Note, when angry at my manager, I did not think that most of what my manager did was PERSONAL. For me, I think that was the key in not acting out very impulsively at work. I would have found the anger, and expression of it, justifiable, as I did in my intimate relationships, if I thought that there was deliberate maliciousness directed towards me.

As I told my best friend, I’m a pretty great co-worker and friend. Just do not live-with or marry me.

Hi again. My wife is, by this definition, both high- and low-functioning. She is high functioning MOST of the time - she can (or has) kept a job, has repsonisbilities, taken care of children, etc., etc. AND she has self-harmed.

As I said I wrote the posts to promote this kind of discussion. My underlying point is that the “type of” borderline I describe in my book is BOTH high- and low-functioning depending on the current emotional state of the sufferer. The very nature of the disorder (at least as I describe it, which covers - I haven’t done the math and don’t know the distribution likelihood on the 256 combo specturm - I’d say at least 80% of BPD and more like 90% of the hundreds of BPs I’ve met) implies periods of high- and low-functioning. If we accept that BPD is chiefly an emotional regulation disorder (rather than, say, an attachment or object relations issue), it follows that periods of high- and low-functioning would occur.

When you mention the 256 possible configurations of BPD (5 or more of 9 criteria) I wonder if anyone has done a frequency analysis of which criteria are MOST likely and which criteria are least? And where each combination of the criteria fall on a distribution curve? I think it would be interesting, because, although it is theoretically possible to have 256 separate configurations, which occur most often? Someone MUST have done this if the data is available.

I personally have seen MOST of the BPs (and loved ones of Non-BPs) with which I have come into contact having criteria: #1 (fear of abandonment), #2 (unstable interpersonal relationships), #3 (if you include “shame” as identity disturbance, other wise, not so much), #4 (impulsiveness), #6 (emotional dysregulation) and #8 (inappropriate anger, which IMO is on outgrowth of #2 and #6).

So, that’s basically 6 of 9.

Unfortunately, #5 (suicidal gestures and/or self-harm) is all too common as well.

Bon

I understand your point and I appreciate the feedback.

When I read our responses, I can’t help but think we might be talking about two different things.

My use of the term, in a simpliest example, would be to separate BPDs that self harm at some point in their life from those that don’t. One person would could be high functioning - another might be low functioning (self harming). Dr. Young (founder of the Schema Therapy Institute) uses the term this way during this interview:
http://www.gulfbend.org/poc/view_doc.php?type=doc&id=13055&cn=91 I use this reference because you mentioned SFT.

Recognizing these more subtle expressions of the disorder is important, because it is a way to identify and connect these people to all the behavioral tools you sited above. Hopefully this would help some families.

The definition you are contesting, if I understand it, labels different expressions of behavior in the same person… such that they may have had a high functioning day vs a low functioning day. Your point being (if I understand it) that you find this use of the term to be misleading.

I agree that if the term was used this way and then extrapolated to mean “that a person with BPD can just behave better whenever they want to” that would likely lead to a non supportive family environment - which is very important.

I apologize for not being clearer on my reference to Dr. Paris - I posted it below. And I’ll put a big caveat on all of this - I’m just a thankful consumer of the work of the professionals mentioned here - I hope I haven’t over stepped or taken anything of of context in my posts.

The behavioral tools that have evolved from the collective work of these individuals are very useful.

Skippy

PS: The Fall of an Icon: Psychoanalysis and Academic Psychiatry by Joel Paris Toronto: University of Toronto Press, 2005, 225 pp.

Hi! Thanks so much for gracing me with your comment! Really, I’m thrilled. I know you’re putting out a new book on a family guide to BPD and I hope it does well; I’m sure it will with your reputation. I also agree that SWOE is not the last word on BPD and Non-BPs. Randi, your book helped me so much in the fall of 2005… however, I found that other things helped me even more… specifically DBT-FST and my experiments with my wife. I wrote my book to share what worked with me and my BP. I DO think there will be lots of discussion about your book in October - my problem is… other than what you have learned from WTO, where is your experience? I have been doing this every day, day in and day out for 20 years. Granted, I have only been aware of BPD for 2 1/2 years - thank in a great part to SWOE! However, what I have tried to do is explain a step-by-step plan of HOW to validate, HOW to insert your feelings, HOW to apply boundaries, etc. Frankly, Randi, if you read my book, I expect that there is a lot f overlap between your methods and mine. I would encourage you to read my book and I’d love to talk about it with you. My major problem with WTO and SWOE is that most people that read that book and are on that list have a BPx… they have no inkling of how to make it work day-to-day with a BP. I have made it work. I’m not reporting a “cure” - which some WTO people report - only a way to make it work effectively. I know you have worked hard on your new book and I expect to buy a copy… I respect your work greatly and think we can help one another.

Let me know.

Kindest Regards,

Bon

Someone just told me about this website, so I came to check it out. What an
interesting discussion about such an important topic.

