Unhappy With BPD Diagnosis? Is ‘Formulation’ The Answer?

Increasingly, many individuals who have been diagnosed with borderline personality disorder (BPD) and who have suffered severe and protracted childhood trauma are starting to question whether the BPD diagnosis is the correct and most appropriate one. One of the main reasons for this is the stigma attached to receiving such a diagnosis (although, thankfully, as the medical profession becomes more educated about the now irrefutable link between childhood trauma and the later development of not only the symptoms of BPD but other disorders as well such as depression, anxiety and, as research now overwhelmingly suggests, schizophrenia, the stigma surrounding the diagnosis is diminishing). Increasingly, too, medical professionals are becoming aware that, it many cases, a diagnosis of complex posttraumatic stress disorder (complex PTSD) is a more appropriate diagnosis for those diagnosed with BPD, especially as its very name – complex posttraumatic stress disorder acknowledges that the condition has been brought on by the stress associated with trauma.

FORMULATION – A MORE HUMANE AND TRUTHFUL WAY OF INTERPRETING THE SYMPTOMS OF BPD?

However, there also now exists amongst therapists that it is better to do away with labels such as BPD altogether and instead to approach the understanding and treatment of emotional and psychological difficulties via a method known as FORMULATION.

Formulation involves the individual sharing with his/her therapist his/her personal story so that a hypothesis may be formed regarding the origins of his/her psychological distress (e.g. domestic violence, extreme poverty, growing up with abusive parents, bullying, neglect etc.) The process of the individual recounting his/her narrative to the therapist may be spread over weeks or months but, rather than leading to a cold, clinical and potentially stigmatizing medical diagnosis (such as BPD), instead leads to real insight and understanding as to why the individual’s current dysfunctional ways of thinking, feeling and behaving, based upon linking them with the adverse experiences s/he suffered growing up, as expressed to the therapist during the recital of his/her background story.

For example, suppose an individual is suffering from symptoms which may currently be used by psychiatrists to make a diagnosis of BPD. According to DSM-5 (Diagnostic and Statistical Manual of Mental Illness, 5th edition),. for an individual to be diagnosed with BPD, s/he must display at least 5 of the following 9 symptoms:

  • emotional instability
  • chronic feelings of emptiness
  • feelings of intense anger
  • paranoid ideas and ‘dissociative’ symptoms
  • impulsiveness
  • suicidal behaviour and self-harm
  • fear of abandonment
  • unstable relationships
  • identity disturbance

Let’s say that a person displays five of the above symptoms: fear of rejection, outbursts of uncontrollable anger, identity disturbance, paranoia and feelings of emptiness.

The compassionate and insightful therapist, after exploring his/her client’s personal narrative relating to his/her (the client’s) past may be in a position to hypothesize the likely links between the client’s dysfunctional ways of thinking and behaving with his/her experiences whilst growing up as a child.

A very simplified example of such a hypothesis:

  • the client’s intense fear of rejection is related to his/her father deserting him/her as a child.
  • the client’s feelings of anger are linked to the physical abuse s/he suffered by her step-father when growing up
  • the client’s identity disturbance is linked to being brought within an enmeshed relationship with an intensely self-preoccupied mother
  • the client’s paranoia is linked to extreme and ongoing bullying s/he experienced growing up
  • the client’s chronic feelings of emptiness are linked to his/her having been unloved as a child

 

Formulation combines 3 key ingredients:

  • the therapist’s skills, knowledge and experience giving him/her the ability to make connections between the client’s current distress and what has happened to him/her in the past
  • the client’s ability to describe his/her past experiences, especially key relationships (e.g. with primary carer)
  • the meaning that the client attaches to his/her life experiences

By linking symptoms to their likely past causes helps the client understand him/herself and how his/her distress and dysfunctional ways of thinking and behaving developed overtime. This understanding, in turn, has important implications regarding how the client is treated for his/her difficulties – such treatment is likely to be much enhanced if, as is, of course, desirable, the formulation process has made the client feel compassionately listened to, understood and validated. In this way, formulation is surely a more humane way of approaching psychological distress than merely providing the sufferer with a medicalizing label which does not take account of fundamental causes and may, therefore, lead to sub-optimal treatment (such as relying on medication alone).

 

When Is BPD Diagnosed? The Continuum Of Personality Problems.

There is no clear demarcation between those who have borderline personality disorder (BPD) and those who do not; this is because the problems that contribute to a BPD diagnosis lie on a continuum. 

