Diagnosis: What are the new DSM-5.0 criteria for BPD?

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[Skip]

The DSM-5, due out in 2013, is anticipated to bring a number of changes to the definition of the personality disorders.  As I understand it, the working group is trying to do away with the complex multiaxial diagnostic approach and to make the personality disorders more discrete (less overlap) - basically the Axes I, II, III will be consolidated to one -- the 10 personality disorders will be reduced to 6 -- and PD will be "scored" on a rating system based on severity.

The basic DSM 5 description is actually simpler than the DSM-IV - it will look something like this (note: no 5/9 criteria)

1 Impairments  The must be impairments in self functioning AND impairments in interpersonal functioning (more on this later)

2 Negative Affectivity, characterized by:

• Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

• Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

• Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.

• Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.

3 Disinhibition, characterized by:

• Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

• Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.

4 Hostility:  Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

[Randi Kreger]

We’re all so used to the 9 traits of borderline personality disorder as defined by the American Psychiatric Association’s current DSM-IV-TR that it’s hard to imagine it changing—even though the DSM-IV-TR is controversial and plagued with problems. Yet we know it will because for many years the APA has been working not only for a new description of BPD but the entire DSM: the DSM-5 will be out in 2013.  

Now, we finally have a look at what they’re proposing.  

[Skip]

Maybe the greatest change for non-professionals like ourselves, is the first criteria -  the APA is attempting to clearly define the line between personality disorder and personality style.

Here is a more detailed look at #1 criteria.

1 Impairments  The must be impairments in self functioning AND impairments in interpersonal functioning (more on this later)

In the DSM 5, the essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:

Self (impairment in at least 1):

Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.  To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.   To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Interpersonal (impairment in at least 1):

Empathy*: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding of the effects of own behavior on others.    To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Intimacy*: Depth and duration of positive connections with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.   To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).


Below is the scale for "empathy".  There are four scales in total (identity, self direction, empathy, intimacy).  To me, it is facinating to see "empathy" defined in such clear terms.

Healthy (0) Capable of accurately understanding others’ experiences and motivations in most situations. Comprehends and appreciates others’ perspectives, even if disagreeing.  Is aware of the effect of own actions on others.

Mild impairment (1) Somewhat compromised in ability to appreciate and understand others’ experiences; may tend to see others as having unreasonable expectations or a wish for control. Although capable of considering and understanding different perspectives, resists doing so. Inconsistent is awareness of effect of own behavior on others.

Impaired (2) Hyper-attuned to the experience of others, but only with respect to perceived relevance to self. Excessively self-referential; significantly compromised ability to appreciate and understand others’ experiences and to consider alternative perspectives. Generally unaware of or unconcerned about effect of own behavior on others, or unrealistic appraisal of own effect.

Very Impaired (3) Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others’ experience, particularly vulnerabilities and suffering.  Generally unable to consider alternative perspectives; highly threatened by differences of opinion or alternative viewpoints. Confusion or unawareness of impact of own actions on others; often bewildered about peoples’ thoughts and actions, with destructive motivations frequently misattributed to others.

Extreme Impairment (4)  Pronounced inability to consider and understand others’ experience and motivation. Attention to others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm avoidance).  Social interactions can be confusing and disorienting.


Here is the scale for intimacy.  There are four scales in total

Healthy (0) -Maintains multiple satisfying and enduring relationships in personal and community life. Desires and engages in a number of caring, close and reciprocal relationships. Strives for cooperation and mutual benefit and flexibly responds to a range of others’ ideas, emotions and behaviors.

Mild impairment (1) -Able to establish enduring relationships in personal and community life, with some limitations on degree of depth and satisfaction.Capacity and desire to form intimate and reciprocal relationships, but may be inhibited in meaningful expression and sometimes constrained if intense emotions or conflicts arise. Cooperation may be inhibited by unrealistic standards; somewhat limited in ability to respect or respond to others’ ideas, emotions and behaviors.

Impaired (2) Capacity and desire to form relationships in personal and community life, but connections may be largely superficial. Intimate relationships are largely based on meeting self-regulatory and self-esteem needs, with an unrealistic expectation of being perfectly understood by others. Tends not to view relationships in reciprocal terms, and cooperates predominantly for personal gain.

