The Myth of the High-Functioning Borderline
Today’s subject is the Myth of the High-Functioning Borderline. I have been scouring the research on BPD to find out if anyone in the research or therapeutic community uses this term or concept high-functioning versus low-functioning Borderline. I have yet to find any author in either the research community or therapeutic community reference this concept. It crops up in the support community (in “Stop Walking on Eggshells” and on both bpd411.org and bpdcentral.com). It also crops up in the “cross-over” community (see more later) but only in a sarcastic way. The idea of high vs. low-functioning BPD doesn’t seem to hold much weight in any other community than the support community.
What do I mean by referencing these “communities”? I think that there are basically three BPD/Non-BP “communities” out there: the research community, the support community and the therapeutic community.
The research community is comprised those scientists doing medical research (and psychological research) on BPD. They publish scholarly articles and research in medical and psychological journals. Some “supposed” psychological researchers publish in the less-well-known and scientifically suspect journals (see my article about “Demonic Possession and BPD” for an example of this type of researcher). For the most part, these researchers don’t try and “cure” BPD, they merely provide data to other professionals about the configuration of BPD, the biology of BPD and the “common” features of BPD. This group of people does not differentiate between high-functioning and low-functioning BPs. In fact I have found no reference to high- or low-functioning BPD at all in any of these research papers or reports.
The therapeutic community is those practitioners (mainly psychologists, psychiatrists, social workers, other “therapists” and consultants) that try and “cure” or remediate BPD in patients. Some (very few) also serve the families, friends, spouses, children, etc. (the Non-BPs). Their purpose in life is to help the BP overcome or to effectively manage their disorder. In this group of people, I have found no mention of high- or low-functioning BPs. The only “partial” mention is that of Dr. Paul Mason, who co-wrote “Stop Walking on Eggshells” with Randy Kreger. Several of these people within the therapeutic community have written popular books about BPD, including “Sometimes I Act Crazy,” “Lost in the Mirror,” “The Angry Heart,” and “I Hate You, Don’t Leave Me.” None of these books, as far as I can tell, refer to the idea of high-functioning vs. low-functioning BPD. Of course, Dr. Marsha Linehan and Dr. John Gunderson are prominent individuals within the therapeutic community. Their theories about BPD have a distinct influence on how therapy is conducted with people with BPD.
The final community is the support community. This community is comprised of ex-BPs, Non-BPs and others who provide advice about how to “deal with” BPD or with someone with BPD. This community includes myself, the authors of “Stop Walking on Eggshells,” the author of “Tears and Healing,” A. J. Mahari, the proprietors of bpd411.org and others. Only in this community have I seen any mention of high- vs. low-functioning BPD.
Some individual and organizations actually straddle the support/therapeutic (or even the research/therapeutic) community split. These include: myself (at least I hope so), TARA, A. J. Mahari and others. Some of these are more therapeutic (or at least psycho-educational) like
The problem with assigning either high-functioning or low-functioning to a person with BPD is that the very nature of the disorder debunks these categories. BPD is chiefly an emotional disorder (with impulse control issues). Emotions are ever-changing, like waves that carry the mind along for the ride. Whether someone is high-functioning or low-functioning at any given time will be subject to their current emotional state. If a BP is emotionally dysregulated they will adapt to that (usually) painful state in whatever way that they have learned will assuage the pain. Some people with BPD will cut themselves, take drugs, avoid situations or behave in other ways that might be considered harmful to themselves or those around them. If a BP is not dysregulated, he/she has no need to behave in these ways. The core point is that BPD is about emotional instability and no person with BPD will be always high- or low-functioning. A person with BPD will swing – sometimes wildly – between several polar ways of feeling and behaving.
