Exploring the Implications of the Diagnosis Borderline Personality Disorder for Consumers and Analysing It's Criteria With Reference to it's Historical, Socio-Political and Cultural Context

Exploring the Implications of the Diagnosis Borderline Personality Disorder for Consumers and Analysing It's Criteria With Reference to it's Historical, Socio-Political and Cultural Context

The diagnosis of Borderline Personality Disorder (BPD) has been chosen for the purpose of this assignment. In my own practice I have struggled with the ethical and moral questions that nursing clients with BPD in an inpatient setting have raised. It has given me much room for reflection and personal learning.

Throughout this assignment the history, and current DSM IV diagnostic category will be looked at critically. Also some alternatives for future inclusion pondered alongside the underlying power struggles between mental health professions that influence diagnoses. From this there will be some discourse on how these points directly affect consumers. In doing so, it is hoped that some illumination will come for my own practice.
Spitzer et al (1979) outline the debate for the inclusion of two new DSM III classifications, borderline personality and schizotypal personality, because at the time there was no agreement on their definition or the overall concepts.

The attempt at inclusion was a decision not readily reached, as Spitzer et al (1979) stated, since the American Psychiatric Association (APA) task force were themselves divided to the intrinsic value of this project. They went on to reflect that this split was congruent within psychiatry. That is the borderline concept represented many things that were wrong with psychiatry at that time. This was because of the confused way in which the term had been used, and also the literature on borderline tended to rely on metapsychological concepts with little hard data regarding it’s validity as a concept.

Twenty five years later Shedler and Westen (2004), open with another call for a clear “clinically useful and empirically sound classification of personality” (p.1350)

They cite excessive co-morbidity between personality disorders, and that this has been present since DSM III. They go on to describe DSM IV’s (1994), task force having “gerrymandered” categories and criteria (Shedler and Westen, 2004, p.1350). This was in an attempt to refine the boundaries between personality disorders. They feel this has not always been while noting clinical observations or relevant empirical data.

What Shedler and Westen, (2004), are in fact saying is that by defining, supposedly more precisely, what is happening, there are now narrower criterion sets. This in turn further blurs the lines between disorders making them less distinct.

Making diagnoses by counting symptoms can then be seen as arbitrary and therefore unreliable. This is not how the patient presents, and in turn is not how the clinician sees the client in practice. Shedler and Westen (2004), go further to cite research into cognitive science that confirms this. That is, clinicians do not diagnose personality disorders in this manner. Rather they try and match a patient with the features of a personality syndrome as a configuration, or in fact use their own theories or formulations to make sense of the symptoms they are presented with. What DSM IV (1994), Axis II does is not allow for the full diversity of personality pathology seen in daily practice. What Shedler and Westen (2004) are trying to do is give an in depth individual psychological picture of a patient with a specific personality disorder.

Kutchins and Kirk (1997), state that the DSM IV (1994), is a group of constructs. They make clear to us that these constructs are liable to change with different contributors. With this brings changing views, beliefs and standpoints about those constructs which the clinician deals with regularly.

They outline that trends change; psychoanalysists, dominant in psychiatry in 1950’s and 1960’s lead the way. The ideas of attribution and behaviour held sway in the 1970’s (Kutchins and Kirk 1997). By the 1980’s a wide variety of groups were also vying for a voice. Experts in assisting with what life can throw at you; social workers, psychologists, psychiatric nurses, counsellors, the list is growing. Psychiatry as a medical speciality needed to assert it’s power once again, do so in a “conceptually coherent way” and not presume it’s authority (Kutchins and Kirk, 1997, p.28).

During such disputes we learned that definition, classification and criteria are not only a problem of constructs and concepts, but can produce political disagreements as well (Kutchins and Kirk 1997).

With all these various conflicts in mind where does this leave the patient? The current DSM IV (1994), procedure for diagnosing personality disorders comes down to deciding about present or absent judgements about the small number of diagnostic criteria, then adding them up and seeing if there are enough there to make a diagnosis. This can leave people with overlapping co-morbidity across several personality disorders (Conklin and Westen 2005).

