A free eBook – 4X4 for Nons
|
Simon Baron-Cohen has been giving interviews about his new book The Science of Evil: On Empathy and the Origins of Cruelty in which he discusses “mind-blindness” in autism and the lack of empathy in other disorders, including BPD. Here is the text of the interview he gave to Time magazine. I have added emphasis on the part that I find most “telling” about BPD. I have to disagree though that people with BPD have zero empathy. They can behave that way at times, but people with BPD can exhibit a lot of empathy and compassion when their motivation is not IAAHF, pain avoidance or threat reaction. When their emotions become reflective, rather than reflexive, the empathy come through.
Mind Reading: Psychologist Simon Baron-Cohen on Empathy and the Science of Evil
By MAIA SZALAVITZ Monday, May 30, 2011
Cambridge psychology professor and leading autism expert Simon Baron-Cohen is best known for studying the theory that a key problem in autistic disorders is “mind blindness,” difficulty understanding the thoughts, feelings and intentions of others. He’s also known for positing the “extreme male brain” concept of autism, which suggests that exposure to high levels of testosterone in the womb can cause the brain to focus on systematic knowledge and patterns more than on emotions and connection with others. (Oh, and yes, he’s also the cousin of British comedian Sacha “Borat” Baron Cohen.)
Baron-Cohen’s new book, The Science of Evil: On Empathy and the Origins of Cruelty, examines the role of empathy, the ability to understand and care about the emotions of others, not only in autism but in conditions like psychopathy in which lack of care for others leads to antisocial and destructive behavior.
What do you mean when you write about “zero negative” empathy?
Zero empathy refers to people at the extremely low end of the scale. They tend to be people with personality disorders, particularly antisocial personality disorder (ASPD). I focus quite a lot on psychopathy [the extreme form of ASPD] and also on two other personality disorders, borderline personality disorder and narcissistic personality disorder.
The ‘negative’ is meant to be shorthand for this being negative for the individual but also for the people around them. It’s meant to contrast with what I call ‘zero positive’ empathy, which effectively describes the autistic spectrum.
[Autistic people] struggle with empathy just like zero negatives but it seems to be for very different reasons. I’m arguing that their low empathy is a result of a particular cognitive style, which is attentive to details and patterns or rules, which in shorthand, I call systemizing.
If we think about the autism spectrum as involving a very strong drive to systemize, that can have very positive consequences for the individual and for society. The downside is that when you try to systemize certain parts of the world like people and emotions, those sorts of phenomena are less lawful and harder to systemize. That can lead to having low empathy, almost like a byproduct of strong systemizing.
How do you account for people who are both highly empathetic and highly systematic, such as some of those with Asperger’s who are actually oversensitive to the emotions of others?
I’ve certainly come across subgroups like that. There are people with Asperger’s whom I’ve met who certainly would be very upset to learn they’d hurt another person’s feelings. They often have very strong moral consciences and moral codes. They care about not hurting people. They may not always be aware [that they've said something rude or hurtful], but if it’s pointed out, they would want to do something about it.
Continue reading Simon Baron-Cohen discusses empathy and the science of evil →
By (author) Simon Baron-Cohen
| List Price: |
$25.99 USD |
| New From: |
$13.64 In Stock |
| Used from: |
$9.50 In Stock |
|
|
|
Just a note or two on BPD vs psychopathy…
Firstly, when shown the Ekman faces (just google it if you don’t know what those are), borderlines are likely to view neutral faces as angry and angry faces as extremely threatening. Borderlines think “that person is angry *at me*”. With fear faces, borderlines actually express empathy, even if Baron-Cohen says they don’t. I disagree with him in this regard. I believe the lack of empathy in borderlines occurs during a “failure to mentalize” and is not a general BPD trait.
Psychopath’s brains only activate on fear faces. Disturbingly, they get “excited” about fear in others (i.e. the pleasure centers of the brain light up).
