out something more concrete.”
susan, I read in the thread that even sven mentioned that you have 20 years of experience in the field. What, if I may ask, are your personal thoughts? Is it ever appropriately diagnosed, and if so, what can or should be done as treatment?
I’ll check out Prozac nation when I get a chance, thanks
You have to think of the term mentall illness as a broad term.
Look we all have physical illnesses. I have asthma, but it’s very well controlled. I can breathe better and exercise more than most people without asthma. But some asthmatics can’t
Some people have warts. That’s a physical disease, so is acne a physical disease. But neither are disease which really impact your life. (other than if someone makes fun of your looks)
A diasnoses of mental illness isn’t an excusse. Most people will have some sort of mental problem. But so what. I would guess if you look REALLY hard enough you could find most people have some sort of physical disease too. But the physical disease is minor so they don’t notice. Or they’ve learned to cope with it.
Sure, in less serious cases, simply ignoring or coping with it works. But sometimes illnesses (physical or otherwise) can be so debilitating as to impact one’s ability to function at 100% (or even 25%, if severe enough). Or are you saying BPD is always a mild, non-life-disturbing condition – like the common cold of mental illnesses?
Girl, Interrupted isn’t a particularly unbiased account - neither the book nor the movie. The author clearly thinks that there wasn’t much wrong with her despite the fact that she was sleeping with her professor and tried to off herself by taking a shit-load of asprin followed by a shit-load of vodka. The girl had issues which were essentially glossed over in the movie. Shit - they cast Angelina Jolie as Lisa. Beautiful, glamourous Agelina Jolie as nasty, criminal, unrepentent Lisa. Ugh.
Having met more than one person with a stable diagnosis of BPD, no, it is certainly not always mild, non-life-disturbing.
Those with BPD are rather unlikeable. You know those people you meet who set your teeth on edge and make you want to run away as fast as you can? Potential BPD. Therapists who specialize in treating those with BPD burn out, on average, after a mere 18 months. Those with BPD are really, really unpleasant to be around.
Having met my share of annoying people vs. my share of those with BPD, they’re not even the same animal. Really, a halmark of the condition is multiple suicide attempts with no acutal suicidal ideation (although suicidal ideation can be present as well). Ugh.
A related question: Who comes up with these diagnoses, anyway? Is there a team of psychologists/psychiatrists that sit around modifying the list of illnesses as they see fit, or…?
Borderline personality personality is real but it is also psychiatric short-hand for “batshit crazy”. It isn’t a good diagnosis to hear because it isn’t especially treatable especially compared to other mental illnesses like clinical depression and bipolar disorder. You would know it if you were ever acquainted with someone that has it. Glenn Close’s character in Fatal Attraction is based roughly on borderline personality disorder and may not be that far off in some ways. I have heard some mental health professionals say that they don’t like dealing with people that have BPD disorder either. SIL is a clinical psychologist and one of them. Her own mother had it and ended up killing herself by drinking drain cleaner.
There is a manual called the DSM (Diagnostic and Statistical Manual) that is the gold-standard for this. It is revised every few years by teams of researchers and clinicians. You can look at a copy in most large bookstores, especially college book stores and most libraries.
I have my own thoughts about what makes BPDs so unpleasant - a combination of whininess, attention-seeking, entitlement and blaming everything on everyone else. I find mystelf grating my teeth within seconds of meeting them.
But I do not come across these people in a clinical context. I would be keen to hear what you or others think is the most unattractive aspect of the BPDs you see.
http://www.portlanddbt.com/pages/linehan.html This is a link to Marsha Linehan and her Dialetical Behavior Therapy for persons with Borderline Personality Disorder. She, in short, characterizes the disorder as an “emotion dysregulation disorder”. Or in simpler language, the person has difficulty regulating/managing his/her emotions, all emotional experiences are intense and fully expressed. If you rate emotions on a 1-10 scale for intensity, someone with BPD experiences emotions almost always at a 10. This is what usually accounts for the dichotomous relationships (love you one minute, hate you the next). The book I Hate You, Don’t Leave Me is another account of life with BPD. This book helps explain some of the etiology, progression, and expectations for the disorder as well how to manage those kinds of relationships in a therapeutic setting. It is a practical guide for a therapist to help retain sanity and maintain boundaries.