Shedler and Westen (2004) consider a prototype matching diagnostic tool. They look at clinicians considering individual criteria in the context of an overall “gestalt” (gist) (p.1351) . In this way no one criteria can determine diagnosis. They state that current research suggests that clinicians find prototype matching for personality disorders simpler than symptom counting. It also allows for continuum based diagnoses rather than just present or absent features.

They feel that the current DSM IV (1994), Axis II limits clinicians. Also that it does not fully encapsulate the complexities and diversities of personality disorders as understood by these clinicians and as seen in practice. In expanding the size of criterion sets and looking at personality disorders as configurations or gestalts we could develop an empirical portrait of the personality functioning of the patients seen in practice with BPD (Shedler and Westen 2004).

At least half of BPD patients have a major depressive disorder, dysthymia or both. Also BPD patients are found to have high co-morbidity with many if not all Axis II disorders; most commonly histrionic and avoidant personality disorders (Conklin and Westen 2005).

Also the daily functioning of this client group, Conklin and Weston (2005) have found, include many adaptive (or maladaptive) behaviours. These include a wide range of self harming behaviours – skin-cutting and burning, suicidality, also hospitalizations, poor maintenance of relationships and difficulties with long term employment. All of which put the patient in the negative patient role with many health professionals. Repeated visits to A&E and psychiatric services do not lend themselves to be favoured by health professionals who can see them as manipulative clients. This will be mentioned further .

In Shedler and Westen’s (2004), research some interesting findings were noted. Using the assessment tool Swap 200 Q Sort, experienced clinicians divide 200 descriptive statements into 8 groups, assigning each statement a score from 0-least descriptive, to 7-most descriptive of patient. These statements were derived from numerous sources including the DSM IV. From this the clinician comes out with an empirical picture of the individual client’s BPD, therefore including other personality descriptors which appeared more diagnostic. Furthermore, if these descriptors mirrored the patients seen in practice then using them to refine the DSM construct would perhaps be a good thing.

Clinicians are experienced observers who build working relationships with clients over long periods of time in an in depth manner. And although there is criticism of unstructured clinical judgements on clients, recent studies suggest that they can provide reliable data when quantified using psychometric instruments such as Swap 200 (Conklin and Westen 2005). This research also notes that any one clinician’s theoretical orientation has shown little variance when asked to describe a specific client rather than their own personal held beliefs and theories on the psychopathology of BPD as a group (Conklin and Westen 2005).

This again would help when looking at forming a new construct for DSM IV as it focuses on the clients themselves, not the theoretical orientation of the APA steering group at any given time.

75-80% of clients diagnosed with BPD are women between 18- 55 years of age (DSM IV 1994). In studies carried out BPD groups distinguished themselves both in the amount of co-morbid diagnoses and also BPD clients appear to function significantly more poorly than say dsythymic disorder, with which they are compared due to the large area of co-morbidity (Shedler and Westen, 1998 cited in Conklin and Westen 2005).

Furthermore, it has been found that 70% of BPD clients had attempted suicide on more than one occasion, most needing medical attention. 63% had had multiple psychiatric admissions, over half use self-injurious adaptive functions, of which 81% used skin-cutting (Conklin and Westen 2005).

As briefly noted earlier, these statistics can lead to prejudice, stigmatisation and negative labelling. Raingriber (2002), notes that depression and suicidal ideation are regularly stigmatised. Gilbert (2000, cited in Raingrruber 2002 ) found that it is a human trait to stigmatise those outside society’s norms, almost as a protection reflex to further isolate and distance those who are seen as different.

This stigma is compounded for BPD as they have multiple undesirable personality traits as seen through our cultured eyes. This can lead to further social isolation and delays in seeking health care, increased distress and discrimination in employment and education (Charland 2006).