Secondly, psychopaths are the only class of disordered individuals that use goal-directed aggression. Borderlines do not. Their aggression is reactive. Now, you may read that and think “oh my god! My ‘BP’ is a psychopath!” yet what is really happening is that you probably don’t see the trigger of reactive aggression. The trigger for a borderline (or another emotionally sensitive person) can very well be internally-generated – by ruminating or misreading the intentions of others. Psychopaths, however, LIKE to see fear in you. Borderlines just don’t like to feel fear in themselves.
The thing is… I am differentiating the groups because the skills taught in WHINE will not work with psychopaths. In fact, it will probably make them more manipulative because they can gain an understanding of your emotions (whereas they have very little ability to mentalize about others’ feelings, intentions, etc. – they just don’t care) and use that knowledge to get what they want.
For more on psychopathy, listen to Dr. James Blair’s presentation to the 2009 ISSPD.
And some books – Dr. Blair’s book included:
 Without Conscience: The Disturbing World of the Psychopaths Among Us  The Psychopath Test: A Journey Through the Madness Industry  The Psychopath: Emotion and the Brain  Handbook of Psychopathy  The Mask of Sanity (Mosby medical library)
The NIAAA study begins to spread out and spur on new views of the findings regarding BPD. Here is a study about Major Depressive Disorder and BPD.
Can Epidemiology Translate Into Understanding Major Depression With Borderline Personality Disorder?
Myrna M. Weissman, Ph.D.
Epidemiologic surveys have mapped the terrain of psychiatric disorders. Personality disorders have bedeviled the clinician’s practice. Rarely have these two been rearranged in a meaningful clinical dialogue. Using the largest psychiatric epidemiologic survey ever, the National Epidemiologic Survey on Alcoholism and Related Conditions, and among the few to venture into axis II disorders, Skodol et al. (1), in this issue of the Journal, give a community-based national view of a common clinical question: What is the effect of specific personality disorder comorbidity on the course of major depression?
The original sample included over 40,000 adults, and 2,422 met criteria for DSM-IV current major depressive disorder. Three years later, 1,996 of the original currently depressed subjects were available for reinterviewing, which makes both a respectable sample size and response rate for generalizability. However, some caution is needed, since the sample was over-represented with Caucasian, college-educated, and married respondents. Fifteen percent of participants had persistent major depressive disorder, and 7.3% of those who remitted had a recurrence over the follow-up period. These figures are within the range of longitudinal studies of patients with major depressive disorder (2). While the presence of any personality disorder elevated the risk for persistence of major depressive disorder, when all axis I and II disorders, age of onset of major depressive disorder, number of previous episodes, family history, treatment, and duration of illness were controlled, borderline personality disorder remained the most robust predictor of major depressive disorder persistence. Neither personality disorders nor other clinical variables predicted recurrence of major depressive disorder. Thus, an epidemiologic survey yielded a practical jewel. The finding, undoubtedly, does not surprise the clinician but is now confirmed nationally. As the authors conclude, borderline personality disorder should be assessed in all depressed patients and considered in prognosis and addressed in treatment.
One can raise a number of methodologic issues about this study, including the use of lay interviewers or the instrument for assessing axis II disorders. The diagnostic interview, the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (3), was developed for this survey. The personality disorders included were adapted from items in the Structured Clinical Interview for DSM-IV Personality Disorders. The test-retest and internal consistency results reported for all personality disorders are fair to good, not great. However, the agreement with clinician interviews for borderline personality disorder (kappa=0.71) is about as good as it gets (4). The only other national survey to venture into assessing all axis II disorders was the National Comorbidity Survey Replication (5), which used the International Personality Disorder Examination. The investigators carried out a clinical reappraisal in a sample of 214 subjects using clinically trained interviewers to follow up screened, positive subjects and reported excellent predictions of classification. They also noted that the International Personality Disorder Examination is commonly regarded as a conservative diagnostic assessment of axis II disorders. The community rate they generated for any personality disorder in the United States was 11%, and in the World Health Organization World Mental Health Surveys (6), involving 13 countries, the rate was 6.1%. These rates seem to be lower than those reported in the National Epidemiologic Survey on Alcoholism and Related Conditions, but different presentations make it difficult to directly compare rates between studies. No articles from the National Epidemiologic Survey on Alcoholism and Related Conditions reporting overall rates of axis II disorders could be found. Unfortunately, given the findings in the Skodol et al. article, not all personality disorders were included in the first wave of the survey, and borderline personality disorder was added in the second wave. Both of these landmark studies used state-of-the-art measures. While they are imperfect, these are the best available. It is too bad they could not share the same methods.
