The DSM-IV and Bon’s view of BPD/ERD – What’s required?

One of my commenters pointed out that the DSM-IV allows (because of the 5 of 9) for 256 different configurations of BPD. I can’t help but feel that perhaps if there are 256 configurations of a disorder, we are talking about a very non-specific diagnosis here. Perhaps we’re talking about several different diagnoses. I don’t really know. I try and address the idea of ERD (although I call it BPD throughout my book because that is the diagnosis that is recognized) in my book, with the core features being emotional dysregulation, impulsiveness and shame. I don’t think all 256 configurations would include all of those – but IMO (and I am NOT a doctor – that’s important to remember – and my book is almost entirely my opinion – with some research of course) a person doesn’t have BPD/ERD without these features. Of course, the medical community might disagree on this.

If we look at the diagnostic criteria of BPD, I’d say some of those features are REQUIRED to have the disorder (again this is my opinion). From the DSM IV:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following – and the diagnosis only applies to 5 or more of ANY of these traits….

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

OK, almost EVERY borderline I have come into contact with or have learned about has this feature including my wife. I didn’t think this was a big deal in my wife until she went into a crisis with one of her close friends and she told me (about the friend) “Don’t touch abandonment! That’s my ISSUE!” Abandonment by her father has had DEEP wounds for her. However, while it is very common, I don’t think it is required.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

I think this is a requirement, but not a “distinguishing characteristic” of BPD. Nons would not have a problem if this wasn’t an issue. It’s about splitting – however, splitting is not a feature that is exclusive to BPD. You see it in other disorders (although it might not be a diagnostic feature of others). You see it in PTSD, you see it in emotional immaturity… it is a very common cognitive distortion.

3. identity disturbance: markedly and persistently unstable self-image or sense of self.

I don’t know if this is required. I think this could be replaced with pervasive SHAME (which IS required IMO). The sense of self is more than “unstable” – it seems a bit self-judgmental… the invalidating of one’s emotions leads to shame, because it is wrong to feel like one feels. I think that causes an “unstable sense of self” because people have (or you yourself have) invalidated your very essence. It is not OK to be the way you are, so you have to search for a different way to be – in vain. That’s where acceptance can help.

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

Personally, I think the impulsiveness is a requirement too. Maybe not the behaviors mentioned here… but BPs are in my experience incredibly impulsive. If you look at this from wikipedia you will see how other countries view BPD:

Comparable diagnoses

The World Health Organization’s ICD-10 has a comparable diagnosis called *Emotionally unstable* personality disorder – Borderline type (F60.31). This requires the following, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.

The Chinese Society of Psychiatry’s CCMD has a comparable diagnosis of *Impulsive Personality Disorder (IPD)*. A patient diagnosed as having IPD must display “affective outbursts” and “marked impulsive behavior”, plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10’s Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.

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

Self-mutilating… probably not. Although I have known of many, many BPs that do cut, burn or pull at their hair. Or starve themselves. I think suicidal ideation is a given. According to some sources 75% of BPs attempt suicide at sometime in their lives.

6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

THIS is IMO the CORE feature of ERD (and possibly BPD if it is the same diagnosis – see WHO above). This – in combination with impulsiveness – seems to the the very foundation for BPD/ERD. I don’t think someone can have the disorder that I describe in my book (which I call BPD – or at least my experience with it) without this. This is the main thing the skills in my book try and address, because IMO this is the engine of all other feelings and behaviors. If this can be healed/managed most other things will fall away. Again I am NOT a doctor.

7. chronic feelings of emptiness

Probably important, but not required. I think many BPs DO feel this. It is difficult for me to see this from the outside (or for any non, unless the BP reveals it).

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

Again, this is probably required and is what gets most nons to seek help. I think this is an out-growth of emotional dysregulation and shame. They FEEL angry, because angry is a powerful emotion and a natural reaction to threat – even if the threat is “imagined” (although felt).

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

Well, this is a hard one. I have seen this in my wife a couple of times. She walked around talking to pillows as if they were people at one point. It’s tough to say if this is “required.”

So, I have a certain view of the disorder that I think works in most cases (but possibly not all). I would encourage you guys to read the book and try it out. It takes some time to figure out what I’m saying though… because of the above view of BPs/nons is slightly “unstandard”. Again I’m not a doctor.