It also reinforces to the client the negative effect found by Conklin and Weston (2005), that BPD already have poor self-esteem, self-loathing, feel depressed or despondant and have problems with emotional de-regulation as core descriptive items found in their studies.

Farnham and James (2000, cited in Charland 2006) state that the coercive nature of health services and the use of mandatory hospitalizations lead to further labelling by assigning people a sick role, or patient role. It was also noted that hospitals are increasingly unpleasant environments populated by, on many occasions, health professionals who have heavy workloads and see the BPD’s presentation as time-wasting or attention seeking.

In the Swap 200 studies several descriptive criteria emerged as central to BPD although not found in DSM IV (1994) criteria. This is even though the studies used DSM IV criteria to define the patient sample groups (Shedler and Westen 2004). Importantly Swap 200 results are showing that BPD patients have chronic, not transient, feelings of unhappiness, depression and despondency. These were underlined by chronic anxiety states. They extrapolate that the DSM IV underestimates the emotional pain and dysphoria BPD patients feel. They strongly support the view that negative affect is a core trait of BPD Shedler and Westen 2004).

Also, emotional de-regulation appears not to be adequately represented in DSM IV (1994). The DSM IV (1994) description is: “affective instability due to a marked reactivity of mood” (Shedler and Westen 2004, p.1362), is not as descriptive as “persons whose emotions can spiral out of control and become irrational, catastrophizing problems”( Conklin and Westen, 2005, p.873). Catastrophization when strong emotions are stirred lead people to find everyday problems as disastrous and unsurmountable. They have problems self-soothing and can therefore become overly dependant on others to solve these situations and regulate emotions for them.

These aspects, linked with poor relationship skills (more than half reported job loss in the past 5 years due to interpersonal problems), can lead to greater reliance on health services to provide problem solving and emotional regulation in the absence of social/ family/ whanau support who would normally provide these services (Conklin and Westen 2005). These points linked to the stigmatization reported by clients on contacting health services can only compound issues, and lead to poor treatment outcomes (M.H.C. 1999)

The DSM IV (1994), did agree on several of the diagnostic criteria that appeared in the 20 items that were most descriptive of patients who receive a BPD diagnosis. These were rejection/ abandonment fears; unstable relationships, unstable identity, impulsivity, labile emotions, feelings of emptiness or boredom and intense anger (Shedler and Westen 2004).

All this together reinforces the point that diagnostic criterion sets should be expanded. This could then better address the complexities of clients with BPD. In doing this it could also look at integrating science and practice, and move away from constructs made to cement any one profession’s powerbase, or any one theoretical view point.

In this discussion about classification and definition there is also another point that cannot be ignored when looking at BPD. In Glas’s (2006) article there is an interesting point made. Definitions of disorder, as denoted in DSM IV, articulate distinctions between disorder and improper behaviour. Glas (2006) makes the point that mental health professionals, law makers and the general public may hold differing standpoints when drawing the boundary between evil and ill.

Furthermore, there are times when psychiatry is pushed into treating persons who have purely behavioural problems and do not conform to any given definition of personality disorder. This societal pressure may then lead mental health professionals to emphasis the objectivity and value the neutrality now encapsulated in the current DSM IV (1994) criteria (Glas 2006). It, therefore, may be argued that this lends a clear as possible distinction between personality disorder, on one hand, and an individual’s personality on the other. If only persons not personalities can be bad, then you can begin to understand why professionals focusing on disorder (functional deficits) can attempt to avoid moral evaluation of a patient’s behaviours.

In Charland’s (2006) work he opens by stating that moral considerations do not appear to play a large role in discussions of the DSM IV personality disorders, and debates about their “empirical validity” (p116).

Charland (2006) holds that Elliott’s (1996 cited in Charland 2006) argument that: “a person with a personality disorder who behaves badly ordinarily intends to behave badly and people should ordinarily be held accountable for what they have intended to do.” (p58).