The major issue now is not a debate about the methods of personality disorder assessment but about the future of personality disorders. The DSM-5 committee is working on the next version of psychiatric classification (7). In parallel, the National Institute of Mental Health is working on moving diagnosis away from clinical presentations to understanding of syndromes based on pathophysiology in a new project called Research Domain Criteria (8). These efforts will certainly effect how personality disorders are described, classified, or reimbursed in the future.
DSM-5 raises issues about the categorical conceptualization of personality disorders because of the high concurrence among disorders, both within and across axes, and the difficulty in differentiating normal from pathological. How dimensions will solve the problem of a lack of understanding of the pathophysiology underlying the disorders is unclear. Some cutoff along the dimension will need to be established for clinical practice.
The Skodol et al. study, based on an epidemiologic survey, may add light to the issue or, at least, generate a hypothesis about diagnosis that can be translated into a more experimental approach. Borderline personality disorder, defined categorically, and not the other axis II disorders explained the persistence of major depressive disorder over 3 years. Other axis I disorders may map out to different axis II disorders. The National Epidemiologic Survey on Alcoholism and Related Conditions, because of its large sample, could be mined for these clues about the relationship between specific axis I and II disorders.
The Research Domain Criteria project, in the long run, may offer more enlightenment for personality disorders if its goals can be achieved. The primary focus is on neural circuitry, with levels of analysis progressing from measures of circuitry function to clinically relevant variation or downward to the genetic and molecular cellular function (8). In the final analysis, the new molecular and neurobiological parameters will need to predict prognosis or treatment response. They will need to do as well as borderline personality disorder in predicting major depressive disorder persistence. If the Research Domain Criteria approach is successful, more than prediction of prognosis might be achieved, including a deeper understanding of the biological mechanism underlying the joined symptoms.
The epidemiologic finding that borderline personality disorder contributes to poor prognosis of major depressive disorder might be viewed as a hypothesis that can be translated into methods in the neurosciences to understand the mechanism behind this association. The features of borderline personality disorder, particularly the pervasive instability of the regulation of emotions and impulse control, would seem ripe for the Research Domain Criteria approach. When these symptoms occur in conjunction with major depressive disorder, a different syndrome may be present. Further experimental work may test how the symptoms of borderline personality disorder contribute to the prognosis of major depressive disorder. But what about the persistence of borderline personality disorder without major depressive disorder? Can the epidemiologic data provide any clues? In the meantime, the clinician treating major depressive disorder would be wise to assess for borderline personality disorder, even as currently defined.
Here is an article about bipolar depression that mentions BPD. The mention says:
Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’
… which in combination with this finding: People with Borderline Personality Disorder over diagnosed with Bipolar Disorder …could have some interesting ramifications for the medical community.
The text of the article:
Bipolar depression unrecognised in primary care
03 Mar 11
By Christian Duffin
Up to a fifth of primary care patients with depression may have an undiagnosed bipolar disorder, a UK study suggests.
The researchers argue that their findings have important implications for GP diagnosis and assessment, because prescribing antidepressants as monotherapy for patients with bipolar disorder may result in mania and frequent mood swings.
The researchers believe that their study is the first to investigate the extent to which bipolar disorder is misdiagnosed as major depressive disorder among UK primary care patients.
The study involved a two-phase sampling technique to produce three estimates of unrecognised bipolar disorder.