I suspect many “high-functioning” BPs do not have BPD at all. I have read many, many posts on Internet boards in which the “BP” in question clearly does not have the disorder. Many times, if you read carefully, you will find that these “high-functioning” BPs are diagnosed by their (usually) ex-wives, just because the “xBPh” (ex-husband with BPD) raged or was selfish during their relationship. BPD is more than raging – and as a Non just because you’re “walking on eggshells,” it doesn’t mean that your “BP” has the disorder at all. In fact, recently the list owner of WTO (the Welcome to Oz Internet list) asked the women Nons on the list if there husbands (or, more appropriately, ex-husbands) exhibited the symptoms of Narcissistic Personality Disorder (NPD). Every “Non-BP” that responded to that request confirmed that their “BP” met the criteria for NPD.
NPD (which IMO is more likely a disorder that appears to be “high-functioning ‘BPD’”) and BPD are distinctly different disorders. There may be a slight bit of overlap – deep, deep down within the psyche of the individual (and that is shame, most likely), but the basic configuration of the disorders are quite different. People with BPD do not like themselves, for whatever reason. People with NPD adore themselves, for whatever reason. That alone separates the two disorders. While people with BPD may exhibit “deserving” behavior (that they deserve love, riches or whatever), people with NPD believe that being “special” is their birthright and want to be surrounded by important or exclusive groups of people. The thing to note with BPD is that the “deserving” behavior is counter-balanced with “undeserving” behavior – polar opposite feelings and behavior that is the hallmark of BPD. So, it seems unlikely to me that “high-functioning” (or low-functioning) BPs can actually exist.
Let’s briefly look at the DSM-IV diagnostic criteria for BPD and NPD , and we can illustrate the differences. First, BPD:
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in (5).
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called “splitting.”
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- 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 behavior covered in (5).
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- 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).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
And now NPD:
- has a grandiose sense of self-importance
- is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- believes that he or she is “special” and unique
- requires excessive admiration
- has a sense of entitlement
- is interpersonally exploitative
- lacks empathy
- is often envious of others or believes others are envious of him or her
- shows arrogant, haughty behaviors or attitudes
Clearly, these two conditions are different. Some interpersonal aspects may seem similar (#8 in BPD and #6 and #7 in NPD); however, the emotional aspect of BPD (#6) is not present in NPD. There seems to me to be a split between self-hatred and the instability of self (in BPD), and self-importance and self-love (in NPD). I’m not sure this a gulf that can be bridged sensibly between the two disorders.
Why does it matter? Well, IMO it matters a lot, because the “prescription” that is effective for BPD is not the same prescription that works with NPD (or other variants on the Narcissistic spectrum). NPD is not a chiefly an emotional disorder, and emotional tools that are so effective with BPD will not be effective with someone with NPD. Now, you might say, “My ‘BP’ is diagnosed and he/she is always thinking about his/herself.” That may be true, yet, IMO, this type of “thinking” about oneself is really experiencing overwhelming negative emotions. It is difficult for anyone to think about anyone else when they are in deep emotional pain. As I have said in the past, I have coined (with the help of others) the term IAAHF (it’s all about his/her feelings) to help represent this state to Non-BPs.
Which brings me to my final point: self-diagnosis. It is dangerous to diagnose your loved one with BPD (or any other mental disorder). Only a trained and knowledgeable (and yes, I know, there are too few of these) professional can diagnose a person with any disorder. Assuming on your own that your loved one has BPD can be troubling for the relationship (at best) and damaging to their (and your) mental health (at worst). After reading a self-help book, such as “Stopping Walking on Eggshells” (SWOE), one has to be careful to diagnose someone else with the disorder. Even my book, “When Hope is Not Enough” (WHINE), can be used to “diagnose” your loved one with BPD, but I’d like to dissuade you from doing so. Instead, I would suggest you use the tools in my book (or, for that matter, SWOE) and see if they work. If my tools do not work, I suspect either you haven’t practiced enough (it takes time, believe me, it took me 2 years) or your loved one does not have an emotional disorder. I personally tried what I learned in SWOE for months before I realized that those “tools” were not effective in my life – which is why I bothered to write a book in the first place.