Three Criteria That Contribute To A Diagnosis Of BPD :

According to DSM-5 (The Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition), an individual must display at least five of these symptoms to be diagnosed as suffering from BPD.

However, as implied above, an individual does not either have these personality problems or doesn’t have them – things are not that clear cut or black and white. So how is it decided whether or not each symptom is serious enough to count towards a diagnosis of BPD?

Essentially, it is a question of three considerations. For each of the above nine key symptoms, it is necessary to ask :

  1. Is the symptom chronic?
  2. Does the symptom cause the sufferer, or other people, significant problems?
  3. Does the symptom adversely affect multiple areas of the sufferer’s life?

 

Let’s briefly look at each of these in turn :

  • CHRONIC – this means the symptoms are persistent and long-lasting. Signs of BPD often emerge during adolescence, and, in the absence of effective therapy (such as dialectical behaviour therapy, or DBT), can endure for a lifetime (although often symptoms reduce in their level of intensity around about the time that the individual enters middle-age).
  • CAUSES SIGNIFICANT PROBLEMS – problems may include extreme verbal aggression towards others at times of stress, impulsiveness, self-harm and highly unstable relationships.
  • ADVERSE EFFECT ON MULTIPLE LIFE AREAS this means the symptoms are pervasive and do not just adversely affect one isolated area of life but all, or most, areas, including friendships, relations with work colleagues, intimate relationships, finances (e.g. due to overspending or gambling), physical health (e.g. due to overeating, drinking and smoking excessively, addiction to other drugs, promiscuous, unsafe sex etc).

BPD can only be diagnosed by an appropriately qualified medical professional such as a psychiatrist. It is not possible to self-diagnose BPD. Indeed, there is no one, self-contained test for detecting whether or not an individual is suffering from BPD – psychometric tests are just one tool in the BPD expert’s tool-box, others include psychiatric interviews, medical examinations and reference to the medical history of the individual being considered for the diagnosis.

There are, in fact, up to 13 different measurement tools to help the psychiatrist or other appropriately qualified medical professional diagnose BPD (Lohanon, 2002) These include the following:

  • The structured clinical interview
  • The Borderline Personality Questionnaire (BPQ)
  • The Personality Diagnostic Questionnaire BPD, 4th edition (PDQ-4BPD)
  • The McLean Screening Instrument
  • The Zanarini Rating Scale
  • The International Personality Disorder Examination (IPDE).

Conclusion :

Essentially, the more of the above nine symptoms an individual has (as stated above, it is necessary to have a minimum of five to be diagnosed with BPD), and the more chronic, the more problematic and the more pervasive these symptoms are, the more likely the individual is to be diagnosed with BPD; so, BPD, like other personality disorders, lies on a continuum: deciding whether or not a person is suffering from it is not a clear cut decision.

However, diagnosis is not an exact science so there is always the possibility of unreliable diagnoses; for example, person A may be diagnosed as having BPD by Dr X whereas person B may NOT be diagnosed as having BPD by the same doctor.

However, if both seek a second opinion from Dr Y, the diagnoses may be reversed (i.e person A is diagnosed as NOT having BPD whilst person B is diagnosed as having BPD. Of course, in the case of individuals suffering from particularly extreme (even within the context of the disorder) symptoms, diagnoses are likely to be more consistent and reliable.

eBook :

 

 

Above eBook now available on Amazon for immediate download. Click HERE for further information.

David Hosier BSc Hons; MSc; PGDE(FAHE).

 

How Childhood Trauma Can Physically Damage The Developing Brain (And How These Effects Can Be Reversed)

The Irrefutable Link Between Borderline Personality Disorder And Childhood Trauma

About David Hosier BSc Hons; MSc; PGDE(FAHE)

David Hosier MSc holds two degrees (BSc Hons and MSc) and a post-graduate diploma in education (all three qualifications are in psychology). He also holds UK QTS (Qualified Teacher Status). He has worked as a teacher, lecturer and researcher. His own experiences of severe childhood trauma and its emotional fallout motivated him to set up this website, childhoodtraumarecovery.com, for which he exclusively writes articles. He has published several books including The Link Between Childhood Trauma And Borderline Personality Disorder, The Link Between Childhood Trauma ANd Complex Posttraumatic Stress Disorder and  How Childhood Trauma Can Damage The Developing Brain (And How These Effects Can Be Reversed). He was educated at the University of London, Goldsmith’s College where he developed his interest in childhood experiences leading to psychopathology and wrote his thesis on the effects of childhood depression on academic performance. This site has been created for educational purposes only.

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