The researchers initially collected diagnostic, clinical, psychosocial functioning and quality of life data from 11 GP practices in south Wales for patients with a diagnosis of unipolar depression.
576 of the 3,117 patients contacted sent back completed Hypomania Checklist (HCL-32) and Bipolar Spectrum Diagnostic Scale (BSDS) screening tool questionnaires, both used to test for bipolar disorder.
Of these, 154 were then given a comprehensive diagnostic and clinical assessment. 29 met the diagnostic criteria for bipolar disorder.
The researchers calculated three estimates of the prevalence of previously undiagnosed bipolar disorder, ranging from 3.3% up to 21.6%.
The estimates were based on different assumptions. The most conservative estimate assumed that all individuals who dropped out of the study did not have bipolar disorder.
Assuming that all of those who were invited to interview but did not attend did not have bipolar disorder resulted in a prevalence of 9.6%, while assuming all who were invited and attended had bipolar disorder resulted in a prevalence of 21.6%.
Lead researcher Dr Daniel Smith, a clinical senior lecturer in psychiatry at Cardiff University, said: ‘Although challenging, these are findings with potentially considerable implications for they way in which GPs approach the diagnosis and treatment of their patients with depression, especially when we consider how commonly antidepressants are prescribed in primary care and the potential for harm when antidepressants are used as monotherapy for bipolar disorder.’
He added: ‘It will be important that GPs are supported in developing strategies to ensure that their patients with depression receive the correct diagnosis with regard to the possibility of a primary bipolar illness.’
Dr Thomas Shackleton, a GP from Bottisham, near Cambridge with an interest in depression, said the research should serve as a reminder to GPs that they should screen for manic symptoms when they make they make a diagnosis for depression and during the follow-up at 5-12 weeks.
Dr Shackleton, also an advisor to NICE for its guidelines on depression, added: ‘This is a big issue because the majority of first presentations are depressive, and if you prescribe antidepressants you can induce a manic episode in someone who has bipolar disorder.
‘It can be difficult for GPs because if patients have impulsive or risky behaviour, such as risky sex or gambling, they tend you hide it from GPs. But GPs can explore patients’ histories and ask them if their family have had any concerns about them.’
Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’
NICE GUIDELINES ON BIPOLAR DISORDER
-
- GPs should fully involve patients in decisions about their treatment and care, and determine treatment plans in collaboration with the patient’s preference.
- GPs should discuss contraception and the risks of pregnancy with all women of child-bearing potential, regardless of whether they are planning a pregnancy.
- People experiencing a manic episode, or severe depressive symptoms, should normally be seen again within a week of their first assessment, and then regularly at appropriate intervals, for example, every 2–4 weeks in the first 3 months and less often after that, if response is good.
- The treatment of bipolar disorder is based primarily on psychotropic medication, but side effects and potential harms will determine the choice of drug. A range of psychological and psychosocial interventions can also have a significant impact.
CG38 Bipolar disorder: NICE guideline, October 2006
An article from the NY Times about getting mental health care for others:
Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive
By A. G. SULZBERGER and BENEDICT CAREY
TUCSON —What are you supposed to do with someone like Jared L. Loughner?
That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.
Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.
In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.
Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.
The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.
With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.
“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”
Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”
Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.
Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.
“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).
But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.
Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.
The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”
Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”
At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.
The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.
Many others feel the same way.
Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.
“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”
Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.
This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.
A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.
“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”
An article from the NY Times:
November 29, 2010
A Fate That Narcissists Will Hate: Being Ignored
By CHARLES ZANOR
Narcissists, much to the surprise of many experts, are in the process of becoming an endangered species.
Not that they face imminent extinction — it’s a fate much worse than that. They will still be around, but they will be ignored.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition.
Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.
Most nonprofessionals have a pretty good sense of what narcissism means, but the formal definition is more precise than the dictionary meaning of the term.
Our everyday picture of a narcissist is that of someone who is very self-involved — the conversation is always about them. While this characterization does apply to people with narcissistic personality disorder, it is too broad. There are many people who are completely self-absorbed who would not qualify for a diagnosis of N.P.D.