If you are tempted to introduce yourself to a support group with the statement, “I am married to a high-functioning BP…,” I’d suggest you take a step back and see if your loved one has the other signs of an emotional disorder (which BPD is and NPD is not).
Bon Dobbs :: Jun.10.2008 :: Resources, Other Disorders, Emotions, Borderline Personality Disorder :: 22 Comments »
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I both agree and disagree with some of the points you have raised. I think the term “high functioning” vs. “low functioning” is more of a reflection of a person’s social functioning–i.e. are they homeless, do they hold down a steady job, are they able to act “normal” in public situations. By those criteria, my wife is definitely a “high functioning” case. She meets 7 of the 9 DSM criteria for BPD, yet nobody outside the home would know that she rages, picks fights, bites me, threatens to stab herself (and me) and had to be sent to the county mental hospital for a 24 hour watch as a result. She can either love me or hate me, but never both at the same time. During the day she holds down a successful career at a large PR firm, is not confrontational or overly emotional, and is considered to be a successful person who “has it together” by her peers and co-worker She has never been sexually promiscuous or had gambling addictions, and has never engaged in self-mutilation. However, she has a pervasive sense of emptiness and is very emotionally labile at home, and she has a very hard time dealing with the stress of day-to-day life and often wishes she could die. She has never felt good about herself and is certainly NOT narcissistic. Everyone who knows her would believe that she is the most gentle, loving, compassionate person in the world; yet only I know the dark side of her personality.
Now, a “low functioning” case would be someone who is the opposite of my wife; living on the streets, unable to hold down a steady career, substance abuse problems, promiscuity, addictions, etc.
I understand your points. I could say that my wife is “high functioning” by these standards. However, my main point is that BPs fluctuate between high andlow functioning behavior, depending on their feelings. I expect that your wife (although I don’t know) would avoid situations in which she feel shameful. To tell you the truth I expected more comments like yours. Like I said I can see both points - but again the point I was making is the swing between apparent competence (high functioning) and active passivity (low functioning). I think this happens in the minds (and behavior) of all BPs. Certainly you are free to (and encouraged) to disagree with me.
Thanks for the comment!
Bon
I understand your point about alternation between “high functioning” and “low functioning” behavior, but I go back to my original point … some BPD individuals are able to COMPLETELY modulate their emotional impulsivity in public settings to the point where they do not exhibit ANY “low functioning” behavior. That, of course, doesn’t mean that they don’t feel completely empty inside. However, I think the definition of “high functioning” really has to do with how they are perceived by others around them and how well they can comply to societal norms (i.e. NOT raging against co-workers or their boss). Some BPD individuals seem to have much less control over the ability to modulate their emotional impulses in public settings, and thus are viewed by the general public as unstable, and usually can’t hold down careers for any length of time.
As far as my wife avoiding situations that make her uncomfortable, I do not feel that she purposely limits the scope of her interactions/situations in an attempt to avoid triggers. She wants to quit her job on a daily basis, but she doesn’t. And I will say that her job would be extremely stressful for anyone, let alone a BPD individual. Strangely enough, the thing that probably makes her successful in her career is her compulsive need for organization — very OCPD-ish.
So, I would say that the bottom line in determining “high functioning” vs. “low functioning” is whether the person has the ability to modulate their emotional impulsivity in public settings and adhere to societal expectations for standards of behavior.
Chris,
Hi. I don’t think that BPs can COMPLETELY control their emotionally impulsive behavior (and if so, they are doing pretty dang well I’d say). My wife is “high functioning” for the most part, but she can’t completely control her behavior. It might be that the OCPD-ish behavior/disorder contributes towards your wife’s ability to control her impulsive and emotional behavior. I don’t really know.
To tell you the truth, I wrote this post expecting and hoping to have this sort of dialog with other nons (especially those that disagreed with me). I was trying to point out some of the core features of BPD and how they work against high functioning - especially emotional dysregulation, shame and impulsiveness - which IMO are the three “cornerstones” of BPD.
