We have seen that if a person has suffered significant and protracted childhood trauma, she or he is at greatly increased risk of being diagnosed, as an adult, with borderline personality disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (usually abbreviated to DSM), a person diagnosed with BPD must meet at least FIVE of the following nine criteria:
1) Extreme swings in emotions.
2) Explosive anger.
3) Intense fear of rejection/abandonment sometimes leading to frantic efforts to maintain a relationship.
6) Unstable self-concept (not really knowing ‘who one is’)
7) Chronic feelings of ’emptiness’ (often leading to excessive drinking/eating etc ‘to fill the vacuum’)
8) Dissociation ( a feeling of being ‘disconnected from reality’)
9) Intense and highly volatile relationships
N.B. These symptoms must have been stable characteristics present for at least six months
However, some theorists and researchers have pointed out certain problems with defining BPD in this manner and question the validity of the diagnosis; I outline the most serious of these problems below :
1) In order to be diagnosed with BPD, a person needs only to display just five of the above nine symptoms. It logically follows from this that two people could each be diagnosed with five of the above symptoms, yet have only one of those five symptoms in common with one another. In other words, two people could each be manifesting very different symptoms, yet receive identical diagnoses.
2) Stipulating that an individual must have five or more of the above symptoms is essentially arbitrary (why not four or six?). Also, linked to this criticism, there seems to be a third problem with the diagnosis :
3) The third problem is this: a person with four of the above symptoms, even if they were very severe, would have to be (according to the diagnostic criteria) diagnosed as NOT having BPD whereas a person who just manages to be judged to be displaying five symptoms (even if none are as severe as the first person’s four symptoms) WOULD be diagnosed as having BPD. This brings us to the fourth problem with the diagnosis :
4) In accordance with the diagnostic criteria, an individual is either deemed to HAVE BPD or NOT HAVE BPD. In other words, it is an ‘all or nothing’ diagnosis, which doesn’t allow for grey areas. This is ironic as one of the symptoms BPD sufferers are said to show is ‘black and white’ or ‘all or nothing thinking’ (such as seeing others as ‘all good’ or ‘all bad’ but never as anything in-between).
Because of this problem, some critics have suggested that it would be better to view BPD as a ‘spectrum’ disorder, with each individual occupying a specific place on this spectrum (in the way that autism is treated as a spectrum disorder).
5) A diagnosis of BPD does not seem to describe a unique, separate, distinct disorder clearly delineated from other personality disorders; indeed, many who have been diagnosed with BPD are found to suffer from co-morbid conditions such as antisocial personality disorder and narcissistic disorder
Many critics of the BPD diagnosis feel many individuals have been wrongly diagnosed with it (and unnecessarily stigmatized – see below) and should be diagnosed with complex post-traumatic stress disorder instead.
Indeed, it has been suspected for a while now that many people who have been diagnosed with BPD should really have been diagnosed with a different syndrome known as complex post-traumatic stress disorder.
Whilst simple PTSD typically results from an intense, one-off, traumatic experience; complex PTSD occurs as a result of protracted and prolonged trauma. Complex PTSD is especially likely to occur in cases of child abuse that continued over a long period, especially when the abuser should have been acting as the child’s primary carer (e.g. a parent or step-parent).
It has been found that a very high percentage of those diagnosed with BPD experienced severe childhood trauma which is why (amongst other reasons, see below) many experts are now questioning whether a large number of those so diagnosed should, instead, have been diagnosed with Complex PTSD.
Complex PTSD is so damaging to an individual as it eats into the very core of how s/he perceives him or herself and affects, on a profound level, how s/he views others and the world in general. In short, it adversely intrudes upon a person’s core and fundamental beliefs.
Symptoms of Complex PTSD
– severe mood swings
– out of control emotions
– out of control behaviours, e.g. shoplifting, pathological gambling, promiscuous and risky sex, severe overspending
– eating disorders.
– Impaired and distorted view of the abuser (leading to emotional attachment). This is also known as Stockholm Syndrome.
– marked distrust of others.
– intense jealousy.
– extreme neediness
– hopelessness / despair.
– feeling that life is utterly devoid of meaning.
– inappropriate feelings of guilt /shame/self-disgust.
– outbursts of extreme anger (sometimes with physical violence).
– severe anxiety.
– suicidal thoughts and or behaviour.
Overlap With BPD Symptoms:
It is because these symptoms overlap substantially with the symptoms of BPD that it is thought many people are being diagnosed with BPD when they should be being diagnosed for Complex PTSD.
I believe that an important cause of such misdiagnosis is that doctors do not spend enough (or, indeed, any!) time talking to supposed ‘BPD suffers’ about their childhood experiences.
Given a choice, I suspect, if there are valid reasons, most people would feel more comfortable with a diagnosis of complex PSTD than one of BPD. This is because, sadly and wrongly, stigma still tenaciously attaches itself to a diagnosis of BPD.
Also, a diagnosis of Complex PTSD implicitly acknowledges the fact that the sufferer has had harm done to him/her and that Complex PTSD is a NORMAL REACTION TO AN ABNORMAL SET OF EXPERIENCES.
This could significantly help sufferers cast off, once and for all, the enormous weight of guilt many feel in one fell swoop.