As stated earlier, however you conceptualize and categorize people with BPD they test our intuitions about character and responsibility. The question is asked, if the behavioural syndromes denoted in DSM IV for BPD are genuinely empirically valid syndromes, does it follow that they should also represent empirically valid clinical syndromes? Incidently, the use of the word syndrome, not disorder here is because of the implication that disorders are seen as clinical conditions and by assumption have an aetiology, course and treatment (Charland 2006).

What is discussed here is that cluster B disorders as explained by DSM IV (1994) are moral disorders and although we can accept them as valid, it would have consequences for treatment of Cluster B clients; i.e. whether clinically trained professionals possess the inferred moral treatment skills that would be needed (Charland 2006).

Charland (2006) cites the language of DSM IV (1994) to back this claim. There are noted differences for Cluster B categories, e.g. “..lacking empathy, is unwilling to recognise or identify with the feelings of others” (APA 1994 pp.650 -651 cited in Charland 2006 p.122), “ inappropriate, intense anger and instability in interpersonal relationships” ( APA, 1994, pp.650-651 cited in Charland 2006 p.122), along with the idea that self-injurious acts are deliberate attention-seeking strategies (M.H.C 1999). What is being pointed out is that society generally finds these traits are morally reprehensible. Whereas the language used for other clusters is more straightforward: “almost always chooses solitary activities”, “takes pleasure in few if any activities” (, APA, 1994, p.641 cited in Charland 2006 p.122).

What is being said is these terms in cluster B disorders are moral in nature. This is not explicitly stated in DSM IV (1994), but is argued as implicit. The use of moral vocabulary is constitutive of the cluster B disorders and is therefore logically required for their identification.

Charland (2006) concludes his argument implying that either by explicit mention, or implication, clients diagnosed with cluster B personality disorders exhibit morally objectionable behaviour towards others, as perceived by society as a whole. In looking at treatment of BPD, a client must show a moral commitment to being patient and loving with both others and themselves. This is therefore seen as an essential ingredient of any serious treatment and cure. This is set against an example of CBT for phobias which calls for willingness, commitment and effort for therapies to succeed, but not the moral willingness to change as noted above for BPD.

This discourse attempts to make the point that cluster B personality disorders such as BPD are fundamentally moral conditions. This logically leads to the need for some sort of moral treatment. Pharmacology treatments for co-morbidity aspects such as low mood can have beneficial results. This can also lead to positive growth of both the client and their relationship with others, including clinicians. This said, Charland (2006) feels there is a “.. moral line in the sand that pharmacology apparently cannot cross” (p723).

His belief that for a full recovery BPD clients need to identify that there is a need for moral change in themselves, and the willingness to put in effort to change. He asserts that in the case of BPD patients the professional client relationship is perhaps where initial contracts can be used and even seen as goals. These could be standard parameters such as privacy, confidentiality and fidelity (Beauchamps and Childress 2001, cited Charland 2006). Amongst other things the therapist’s aim in the case of BPD is to convince their client to move towards being more truthful and honest, less manipulative, resentful and impulsive.

Beauchamps and Childress (2001, cited in Charland 2006), state that these are deeply human concerns and success can hinge for the most part on a therapist’s ability to conduct himself as a moral being. It is a moral initiative undertaken between two moral beings searching for a consensus on how to behave morally and respectfully towards one another.

The Mental Health Commission (1999) seems to back some of these ideas. They feel that treatment for BPD should be looked at in 3 stages:

1) Stabilization, safety and trust.
2) Emotionally expressive work (moral issues thrown up by past trauma issues.
3) Generalized change in the “wider community of the client”.
(p31)

They go on to outline Dialectic Behavioural Therapy (DBT) which also follows a 3 stage treatment strategy. What DBT does is indicate the importance of commitment and orientation to therapy, i.e. the moral contracting mentioned earlier. Also within the MHC (1999) paper it is underlined that the relationship building stage or engagement/ contracting stage is vital. They note that inexperienced therapists can move on to working through trauma issues too soon and lose the client. The trust and stability in the client-therapist relationship has not become strong enough to weather more indepth work than the goal setting mentioned earlier. This engagement period can take a long time and boundaries of contracts will be pushed. This can be the client feeling out how well the therapist is engaged in the process too.