The central requirement for N.P.D. is a special kind of self-absorption: a grandiose sense of self, a serious miscalculation of one’s abilities and potential that is often accompanied by fantasies of greatness. It is the difference between two high school baseball players of moderate ability: one is absolutely convinced he’ll be a major-league player, the other is hoping for a college scholarship.
Of course, it would be premature to call the major-league hopeful a narcissist at such an early age, but imagine that same kind of unstoppable, unrealistic attitude 10 or 20 years later.
The second requirement for N.P.D.: since the narcissist is so convinced of his high station (most are men), he automatically expects that others will recognize his superior qualities and will tell him so. This is often referred to as “mirroring.” It’s not enough that he knows he’s great. Others must confirm it as well, and they must do so in the spirit of “vote early, and vote often.”
Finally, the narcissist, who longs for the approval and admiration of others, is often clueless about how things look from someone else’s perspective. Narcissists are very sensitive to being overlooked or slighted in the smallest fashion, but they often fail to recognize when they are doing it to others.
Most of us would agree that this is an easily recognizable profile, and it is a puzzle why the manual’s committee on personality disorders has decided to throw N.P.D. off the bus. Many experts in the field are not happy about it.
Actually, they aren’t happy about the elimination of the other four disorders either, and they’re not shy about saying so.
One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual.
Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how “unenlightened” the personality disorders committee is.
“They have little appreciation for the damage they could be doing.” He said the diagnosis is important in terms of organizing and planning treatment.
“It’s draconian,” he said of the decision, “and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”
He also blamed a so-called dimensional approach, which is a method of diagnosing personality disorders that is new to the DSM. It consists of making an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient.
This is in contrast to the prototype approach that has been used for the past 30 years: the narcissistic syndrome is defined by a cluster of related traits, and the clinician matches patients to that profile.
The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians.
It is one thing to call someone a neat and careful dresser. It is another to call that person a dandy, or a clotheshorse, or a boulevardier. Each of these terms has slightly different meanings and conjures up a type.
And clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.
Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: “Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”
Schism is probably not an overstatement. For 30 years the DSM has been the undisputed standard that clinicians consult when diagnosing mental disorders. When a new diagnosis is introduced, or an established diagnosis is substantially modified or deleted, it is not a small deal. As Dr. Gunderson said, it will affect the way professionals think about and treat patients.
Given the stakes, the blow-back from experts in personality disorders should come as no surprise.
Dr. Gunderson has written a letter co-signed by other clinical and research leaders to the trustees of the American Psychiatric Association and the task force that governs DSM-5. And Dr. Shedler and seven colleagues published an editorial in the September issue of The American Journal of Psychiatry. In the relatively small world of mental health diagnostics, this is most certainly a battle worth watching.
Right now, this much seems clear: It is way too early for the narcissists to give up their seat on the bus.
See my take on BPD vs. NPD.
Only 23% of the British Population is not personality disordered?
Personality pathology recorded by severity: national survey
Min Yang, MD, MPH
Division of Psychiatry, School of Community Health Science, University of Nottingham, Nottingham
Jeremy Coid, MD, FRCPsych
Queen Mary College, London, Forensic Psychiatry Research Unit, St Bartholomew’s Hospital, London
Peter Tyrer, MD
Centre for Mental Health, Imperial College, London, UK
Correspondence: Correspondence: Professor Peter Tyrer, Centre for Mental Health, Imperial College, St Dunstan’s Road, London W6 8RP, UK. Email: p.tyrer@imperial.ac.uk
Declaration of interest
P.T. is the Chair of the World Psychiatric Association Section on Personality Disorders and the Chair of the World Health Organization Personality Disorder Working Group for the ICD–11 Classification. He is also Editor of the British Journal of Psychiatry but had no part in any decisions about this paper.
Background
Current classifications of personality disorders do not classify severity despite clinical practice favouring such descriptions.