On a side note, I wonder if you’d like to join my Google Group ATSTP? I think your intelligence, insight and wisdom about your wife’s behavior (and clearly you are still with her, so you’re doing something right - haha) might make a nice contribution to the group. So, whether or not you would like to… it’s been a nice “conversation” thus far.
If you’d like you can request membership here:
http://groups.google.com/group/ATSTPGroup
… but I totally understand if you’re too busy or private (although it is a private group) or whatever….
Take good care,
Bon
Recently my BF who I have just left decided to diagnose me as having BPD. I have seen several therapists over my life and underwent MMIPs during a custody battle and no one has ever told me that I was anything but normal
That said my BF has tremendous emotional lability and is on both lamictal and welbutrin. He is OK when he is on the meds but if he goes off he becomes manic, and agressive. The reason for the break up was his inability to commit to any long term plans. We have been together for almost 10years and I only came to learn the extent of his emotional problems over the past year.
He had an uncle who was institutionalized, and a first cousin who was incarcerated with a dx of hi functioning BPD. (she attempted to poison her BF).
Is there anything I can say or do. he is very upset about the breakup and seems to be fixated that I engage in “splitting” and am therefore BPD
Hi, thanks for the nice words. I will certainly join the group!
One last thing to say about the “high functioning” / “low functioning” topic… I understand where you are coming from when you talk about the hallmarks of BPD being emotional dysregulation, shame and impulsiveness. That is certainly 100% true. However, at least from my wife’s perspective, the shame aspect has much to do with her determination not to ever be “exposed” as she puts it. She is such a good “life actor” that even some mental health clinicians don’t believe that she has BPD. When she was admitted to the ER as a “5150″ (danger to self), the incompetent attending psychiatrist talked to her and literally laughed at her when she told him she had been diagnosed as BPD.
And in my readings on various places on the internet, I have noticed that “life acting” is a common theme among high functioning BPs. Basically, they are putting up an elaborate exterior facade, and can appear to be completely competent to everyone but their immediate family. My mom and sister, had no idea of the issues my wife had before I broke the news to them after the suicide attempt, and were literally shocked when I told them. I’ve heard that “high functioning” BPDs can often be found in positions of great importance such as college professors, nurses, lawyers, etc. They can be very successful at their jobs, and appear to be warm and caring individuals to outsiders (which they are), but when they’re at home with their husbands, wives and kids and the facade comes off, the true BPD behavior is visible (emotional instability, chronic feelings of emptiness, self-hatred, wanting to die, anger, raging, physical violence, splitting, bizarre arguments that last until 4 am, manipulative behavior, etc.)
The bottom line, and I’m sure you will agree with this, is that whether or not a true clinical distinction can be made between “high functioning” and “low functioning” individuals, they all suffer the same internal shame, guilt, pain, and feelings of worthlessness and emptiness.
Rho,
Too bad about your BF. It can be so painful to be labeled as something you’re not. Splitting is a very common cognitive distortion and whether or not you actually DO engage in it doesn’t indicate BPD exclusively. I think many people assign blame and create “good and bad” categories for others. Even the non-BP/BP sp;it can be seen as some form of splitting. I don’t know much about the details of your realtionship, so I can’t really give you advice. Good luck to you. It’s so painful to have to deal with someone who will not commit.
Bon
is the inability to commit something seen in BPD?
It could be, but not isolation. Usually there is a polar opposite dynamic at work - you know, engulfment vs. abandonment. So it will be totally committed one day, you’re evil the next. When abandonment is touched upon, sometimes a BP will do a “I’ll leave you before you leave me” thing. Fear of intimacy and extreme emotional vulnerability can be at play. It’s hard to say whether the inability to commit is BPD or many other mental/emotional disorders. It could be bad past experiences too. Hard or me to know.
Hi,
I haven’t completely read your post as I stopped at:
“I suspect many “high-functioning” BPs do not have BPD at all.”