Before going into the subject, I just want to mention that while Stop
Walking on Eggshells (SWOE) has become the family member “Bible,” it was
never mean to be an authoritative text on BPD. My coauthor and I were
careful to point this out.

In the Introduction on page 7, we wrote:

“The result of our three years of effort [research and writing] is the book
you now hold in your hands. It is not the last word on the subject. It is
only the beginning. We hope our book sparks interest in new research.”

My point is that I think that people SHOULD look at what SWOE puts forward
and ask, “Is this right? Do I agree? Is there another way of looking at
this?” It is though discussions like these that we all learn from one
another.

Now, regarding high and low functioning, researchers have been attempting to
explain why people with BPD present in such dissimilar ways for more than 50
years. Clinicians have developed various subcategories accompanied by all
sorts of theories.

When I was doing a content analysis of the posts from family members on
Welcome to Oz back in 1996 and 1997, what I observed became the basis for
the theory of high and low functioning and acting in and acting out. (By the
way, there are people in the middle. These were never meant to be either
or.)

However, a decade has gone by since Paul Mason and I wrote SWOE. In my new
book, the Essential Family Guide to Borderline Personality Disorder: New
Tips and Techniques to Stop Walking on Eggshells, I developed a more complex
model.

In this model are several criteria–acting in/out and high/low functioning
are two criteria; others include the type of comorbid disorders, willingness
to obtain help, and the impact of the disorder on family members. The two
overlapping categories are now Higher Functioning “Invisible” people with
BPD and Lower Functioning “Conventional” people with BPD.

Hopefully when the book comes out in October, there will be much discussion.
What I am most interested in is not just people disagreeing, but people
coming up with their own theories. I look forward to discussing them here
and elsewhere.

Randi Kreger
BPDCentral.com
Welcome to Oz Community Owner
Stop Walking on Eggshells and the SWOE Workbook
The Essential Family Guide to BPD (October, 2008)

BTW, the reference to Joel Paris, MD, I suppose is a reference to his website? Actually, the article on his website is written by Valerie Porr (the operator of TARA) about BPD. It is not “scholarly” and in some ways she is criticizing the idea that doctors know enough about the disorder to properly diagnose it.

Here is the quote from Ms. Porr:

“I remember a night when my daughter locked herself in the bathroom after a rage attack. I called the police. She kept the police waiting outside the door for thirty minutes while I escalated to absolutely frantic concern. When she finally emerged, dissociated from her rage, she acted with regal serenity “as if” she were Grace Kelly. The police gave me that “raised eyebrow” look to which I have since become accustomed. It is a look all too familiar to families of people with BPD who feel foolish and embarrassed when authorities arrive to assist with a problem that now seems not to be there. It is “as if…”

If one combines the professional’s attitudes toward people with BPD with the ability of a high functioning person with BPD to act “as if ” - one is having dinner with Boyer and Bergman as the lights dim. The supportive family member is frustrated and confused by the patient’s demonstration of the ability to effectively act out a denial of the illness, while the doctor minimizes or avoids it with dismissal comments like, “She’s just a teenager. She’ll outgrow it…” and the gaslights seem to dim, again. ”

It is on Dr. Joel Paris’ site, but I don’t see anything HE has written with the high functioning label. Ms. Porr, God bless her, is not a clinican.

Thanks for the comment. I specifically posted this post to solicit this kind of discussion. I wanted to point out that INSIDE the disorder is different than it appears OUTSIDE the disorder. What you point out about the 5 of 9 diagnosis code is true - but I think that shows the weakness of the diagnostic guide. No disorder should have 256 configurations IMO. I hope that the APA will change the diagnostic guide, the name of the disorder and the Axis of the disorder next time it issues a DSM. I think the core features of the disorder (of course I’m not a doctor either) are emotional dysregulation, impulsivity and shame. All of the other symptoms IMO arise from these three. Personally, I don’t put much weight in what Kernberg has to say. Although he is well-reknowned in the field, his theories are too abstract and based on Freudian psychoanalytical models. Behavioral-based models have more utility with BPD, in my opinion (and in research, more effective) - DBT, Mentalization, STEPPS and SFT are all derived from CBT and seem to be the most effective treatments for BPD.

My main point in posting this was to debunk the idea that a person with BPD can choose when to act out and when not to. My wife often “white knuckles it” through the day, it is painful and difficult for her - and she could be said to be “high functioning.” I think the classification of “high” vs. “low” creates a false idea that a person with BPD can just behave better whenever they want to - and that it is a choice on the part of the sufferer - that it is just “behaving badly” or spitefully.

Again, thanks for the comment!

Bon

===================

This is an interesting discussion - I would like to suggest that “high functioning” is a useful term - especially for non-clinically trained husbands, wives, and parents.

•• First, what does High Functioning Borderline Personality Disorder refer to - what does it mean?

Borderline Personality Disorder (BPD) is a defined as a constellation of 9 possible symptoms of which 5 are required for diagnosis. This begets the often made statement that there are 256 expressions of the disorder.

