BPD Part 2 – Borderline Personality Disorder – The Diagnosis in Brief

BPD (Borderline Personality Disorder) is a complex condition that is currently listed as a mental illness. To be given this diagnosis requires meeting certain criteria, which we will examine below.

In Part 1 [Link] we looked at what BPD isn’t, and some of the many names that BPD is also known by.

In Part 2 [this one] we will look at some of the diagnostic criteria that is used when giving someone a diagnosis, including a list of aspects that I look for when determining if BPD is an appropriate label for someone’s experience.

In Part 3 [Link] we will look at what is probably going on behind the scenes that leads to the experience and behaviours that meet the criteria in Part 2.

In Part 4 (yet to come) we will look at how to tell if something needs to be done about your experience of BPD, and if so, what that might be.

There are two primary diagnostic tools that therapists use. The ICD (International Classification of Disease – World Health Organisation) and the DSM (Diagnostic and Statistical Manual of Mental Disorders – Unites States of America).

ICD

The ICD [code F60.3 EUPD] – “Emotionally Unstable Personality Disorder” covers three variants – Aggressive personality (disorder), Emotionally unstable personality disorder (mostly what people think of as BPD) and Explosive personality (disorder). The summary brief reads as

“Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.”

DSM

The DSM [code 301.83 BPD] – “Borderline Personality Disorder” has a specific entry just for BPD.

“A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) or the following:”

1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)

2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation 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. spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behaviour coverered in Criterion 5)

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

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, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Also check out the Australian BPD Foundation found at https://bpdfoundation.org.au/diagnostic-criteria.php

Reading through those diagnostic criteria seems pretty chaotic and a bit contradictory in places. It can leave you with a very poor impression of people who are diagnosed with BPD. It will also give you very little idea about what it actually looks like.

Joshua Davidson Therapy BPD Checklist

Here is the checklist that I look for. It is not a formal list, but I find it easier to get teh gist of “is BPD a factor in this experience?” than the medical lists above. If I find most of these to be present, then it is time to look closer.

* A Loss of Self – a chameleon like ability to adapt to the person they are with. If more than one person is present, then whomever is deemed the bigger personal threat or has the strongest personality will guide the way the person is. The chamoflague is all about being safe, which can include being submissive, agreeable, overly generous, obstructive or aggressive. Being alone is either a great relief, or incredibly scary, as there is no other person to define oneself with.

* Dysregulated Mood – all moods are at extremes and calm is a foreign concept. Everything is now, everything is extreme, and everything is dramatic. From seeming calm to explosive is rapid, which can also lead to very impulsive actions.

* Perception Distortion – always looking for the threat in the situation, but more in the people they interact with. Always checking for abandonment, betrayal or abuse. People’s actions are checked for malice over charity. Sometimes the reverse of this is true, which leaves the person vulnerable to abusive people as too much charity is given.

* Black and White Thinking – as hinted at in Perception Distortion, actions are filtered via charity or malice with little room in between for “just is”. Things are either black, or white, never grey, and certainly not coloured. A thing that was categorised as “white” will be switched to “black” seemingly rapidly as a certain threshold is tipped.

* Boundary Confusion – either there is a great absence of daily living rules, or a set of rules that are too rigid. A great focus on “how it should be” and low ability to adapt to “this is how it is”. When others break the rule the person has set, it can trigger confusion, anger, anxiety or generally dysfunction. There is no “Goldilocks Zone” in the rules.

* Chaos – people around them are often thrown into chaos dealing with the persons inner chaos, life and relationship chaos, self harm and or suicide attempts, emotional dysregulation and so on. If you look at how the people are acting, realise this is a reflexion of the inner chaos of the person. This is not a trait per se, this is the result of the traits.

Each of these items can be found in a few conditions. For example, a dysregulated mood could be Anxiety Disorder, or Bipolar Affective Disorder. The Boundary Confusion could be Autism Spectrum Disorder. Black and White Thinking could just be a cultural aspect of certain trades, or old concrete thinking.

It is the combination that suggests to me that we should be looking at BPD.

Next time I will go through what drives aspects of my list, which will then help understand what the medical lists are trying to drive at.