In a recent lecture by Dr. Jerold Kreisman, author of what is widely considered a landmark book on Borderline Personality Disorder, I Hate You, Don’t Leave Me, he spoke of how Borderline Personality Disorder (BPD) has been perceived and diagnosed over the years, and how that perception and the criteria for diagnosis is changing.
History of BPD
Going back a century or more, Kreisman pointed out that perception of the behaviors characteristic of Borderline Personality Disorder have not been without stigma. The early cases of “hysteria” described by Breuer and Freud would probably now be diagnosed as Borderline Personality Disorder, though the term did not come into being until the 1930s.
Individuals displaying symptoms of Borderline Personality Disorder were often misdiagnosed as schizophrenic or bipolar, or found by some professionals to be simply difficult to work with. This is evidenced by an article published in the New England Medical Journal in 1978 titled “Taking Care of the Hateful Patient,” in which author J.E. Groves described patients displaying particular symptoms of BPD as being those “whom most Physicians dread.”
Over roughly the last two decades, a more empathetic relationship between professionals and individuals seeking treatment has emerged, including a way to diagnose those exhibiting the symptoms that can make daily life and interactions so difficult. The Diagnostic and Statistical Manual of Mental Disorders (DSM) now cites nine symptoms and criteria, five of which an individual must display in order to be diagnosed with Borderline Personality Disorder. Still, there are shortcomings in the process that need to be addressed.
“This is a categorical diagnosis,” said Kreisman. “The problem is that if one of those five symptoms goes away, the diagnosis disappears.”
A Changing BPD Diagnosis
An upcoming change in the diagnosis of Borderline Personality Disorder is coming with the new DSM-5, which will come out in May 2013. The new diagnosis will keep the categorical definition, but will also take into account, on a scale of one through 10, the level of how closely a patient matches the characteristic, which will help professionals in their diagnosis.
Kreisman also pointed out that, beyond the nine symptoms found in the DSM, “more cogent, colorful and more accurate descriptions are what our patients or individuals who are dealing with BPD tell us.” He cited a metaphor he often hears, “The idea of ‘having a monster inside’ or a sense of being ‘taken over with rage, impulsivity or self-destructiveness’ are common.”
Kreisman is troubled by the fact that, after all we’ve learned about Borderline Personality Disorder in the past 20 years, 10 to 25 percent who are in treatment will satisfy the criteria for BPD yet don’t have the diagnosis. They are either misdiagnosed or a co-occurring disorder is masking the BPD.
“If there’s a prominence of major depression or substance abuse, sometimes the underlying condition of BPD gets missed from recognition,” Kreisman said.
It is hoped that the change in the diagnostic criteria for BPD will also help those who suffer from a co-occurring disorder to not be misdiagnosed.
More hopeful yet is a new understanding of the outcome of individuals with Borderline Personality Disorder.
“Certainly until the past 10 or 15 years Borderline Personality Disorder has been thought to be a disorder that was ingrained in personality and would never get better,” said Kreisman. “That’s a discouraging syndrome to attempt to deal with, for both professionals and family members of the individual.”
Long-term studies now clearly show that is not the case, and that the majority of these individuals do get better over time with proper BPD treatment. These studies also show that almost all individuals affected by symptoms of BPD will have periods of remission, meaning that the individual no longer satisfies five of the nine defining criteria.
What caused this change in perception and outcome in such a relatively short period of time?
“We have developed techniques that have really helped us understand what these individuals are going through and also how to treat them,” said Kreisman. Those include Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), and holistic therapies such as yoga.
“You’ll find more commonalities than differences between these treatments,” said Kreisman. “They all try to curb destructive behavior, attempt to heal distorted views, and attempt to establish a supportive relationship with therapists while challenging maladaptive behaviors to help the individual deal with the world they live in.”
With all of the research being done on Borderline Personality Disorder and new advances being made, the future of BPD treatment looks promising.