Aims
To assess whether an existing measure of severity of personality disorder predicted clinical pathology and societal dysfunction in a community sample.
Method
UK national epidemiological study in which personality status was measured using the screening version of the Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II) and reclassified to five levels using a modified severity index. Associations between levels of severity of personality pathology and social, demographic and clinical variables were measured.
Results
Of 8391 individuals interviewed and their personality status assessed, only a minority (n = 1933, 23%) had no personality pathology. The results supported the hypothesis. More severe personality pathology was associated incrementally with younger age, childhood institutional care, expulsion from school, contacts with the criminal justice system, economic inactivity, more Axis I pathology and greater service contact (primary care and secondary care, all P<0.001). Significant handicap was noted among people with even low levels of personality pathology. No differences contradicted the main hypothesis.
Conclusions
A simple reconstruction of the existing classification of personality disorder is a good predictor of social dysfunction and supports the development of severity measures as a critical requirement in both DSM–V and ICD–11 classifications.
“How to set boundaries to protect yourself and improve living with a BP?”
OK, I don’t normally do it, but today I went out to my old (circa 2005-2006) haunt – WTO (i.e. “Welcome to Oz”). WTO is the largest non-BP board on the Internet. It’s been around or at least 10 years and has over 4,000 members. Most of the members are quiet (like me). I used to post way back when and got into a number of “altercations” with people because I was presenting a different approach to people with BPD than the majority of the members. Mostly, it’s people who have just started trying to figure out what BPD is all about and are hurt and frustrated.
The quoted text above is a subject line of a recent post. I feel for the woman, I really do. Yet, that line seems to typify the very problem with BPD support groups. Firstly, there is an assumption that boundaries are the default tool for making a relationship work. They aren’t. I explain in great detail in my eBook “Beyond Boundaries”. However, the short version about boundaries is (from the Beyond Boundaries eBook):
If you do any research on BPD, you will find a plethora of advice from all types of people. There are Internet support groups, self-help books and personal stories that tell you what to do as a Non-BP. Some of this advice is good and works effectively with someone with BPD. Some of this advice is not good and is ineffective with someone with BPD. Some of this advice is misperceived by the Non and applied in a way that is not intended by the advice giver. The most misunderstood tool is boundaries.
If I had a nickel for every time someone joins my Internet list and says: “I set boundaries and try to enforce them.”
… or something like that, I’d be rich. Well, not really but I would probably have a couple of hundred dollars anyway.
Unfortunately, most people who try to create and apply boundaries to their BP relationship, do so improperly and with misunderstanding. This misunderstanding is amplified across the Internet and in publications about dealing with an emotionally sensitive person. The misunderstanding arises in two forms: one is the meaning of a boundary, and the second is to whom the boundary applies.
Many people believe that a “boundary” is equivalent to a rule and that they have to enforce their personal boundaries with a person who has BPD. This is not the case. A personal boundary is not a rule that needs to be enforced. Instead, a personal boundary is a limit that one puts on one’s own behavior. It is a choice that you make about your own behavior and a limit on the behavior you’re willing to engage in.
Boundaries have their place, but the assumption that boundaries (or limits) are the end-all, be-all (or even the default approach to BPD is IMO misguided. Other tools are much more important, effective and productive than boundaries.
Now as for “protecting oneself” I can certainly understand why one would feel that they need to protect themselves. However, I see a relationship not as a power struggle or “battle of wills” but as a cooperative sharing of feelings. Unfortunately, a borderline’s feelings are very overwhelming and, at times, seem to be the only feelings in the relationship. If someone is trying to hurt you, it’s quite possible that they’re not borderline, they’re a psychopath (in the true sense of the term). If you’d like to know more about true psychopath you can listen to this (the middle part is the presentation of Dr. James Blair about psychopathy).
You see borderline aggression is reactive in nature. It is reactive to what the borderline perceives as a threat. If the environment is a power struggle, they are going to be trigger continuously. If the environment is a cooperative sharing of feelings, the threat level will go down and you will get less aggression.