The problem a lay person has understanding BPD is that most of these 9 criteria are internal thoughts known only to the person with the disorder. So a lay person (and many primary care physicians or older therapists) tend to place too much importance on the most tangible of the 9 criteria. They will rule out BPD, for example, in the absence of #5.

# 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

# 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

Using the 5/9 definition, 1-3 of these criteria might not be present - for example the spouse or child may not be suicidal or self harming and still be affected by BPD.

“High functioning” is just a broad term to define among the 256 constellations of symptoms, those that do not include symptom #5 and some of the other highly dysfunctional symptoms. More here at this bpdFamily.com link: http://www.bpdfamily.com/tools/articles2.htm

•• You say that many “partners” discussed in support communities are not diagnosed for BPD and probably are not BPD at all.

I suspect that this is partially true and partially not. Clearly some of the ‘BPD partners” are falsely labeled and your example is good. But at the same time, it is widely stated in the technical literature that most Borderline Personality Disorder is not diagnosed.

There are a number of reasons for this - such as many clinicians are hesitant to diagnose for insurance reasons, some don’t want to diagnose because it stigmatizes and discourages the patients, and some are too unsure of their knowledge of the disorder to diagnose it. In addition, many borderlines are in denial of the presence of illness and generally don’t present to clinicians (this is true for many mental disorders).

Furthermore, many “difficult” relationship partners are sub-clinical - having significant BPD traits - but not meeting the threshold for diagnosis.

But the most important point is that the same relationship / behavioral tools often apply in these cases. If the tools work, it allows a couple or a family to function better - than it seems to be not a worrisome issue.

•• You mention that their is no mention of High Functioning in the medical literature. That might not be correct…. I make two reference here just as examples.

Joel Paris uses the term. Joel Paris, M.D. is a professor of psychiatry at McGill University in Montreal, Canada a leading opinion leader in the field.

American Journal of Psychiatry 2005; 162:867–875 “… on a 7-point rating of chronic level of personality functioning based loosely on Kernberg’s model of levels of functioning (44) (using four anchors: “psychotic,” “personality disorder,” “substantial problems,” and “high-functioning”), clinicians rated the dysthymic disorder patients”

The medical community, at this early stage in understanding the disorder, has a prioity to help those that self harm, are suicidal, and can’t hold employment.

The support communities are focused further down the continuum of “dysfunctionality” - basically on relationship partners that are reasonably functional but exhibit a lifelong pattern of instable relations - of which the support member is typically in and trying to understand.

I am not a medical professional. I am a member of an active support group for family members of individual with BPD, BPD traits.

Skip

The SWOE book made it’s impact on me, though, as if someone had been looking through my window for a decade plus. The psychologists would say that she doesn’t have a lost sense of self, because she scored that she didn’t, but I’m the one that sat up with her, exploring her feelings into the wee hours of the morning, night after night for years, and this after she raged on me all hours of the night. I heard the words coming out of her mouth, I saw the regressive nature of her pose as she was curled up, talking about shame, guilt, self-hate, only to get too close and rebound and blame me and what I wasn’t giving her.

I’m rambling here, but this is the quandry of those of us who’s spouses rage, berate, keep us up for hours on end blaming, screaming (with kids sleeping- doesn’t matter to them), shoving, and then blocking and screaming “Abandoner!!!” when it’s too scary and too much to take and we head for the door or a locked bedroom, bathroom, etc.

Where’s the diagnosis for this? If BPD’s are all cutters, substance abusers, sexaholics, or some combination, then what am I dealing with? When I can’t voice my concerns, no matter how they are couched, no matter how well I appeal, but I am greeted with blame, rage, sarcasm, stabbing words, and physical attacks, I struggle to understand what I’m dealing with.

I’m out now, I miss my kids terribly, I’m struggling with the decision to proceed with the divorce or not, and the religious aspect troubles me. Maybe it doesn’t matter if she’s high-funtioning or not, I’m the only one she does this to, no one knew before and no one will understand or believe me now except my therapist.

Back to the point of the post… sorry,… I know that there were times when she experienced the dysregulation in public, but her response nearly every time was to walk away from me briskly. That was how she dealt with her emotions in public. In private, there were no such actions, if she felt the need, she hurled it at me. On the subject of feelings, she is admittedly someone that doesn’t feel her emotions on a regular basis. She’s admittedly is not body-conscious, unaware of her stress or physical symptoms. She’s a task-oriented person, and I feel like I’ve lived with a roomate for all these years, no real emotional intimacy. I see it now, I see that I’ve wanted it and longed for it, and I was capable of it. I spent a decade plus being blamed for not providing it.

Rage and blame are a scary thing. Being berated all night - while lying in bed, trying to get sleep to go to work in the morning, is not fun. Having someone try to minimize their actions and their catastrophic effects on a relationship, and instead turn the blame on you for being emotionally unavailable, is mind twisting. I finally had to accept her accusation that I was an “Escapist”, and escape. I decided that this crazy behavior was worth escaping from, just like a prison war camp.

This is more catharsis than contribution, I promise to be more attuned to the discussion in the future if you’ll have me back!