Sunday, January 27, 2013

DSM-5: New Guidelines for Borderline

The American Psychiatric Association (APA) is coming out with a fifth version of their Diagnostic and Statistic Manual of Mental Disorders in May 2013. The DSM manuals play a significant role in how medical professionals diagnose and classify disorders. For example, the APA declassified homosexuality as a mental disorder in the 70’s. The evolution of the DSM is demonstrative of the how humans attempt to understand themselves over time.

The newest manual, DSM-5, is said to be making a lot of changes to the previous DSM-IV published in 2000 (not to mention the change from Roman to Arabic numerals). I recently came across an article from Psychology Today that talked about how the diagnostic criteria for Borderline Personality Disorder are going to change in the DSM-5 (  This article caught my attention because one of my best friends was diagnosed with BPD in 2011. My friend strongly disagreed with her diagnosis and refused to see that psychiatrist ever again on the basis that he was sexist and that BPD is a fancy guise for misogyny (for which is has been historically targeted by some feminists).   
Because of my friend’s strong reaction to her diagnosis I began to research BPD. I of course was researching the criteria for BPD as classified by the DSM-IV. As the article put forth, the DSM-IV breaks down the criteria for BPD as having five or more of the following nine criteria:

1.       Fear and/or “frantic” avoidance of “real or imagined” abandonment.
2.       Relationships with people that they idealize or devalue.
3.       Unstable sense of self.
4.       Impulsiveness.
5.       Suicidal or self-harming behavior.
6.       Unstable and changing moods often based on reaction.
7.       “Chronic feelings of emptiness.”
8.       Experienced anger that is uncontrolled, intense, or inappropriate.
9.       Paranoid thinking based on stress or dissociative symptoms.

Not being a medical professional attending to my friend I could not account for 3, 7, and 9. I do think, however, that my friend’s behavior fit the other criteria almost as if she were a textbook example. She had in fact spoken to me about 1, 2, 6, and 8 without any knowledge that these issues were related to BPD and, I believe, not really having any idea of what BPD is beyond the fact that women are more likely to be diagnosed.

Being friends with someone who has BPD or at least fits the criteria can be difficult. For example, I would never tell her that I researched BPD to better understand her behavior because she might then believe me to be a horrible person (DSM-IV criteria #2). With the DSM-5 I wondered if she still would fit the criteria at all or if she would maybe be an even better match.  With the DSM-5, rather than having to fit five out of nine criteria like with the DSM-IV, the patient would have to fit all of the five criteria that are broader. These criteria are broken down into more specific examples that the patient may or must meet in order to diagnose. The criteria for BPD of 2013,  paraphrased and without inclusion of specific examples and explanations, are:

1.       Personality that is impaired in functioning by self-functioning EITHER by identity OR self-direction, AND by interpersonal-functioning EITHER by empathy or intimacy.
2.       Pathological personality traits in the realms of Negative affectivity (characterized by ANY of the following: emotional lability, anxiousness, separation insecurity, depressivity) AND Disinhibition (characterized by ANY of the following: impulsivity and risk-taking) AND Antagonism (characterized by antagonism).
3.       Impairments of personality functioning are consistent.
4.       Impairments are not more likely stemming from environment or “stage of development.”
5.       Impairments are not results of a substance or general medical condition.

The main difference I notice between the DSM-5 and DSM-IV are causality. DSM-IV did not account for what may be causing certain behaviors in a person (3 through 5). It also seems like the nine criteria from the DSM-IV were addressed in the DSM-5 first two criteria. Furthermore, rather than being diagnosable with some criteria, BPD diagnosis will now require specific criteria to be met, but allows them to be met in different ways. I think the new model of qualification alone better fits how an individual reacts to medical issues in general. With mental disorders (versus something like a flu virus) I can only imagine that it is extremely difficult to distinguish between behavior unique to an individual and behavior unique to a disorder.
As far as my friend goes under the DSM-5 I feel like she is a textbook example for the first two criteria the same way she was for DSM-IV criteria. But, with the very thorough breakdown of criteria, I feel like BPD is more accurately explained and a more specific kind of impairment in personality. For example, interpersonal-functioning issues with intimacy further explained how a patient might idealize and devalue a person in their life by becoming over-involved or withdrawing from that person. I, led by what I thought to be spot on descriptions of my friend, was again convinced she should reconsider her BPD diagnosis (though, again, I would never tell her).

But the DSM-5 gave me something to think about with the last three criteria about causality. I was once again reminded that I am not in the least qualified to agree or disagree with what disorder my friend may have. In fact, my believing that she did have BPD may have led me to draw conclusions about her behavior that were not true or only consistent because I wanted them to be (DSM-5 number 3). One thing that feminists have said about BPD is that it is often confused with Post Traumatic Stress Disorder, a diagnosis my friend more readily accepts (DSM-5 number 4). She also is taking what I consider to be quite the cabinet full of medications (DSM-5 number 5). The more I thought about it, the more I realized I should stop thinking about it at all; I needed to stop playing psychiatrist and stick to being a friend.

I don’t regret researching BPD because in my search for understanding probably saved our friendship, or, more specifically, kept me from doing what she told me she always fears I will: abandon her. But what the DSM-5 brought to my attention was that a disorder causes symptoms that are not always caused by that disorder. That and leave the diagnoses to the professionals.   

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