This pattern is not the same as a true psychopath.
I was disturbed to read this column in which Caroline Hutchinson of (apparently) “Mix FM” (some sort of radio station) said this about a story in which a boy was bullyed at a disco in Sydney. What I find troubling about her post about the incident is this… She says:
There is a diagnosable condition known as a personality disorder. According to the American Psychiatric Association personality disorder typically rears its ugly head in late adolescence but, in rarer instances, childhood. It’s subjective, but a person with borderline personality disorder, should exhibit three or more of the following:
1. Failure to conform to lawful social norms – repeatedly performing acts that are grounds for arrest;
2. Deceitfulness – repeated lying, use of aliases, or conning others for personal profit or pleasure;
3. Impulsivity or failure to plan ahead;
4. Irritability and aggressiveness – repeated physical fights or assaults;
5. Reckless disregard for safety of self or others;
6. Consistent irresponsibility – repeated failure to sustain consistent work behaviour or honour financial obligations;
7. Lack of remorse – being indifferent to or rationalising having hurt, mistreated, or stolen from another.
I’m no psychologist but if you ticked too many of those boxes for yourself or a loved one, with a GP’s referral you can see a qualified psychologist for free in Australia. One referral entitles any Medicare cardholder to 12 free consultations and 12 group sessions.
No, you’re not psychologist all right. The criteria to which she is referring is the criteria for Anti-social Personality disorder, not Borderline Personality Disorder. I think before you post something about which you know next to nothing about, at least get it fact-checked.There’s already enough stigma around BPD without having people attribute ASPD criteria to it as well.
Here is a chart comparing DSM-IV personality disorders to DSM-V personality types. Notice that NPD, Paranoid, Schizoid, and others have no DSM-V comparable disorder and are a combination of prominent personality traits.
DSM-5 Type and Trait Cross-Walk
| DSM-IV Personality Disorder |
DSM-5 Personality Disorder Type |
Prominent Personality Traits |
| Paranoid |
None |
Suspiciousness
Intimacy avoidance
Hostility
Unusual beliefs |
| Schizoid |
None |
Social withdrawal
Social detachment
Intimacy avoidance
Restricted affectivity
Anhedonia |
| Schizotypal |
Schizotypal (4 or 5) |
Eccentricity
Cognitive dysregulation
Unusual perceptions
Unusual beliefs
Social withdrawal
Restricted affectivity
Intimacy avoidance
Suspiciousness
Anxiousness |
| Antisocial |
Antisocial/Psychopathic
(4 or 5) |
Callousness
Aggression
Manipulativeness
Hostility
Deceitfulness
Narcissism
Irresponsibility
Recklessness
Impulsivity |
| Borderline |
Borderline (4 or 5) |
Emotional lability
Self-harm
Separation insecurity
Anxiousness
Low self-esteem
Depressivity
Hostility
Aggression
Impulsivity
Dissociation proneness |
| Histrionic |
None |
Emotional lability
Histrionism |
| Narcissistic |
None |
Narcissism
Manipulativeness
Histrionism
Callousness |
| Avoidant |
Avoidant (4 or 5) |
Anxiousness
Separation insecurity
Pessimism
Low self-esteem
Guilt/shame
Intimacy avoidance
Social withdrawal
Restricted affectivity
Anhedonia
Social detachment
Risk aversion |
| Dependent |
None |
Submissiveness
Anxiousness
Separation insecurity |
| Obsessive-Compulsive |
Obsessive-Compulsive
(4 or 5) |
Perfectionism
Rigidity
Orderliness
Perseveration
Anxiousness
Pessimism
Guilt/shame
Restricted affectivity
Oppositionality |
| Depressive |
None |
Pessimism
Anxiousness
Depressivity
Low self-esteem
Guilt/shame
Anhedonia |
| Passive-Aggressive |
None |
Oppositionality
Hostility
Guilt/shame |
|
Loading ...