If You Feel Your Diagnosis Of BPD Is Correct, Should You Tell Others That You Suffer From It?
Deciding whether to tell others about the fact one is suffering from BPD presents a challenging dilemma: on the one hand, there is the worry of being stigmatized (see below) and discriminated against, and, on the other, there is the possibility that others will become more understanding of one.
Because few people, through no fault of their own, are well educated about psychological issues, the decision a sufferer of BPD must make as to whether or not to tell others is one that cannot be taken lightly. However, it need not be an ‘all-or-nothing’ decision: it is obviously possible to tell some people (if reasonably believed to be entirely trustworthy) whilst not telling others; similarly, it is possible to decide how much detail it is necessary (or not) to go into.
First of all, let’s look at the possible benefits (and it important to note the word ‘possible’, as they are by no means guaranteed) which might come from telling others:
– those told might become more empathetic, understanding and forgiving.
– those told might feel closer to you as a result.
– those told might wish to offer some help and support.
I REPEAT, THOUGH, NONE OF THESE POSITIVE OUTCOMES CAN, IN ANY WAY, BE COUNTED ON:
So let’s now consider some possible negative repercussions:
– those told may hurt the sufferer further by ‘not wanting to know’.
– those told may tell others that the sufferer did not wish them to tell, thus betraying their trust. Then, sadly as we all know, some people have an unlimited capacity to entertain themselves with malicious gossip.
– the sufferer may be met with discrimination.
– if the sufferer tells people that s/he has a personality disorder, which carries with it very negative connotations, they may consider the sufferer ‘crazy’ or ‘mad’ due to their lack of knowledge and, conceivably, fear.
– people told may lose the confidence or motivation to interact with the sufferer further.
– people may cynically think that the sufferer is trying to provide an excuse for their mistakes.
It is worth re-emphasising that, because it is impossible to predict with complete accuracy how another will respond, the decision about what to tell and whom to tell should be given a great deal of thought.
THE USEFULNESS OF FIRST GETTING PROFESSIONAL ADVICE AND SUPPORT:
It is recommended, very strongly, that anyone suffering from BPD should seek professional therapy. With more and more research being conducted on the condition, positive treatment outcomes for those with BPD are continually increasing in likelihood. Professionals who can help treat BPD, and provide advice and support include:
– social workers specialising in mental health issues
– family therapists.
– community mental health nurses.
Such professionals can help the sufferer to decide on considerations which may include:
– whether to tell others/whom to tell.
– any treatment being received or considered.
– specific symptoms the sufferer experiences which are believed to stem from the condition of BPD.
– the causes of BPD (particular care is advisable here if explaining these to someone the sufferer believes may have contributed to their development of the condition).
N.B. Any decision to inform an employer of one’s condition should only be undertaken once the relevant advice (including legal advice regarding the relevant discrimination laws, which are a mine-field) has been sought. It should be borne in mind that legal disputes with an employer, especially regarding such a sensitive issue as discrimination law, can be extremely stressful and emotionally draining.
Finally, it is worth saying that, in general, it is more comfortable to discuss the condition with others if one has spent some to researching it.
As mental illness is dictated by a combination of environmental and genetic factors, it can happen to absolutely anyone. Even individuals a long way into adulthood, who have previously always enjoyed good mental health, can suddenly be plunged into a severe clinical depression by a single traumatic life event. Nobody is immune. Mental illness HAS NOTHING TO DO WITH PERSONAL FAILINGS.
However, stigma connected to mental illness is still far from uncommon. Others can stigmatize those of us who have suffered mental illness, and turn their backs in disdain and contempt with a feeling of smug, self-satisfied superiority, due to their lack of education on the matter; also, however, some people who suffer mental illness (having internalized society’s often less than compassionate take on the condition) can, in effect, self-stigmatize: because mental illness often causes negative thinking patterns and feelings of worthlessness, it is all too easy for us to fall into the trap of compounding our suffering by feeling bad about being mentally ill (we may see ourselves as weak, for example). In other words, we may add a kind of additional, unnecessary layer to our distress: feeling bad about ourselves for feeling bad about ourselves, as it were. This has been referred to by some psychologists as METAWORRYING.
It is, of course, generally easier to alter the way that we feel about ourselves than it is to change the way others think about us; ignorance, after all, can have a dispiritingly tenacious quality. Therefore, an excellent place to start in the fight against stigma is to change how we see ourselves for having experienced mental illness: we need, in short, to stop stigmatising ourselves.
TACKLING STIGMATIZATION BY SOCIETY:
Whilst stigmatization by society, as I have said, still, obviously, exists, attitudes are improving all the time with higher public education and more and more individuals, with a prominent public profile, willing to talk openly about their own experience of mental illness (most notably, perhaps, in the UK, the writer, actor and comedian – and probably a lot of other things I can’t currently call to mind – Stephen Fry, who suffers bipolar disorder).
Progress has been made in society concerning racism and homophobia, and, it would seem, there is no apparent reason why similar progress should not be made with society’s attitude towards those unfortunate enough to experience mental illness.
THE FIRST STEP:
The first step we can all make, as I have suggested, is to stop blaming ourselves, and feeling bad about ourselves, for having suffered psychological difficulties.
David Hosier BSc Hons; MSc; PGDE(FAHE).