Something else of importance that is noted in the MHC 1999 publication is the lack of identified Maori, and Pacific Island authorities on BPD to make comment on there experiences. They state that it would be inappropriate for Pakeha to do so. Crowe (2000) does however comment on differences between Maori and Western culture. She contrasts Western and Maori, stating that Maori do not place the same importance on the individual, rather with connections with others, and there environment. This has implications for treatment. DBT is very much about the individual, and his or hers sense of self. What this underlines is the narrow perspective persons who have the diagnosis of BPD are viewed from. That is predominantly a white western one.

Epstien (1999) a consumer with a history of BPD illuminates all of this for us. She states that her experience of undergoing the diagnosis of BPD was telling her that she was fundamentally inadequate as a human being and her whole being was wrong. Also she underlines the fact that the diagnosis BPD leads to notions held by professionals such as

1) The notion that PD’s are beyond redemption
2) The belief that PD’s are a management problem
3) The idea that self-injurous acts are deliberate attention-seeking strategies. (p39, MHC 1999).

Further more, manipulation, acting out, dysfunctional relationships and blame are standard descriptive tools used in both the DSM IV and general practice.

While all this is still in the culture of the health service and consumers point out that the “medical model” of care, which is dominant at this time have been notably inadequate, even facilitating a poorer outcome. What Epstien (1999) recommends is a change to psychology based programmes, and the change in attitudes of professionals towards BPD. Without this the ideas outlined in the above article would achieve little.

The feeling that these problems are insurmountable can be pervasive when reading around the subject of BPD, but is that catastrophizing the issue? The ideas put forward here appear possible. A change in focus of diagnosis which embraces both science and practice, and gives a fuller portrait of clients with BPD; and then a focus on the engagement process with clients which is of a meaningful, moral nature leading to systemic change in the client’s presentation. She recommends consumer-led staff education programmes alongside public anti-discrimination campaigns which are focussed on the severity and enduring nature of this disorder.
References

Charland, L C. (2006) Moral Nature of the DSM IV Cluster B Personality Disorders. Journal of Personality Disorders 20(2), 116-125

Conklin, C Z. Westen, D. (2005). Borderline Personality Disorder in Clinical Practice, American Journal of Psychiatry 162(5), 867-875.

Crowe, M. (2000). Psychiatric Diagnosis: Some Implications for Mental Health Nursing Care, Journal of Advanced Nursing 31(3), 583-589.

Crowe, M. (2000). Constructing Normality: A Discourse Analysis of the DSM IV, Journal of Psychiatric and Mental Health Nursing 7, 69-77.

DSM IV. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association Washington, DC.

Glas, G. (2006). Person, Personality, Self and Identity: A Philosophically Informed Conceptual Analysis Journal of Personality Disorders 20 (2) 126-138.

Kendell, R E. (2002). The Distinction Between Personality Disorder and Mental Illness, British Journal of Psychiatry 180, 110-115.

Kutchins, H. Kirk, S A. (1997). Making Us Crazy DSM: The Psychiatric Bible and the Creation of Mental Disorders. The Free Press. New York.

Krawitz, R. Watson, C.(1999). Boarderline Personality Disorder: Pathways to effective service delivery and clinical treatment options. Mental Health Commission publications.

Raingruber, B. (2002). Client and Provider Perspectives Regarding the Stigma of and Nonstigmatizing Interventions for Depression, Archives of Psychiatric Nursing. 15(5), 201-207.

Shedler, J. Westen, D. (2004). Refining Personality Disorder Diagnosis: Integrating Science and Practice, American Journal of Psychiatry 161(8) 1350-1365.

Spitzer, R L. Endicott, J. Gibbon, M. (1979). Crossing the Boreder into Borderline Personality and Borderline Schizophrenia. Archives General Psychiatry 36, 17-24.