Mental health treatment offers a template on how to treat particular disorders but the emphasis is always on treating and working with each person and his/her own unique experiences with the disorder. There are tried and true techniques that work (e.g., treating infections with antibiotics) but this is just the start. The relationship is the most important thing and nothing will work if there is no rapport or trust. Therapy is not dogmatic. Mental illness is a real thing and it is culturally based, which, as pointed out before, means that if it is centrally disrupting one’s life then it is a problem (mental illness). Unfortunately, all we have to go on are behaviors as a means of diagnosis, unlike physical illness which has clear, defined symptoms and etiologies. The diagnoses found in the DSM-IV TR are the observations, opinions, and agreements made by a panel of doctors (PhD and MD) to help give some definition and common language/reference points for other professionals. The diagnoses have become more and more specific over the years, which is why we are currently at DSM-IV TR and are working on the DSM V. Some of the diagnoses have neurobiological bases (schizophrenia, anxiety, depression) while others seem to be a collection of syndromes, beliefs, or behaviors. Those in the profession of mental health treatment are well aware of the limitations and continue to work at finding more specific ways of diagnosing and treating the disorders. Our primary objective is improved life quality.
Sometimes, psychiatrists will give a diagonsis that is closest to the symptoms presented so that the medication prescibed is justified. For example, because of the perjorative nature of a BPD diagnosis a psychiatrist may diagnose the person with a bipolar disorder, not only because it will ease the minds of others who may be treating the person, but also because some of the meds that help with bipolar disorder also work with BPD. Additionally, insurance may not pay for the medications if used to treat BPD. This practice is not uncommon and does border on unethical but it is done with the best interest of the client in mind. However, I have seen psychiatrists who just medicate each symptom as it presents leaving the patient with a grocery list of medications. This is ridiculous in my opinion. I have also worked with psychiatrists who manipulate the 2 or 3 medications they have prescribed until the right dose and frequency and combination have been found. I see this as a more reasonable, less inhibiting, less destructive way of treatment. The person also participates in “talk therapy” to learn behavioral and cognitive ways of dealing with the symptoms that are supplemental and supportive of the medication. Medicine can’t fix everything, it needs help, just like dietary supplements are best used in conjunction with diet and exercise. Cholesterol medication works best when coupled with a low cholesterol diet. High blood pressure medications work best with a change in diet and exercise.
Sorry to hijack – how could a person attempt suicide without suicidal ideation? I thought “suicidal ideation” just meant “thoughts about committing suicide”.
Even if she didn’t pick the absolute right word, I know what she is talking about. A person with severe clinical depression may contemplate suicide all the time while thinking deeply into. A person with borderline personality disorder may get into a fight with her boyfriend, jump out of the car and then launch herself off of a bridge with little warning. I have a related academic background in this stuff but I have also known three people with borderline personality disorder personally. They are bad, bad news and very distinctive. I was in the car with an ex-boyfriend of a borderline women when she spotted us and engaged in a 100+ mph road chase that lasted for about 15 minutes trying to force us off the road with no provocation. We eventually lost her but he tried to commit suicide the next day because he was convinced that he would have to spend the rest of his life being stalked like that. He moved 50 miles away with family as soon as he got out of the hospital and no one was allowed to tell her where he went.
WAG, but I think alice is referring to attention-seeking or manipulation via suicide attempts.
Kinda like my ex-wife waking me up in the middle of the night holding a razor to her wrist, telling me she was going to off herself right then and there if I didn’t agree not to go on a business trip the next day.
Others have given many excellent responses and references. I’ll second I Hate You–Don’t Leave Me and Linehan. You might also look at Judy Herman’s Trauma and Recovery and Mason and Kreger’s Stop Walking on Eggshells: Taking Your Life Back When Someone You Care about Has Borderline Personality Disorder.