Have only skimmed through your other comments as well.
But: I’ve been diagnosed with BPD. Full hit on all the DSM-IV criteria, 9 out of 9. By a real professor in these kind of disorders, so I suppose he knows what he’s talking about. My diagnosis contained the following: “Because of her intellect and ability to reflect on her emotions and strong desire to withhold any emotions or actions that could have severe consequences, the patient seems to have already found a way of somewhat dealing with her disorder. With psychotherapy she could develop these and other skills further and have a fruitful and stable life.”
I’ve been my own therapist for ages, but that doesn’t mean I don’t have BPD.
I also have completed two Masters studies, am in a stable, loving (for as far possible with BPD) relationship and have my own company.
Yes, I have been worse. I am doing quite okay now at the moment. But not even lying on the floor and crying for days and planning my escape from this world could have ever stopped me from working and studying. It was the only thing I had.
My reward for choosing work over social contacts: I’m a high-functioning BPD. ;p
Says more about what our society finds important, than about the person with BPD though.
I like Chris76′ comment.
“And in my readings on various places on the internet, I have noticed that “life acting” is a common theme among high functioning BPs. Basically, they are putting up an elaborate exterior facade, and can appear to be completely competent to everyone but their immediate family.”
“The bottom line, and I’m sure you will agree with this, is that whether or not a true clinical distinction can be made between “high functioning” and “low functioning” individuals, they all suffer the same internal shame, guilt, pain, and feelings of worthlessness and emptiness.”
My boyfriend would have said it exactly the same. I am only just starting to open up to people about my shame and problems. It never occurred to me they would be bothered. I mean, why would you care for someone weak? And they are such an easy target to make fun of… Better to pretend everything is perfectly fine.
I am escaping a marriage of severe verbal and emotional abuse. My husband and I were a very clear textbook case, and his warning signs were very typical. Unfortunately, I didn’t realize any of this until after it was too late! After undergoing months and days and hours and hours of yelling, berating, criticism, name calling and worse, I felt like I was losing my mind. The constant fear of what he was going to do next left me with strong mood swings between hope and fear. It is actually common for abuse victims to start questioning their own reality. One night, after he’d been yelling for hours and had removed the door to the room where I was hiding to escape from him, I was ready to kill myself. I was hysterical and crying and disassociating from the yelling. I curled into a ball and started kicking him away from me. I was frantically looking for some way to make it all end, reaching for a bottle of Benadryl or a shaver, whatever it took. Because of that incident, my abuser decided I had BPD and convinced me that I did as well. Afterall, I was having confusing mood swings, anger and suicidal thoughts everyday! At that point in my life, I was meeting the criteria (even though I never had before and don’t now.) I started reading everything I could find, buying Lineham’s DBT books, trying to get into an inpatient program, DBT programs, etc.
He took me to several therapists trying to get a diagnosis and every single one disagreed. I saw a main psychologist for nearly a year, and she kept trying to convince me I didn’t have it. She tried to let me know that I wasn’t any of those things he was berating me about, and kept telling me that it would be okay if I left him. I even checked into the hospital because I thought I was losing it. Finally, a huge team of nurses and psychiatrists and therapists were able to convince me that I didn’t have BPD, I had a crazymaking abusive husband and was experiencing adjustment disorder from the trauma. When he got really out of control and the police had to escort me to a domestic violence center for protection, I finally accepted the truth- I had married a monster and he was killing me emotionally, mentally and physically. I have learned from abusive recovery books and groups that many women get dragged down from successful, strong careers and positions into whimpering crazy women due to severe abuse.
Unfortunately, he never wanted to accept responsibility for his behavior and went to his own therapist saying I had BPD and he was codependent. Because of his self diagnosis that I had BPD, he was able to completely excuse his own abusive behavior and make himself into a martyr. Because he had convinced me, he used that as further “proof” that he was innocent. He read and copied my private recovery journals and workbooks as “proof” that I had BPD. He terrorized me and bullied me in marriage counseling and every therapist we saw (other than the one he went to alone) looked at me with sympathy and let me know that I shouldn’t feel guilty if I had to leave him.
Four months away from him, and I’m still having nightmares about all the things he said and did to me! Still, after getting out of that traumatic situation, my “BPD” symptoms are completely gone and I am recovering to be the person I was before I met him. I am now embarrassed that he was able to drag me down so low and brainwash me for two years of a “relationship.”
Now, when I hear angry spouses making their own diagnoses, I actually feel more sorry for the person who is perhaps being unfairly labeled. BPD is serious and only a professional can make that diagnosis. Sometimes, it is actually the person with BPD who is trying to diagnose a partner with it. I wonder how many cruel spouses are claiming that their partner is BPD just so they have an excuse for themselves and their own behavior.
Well, my needs for validation and the appropriateness of this topic lead me to post! I am 5 months out of my home, and I’ve been operating on the assumption that my wife is a high-functioning, or borderline-borderline. I too have struggled with this term, because there doesn’t seem to be much in the way of details, and especially when my wife agreed to take the tests and the results came back negative. The psychologists discounted her due to the lack of hits on the 9 markers, instead positing that she might be dealing with IED - Intermittant Explosive Disorder.
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!
“The problem with assigning either high-functioning or low-functioning to a person with BPD is that the very nature of the disorder debunks these categories. BPD is chiefly an emotional disorder (with impulse control issues). Emotions are ever-changing, like waves that carry the mind along for the ride. Whether someone is high-functioning or low-functioning at any given time will be subject to their current emotional state.”
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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
Skip,
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
Skip,
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.
Hi there:
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)
Randi,
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
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.
Skip,
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
Thank you for the interesting post. I’ve enjoyed reading it and the comments, and am happy to see that there will be some guidance in the next SWOE on defining high functioning versus low functioning for people with BPD. I can attest that I have BPD and have had a successful career and close friends with whom I have stable relationships. My wife also has BPD, and is in upper level management and holds a Ph.D. My relationship with my wife was/is not stable. I also suspect that more than a few of my friends have BPD, and one with NPD. These people are well educated and maintain successful careers in academia and business. It seems that what I’ve noticed is that the work performance put in is often so steller, that “quirks”, including bouts of anger, are tolerated. Any anger I had towards my manager was for the most part constrained to displaying anger at home or behind closed office doors, where I ruminated and expressed anger for hours on end. If you think about it, “low functioning” people with BPD do not (typically? tend-to?) self-harm (if that is one of the criteria for low-functioning) directly in front of their manager or loved one, or a group of peers. There are some ways in which impulsive behaviors are under a degree of control.
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 Bon,
Interesting debate. I am in the position of being a mental health professional and having been married to someone with a pd (of some type) for over 25 years. From both perspectives, I believe that diagnosis is a bit of an illusion for these types of condition. Unlike diabetes for instance, there isn’t something you can identify as an illness, treat, and the symptoms become manageable. My partner has characteristics which correspond to at least two forms of pd, bpd and npd. As far as I can work out there is an issue about whether someone’s narcissistic traits are based on indoctrinated over confidence, or whether they are a defence mechanism to massive insecurity, or a combination of both. It is interesting that there is a distinct gender split in the proportion of people diagnosed with each condition too. The point I am coming round too, is that I find Randi Kreger’s model, of high functioning BP very helpful in understanding my partner. She is able to find professional work, and in some circumstances maintain it and do it well. However, she has a track record of jobs ending disastrously through her conflict with colleagues, of major clashes with her own family, and of regularly haranguing me and the kids. Despite this, she keeps up a strong public profile of ’success’, and I, for better or worse, have colluded in supporting her in this. Sorry I haven’t yet read your book. At present I am ’self-helped out’. Randi’s book, and ‘Wolf in Sheep’s Clothing’ have both been a great help. Will get to yours when I have worked through some more of the issues.