A clinical opinion, not counseling advice: I wouldn’t say I’m ever treating a client’s BPD per se, since that diagnosis labels a constellation of difficulties. Most of the people I’ve worked with who’ve met the BPD criteria had prior (and sometimes current) abuse histories. Which came first, the trauma or the difficulties? I don’t know. I’m less interested in figuring out where it came from than how the person might function more comfortably and effectively in the present. That may mean working to understand and decrease (or work around) trauma responses, improving coping strategies, improving interpersonal skills, checking out assumptions about others’ motives, decreasing substance use, general self-care, addressing co-occurring or constellating problems like anxiety, and improving emotional regulation. In a workshop or classroom context (I teach some classes that draw people who are trying live and work more effectively), I can express interest and empathy and provide some meta-processing or commentary and answer questions (a made-up example of in-class discussion: Student: “Why is my father such a fucking asshole?” Me: “Yeah, why do people act badly? This is a great question, thanks. Let’s ask the question this way–all of us sometimes behave in ways that other people don’t like. What are some of the things we do, and what are ways that other people respond to us? How do you know whose feedback to trust about our own behavior? If we look at this from our own perspective, it might help us figure out why other people are sometimes jerks.”
ETA: Sometimes people engage in self-injury without suicidal ideation because they are not intending to kill themselves, but to punish themselves, punish others, or feel pain that’s simple and external. Cutting is one example of this. Another way this happens is that people are dissociated at the time of action, and therefore truthfully say later that they weren’t having thoughts or intentions of suicide. The part of them that they think of as “I” was checked out. (This is a topic for longer discussion.)
BPD is definitely real, and plenty of people with BPD can function fine in society because so many of the traits that make them what they are are idealized by our media and society.
Take my mother, for example. There is no such thing as shades of gray for her. All of life, whether it’s the people she knows, religion, politics, even the love of her children - is black and white. Good and evil. She either loves me or she hates me. It all depends on our most recent interaction. I never know which it will be. But, everything in the media encourages her behavior by distilling complex issues down to talking points and memos. In the movies the good guys are good and the bad guys are bad. Good always wins over evil. For her, this is not just literary symbolism or shorthand, it is her complete reality.
Another indicator of BPD is impulsive and addictive behavior, which for my mother manifests as an addiction to shopping. Nevermind the fact that she hasn’t worked a single day in 30+ years, or the fact that my father is already drowning in credit card bills, or that they could very well lose their house. She’s a good little consumer, and even “jokes” about doing her part to help the economy. Only it’s not a joke, because she doesn’t smile when she says it, and somewhere deep down she really does think she’s doing something good by going out and buying a bunch of random crap. She’s reinforced by the people around her, by television, by advertising. Every time someone complements her on her shirt, or her bracelet, or her new shoes. Because she absolutely lives for the attention and because shopping allows her to craft a glamorous caricature to fill the giant gaping void where her personality should be. I can’t visit her house (not even for 5 minutes) without her foisting off bag after bag of things she bought for me. But none of it ever fits or even matches my style, because she is incapable of seriously considering the needs of others. She shops to fill her own need to consume, and she gives things to people so that they will give her attention.
I could go on, and on, and on but others have already given a lot of good information. I second Stop Walking on Eggshells, but as a child of someone with BPD it can be frustrating to read because it tends to gloss over the pain and suffering that someone with BPD can cause for the other people in their life.
One thing that’s important to keep in mind about personality disorders in particular is that most of these individuals don’t see themselves as having a problem - after all, it’s the only way they’ve ever known how to be, so they don’t recognize it as abnormal or dysfunctional. You might get a totally different perspective on the situation if you talked to her family about what she was like during those years.
I had this friend in my 20s who was diagnosed with BPD. She dropped out of college in her 5th year of a 5 year degree and did lots of self-destructive things, including a coke habit, bad relationships, stealing, etc. She was on disability for her mental illness at the time. When I met her, much of this was in the past, but she was still one of those “I hate you, don’t leave me” types. One day she loved you, wanted to spend every minute with you, and the next day, you had mysteriously somehow offended her horribly and she hated your guts. You never knew which one you were going to get. All her relationships were screwed up and dysfunctional, and she was just not a happy, functioning person. She did the Linehan therapy but it seemed not to help, and I despaired for her.
Anyway, I lost contact with her when she left town, but recently, she found me on Facebook. She has 2 children and a long-term partner, owns a home, etc., things of which I’d have thought she was not capable. So my question is: can people “recover” from BPD? I think I read somewhere (maybe here) that it’s something that is worst when the person is in her 20s and which diminishes over time for some people.
Obviously, I ask this because I’m wary of getting involved with her again because she was scary when I last spoke with her. I do care about her, though, and would be friends with her again if I could deal with her sane side and not the crazy side.
Sorry to hijack – how could a person attempt suicide without suicidal ideation? I thought “suicidal ideation” just meant “thoughts about committing suicide”.