Very Impaired (3) Some desire to form relationships in community and personal life is present, but capacity for positive and enduring connection is significantly impaired. Relationships are based on a strong belief in the absolute need for the intimate other(s), and/or expectations of abandonment or abuse.  Feelings about intimate involvement with others alternate between fear/rejection and desperate desire for connection. Little mutuality: others are conceptualized primarily in terms of how they affect the self (negatively or positively); cooperative efforts are often disrupted due to the perception of slights from others.

Extreme Impairment (4)  Desire for affiliation is limited because of profound disinterest or expectation of harm.  Engagement with others is detached, disorganized or consistently negative. Relationships are conceptualized almost exclusively in terms of their ability to provide comfort or inflict pain and suffering. Social/interpersonal behavior is not reciprocal; rather, it seeks fulfillment of basic needs or escape from pain.


The remaining scales are listed here:  dsm5.org/ProposedRevisions.aspx?rid=468

[GENERAL ANNOUNCEMENT]

GENERAL ANNOUNCEMENT This board is intended for general questions about BPD and other personality disorders, trait definitions, and related therapies and diagnostics. Topics should be formatted as a question. Please do not host topics related to the specific pwBPD in your life - those discussions should be hosted on an appropraite [L1] - [L4] board. You will find indepth information provided by our senior members in our workshop board discussions (click here).

[an0ught]

My late father showed a lot of empathy when we were kids to us and to others. As did the two BPDs I was and were involved with. But as the illness progressed it got worse and my sister described my father as sociopath. My warm and giving ex gf became extremely demanding. My wife focused on coping and raged. One characteristic of BPD (as currently understood) is high sensitivity and this sensitivity in combination with lack of emotional regulation is the breeding ground for trouble. Often BPDs are found in caring jobs.

So the lack of empathy in diagnostic criteria may be a good characteristic of later severe clinical cases but misleading or wrong in sub-clinical and earlier phases.

This illness is a chameleon. Any static system describing the color is flawed.

[Randi Kreger]

You may know that borderline personality disorder is currently known as an “axis ll” disorder, a “permanent state” disorder and not a “temporary trait” disorder.

Randi

[GCD145]

Below is the scale for "empathy".  There are four scales in total (identity, self direction, empathy, intimacy)

Healthy (0) Capable of accurately understanding others’ experiences and motivations in most situations. Comprehends and appreciates others’ perspectives, even if disagreeing.  Is aware of the effect of own actions on others.

Mild impairment (1) Somewhat compromised in ability to appreciate and understand others’ experiences; may tend to see others as having unreasonable expectations or a wish for control. Although capable of considering and understanding different perspectives, resists doing so. Inconsistent is awareness of effect of own behavior on others.

Impaired (2) Hyper-attuned to the experience of others, but only with respect to perceived relevance to self. Excessively self-referential; significantly compromised ability to appreciate and understand others’ experiences and to consider alternative perspectives. Generally unaware of or unconcerned about effect of own behavior on others, or unrealistic appraisal of own effect.

Very Impaired (3) Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others’ experience, particularly vulnerabilities and suffering.  Generally unable to consider alternative perspectives; highly threatened by differences of opinion or alternative viewpoints. Confusion or unawareness of impact of own actions on others; often bewildered about peoples’ thoughts and actions, with destructive motivations frequently misattributed to others.

Extreme Impairment (4)   Pronounced inability to consider and understand others’ experience and motivation. Attention to others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm avoidance).  Social interactions can be confusing and disorienting.

So, now there is a formula for rating impairment.  I find this proposal quite interesting.  It tackles the subjective nature of trying to diagnose these personality disorders, and the difficulty of even defining what the traits are.

Sometimes, I think we get too hung up on having a diagnosis.  We want it either because we hope for a cure for our pwBPD, or to give ourselves permission to give up.  

GCD145

[Matt]

I have just one simple comment and one simple question:

The comment is, I really wish they would change the name!  It's so misleading and confusing - one more barrier to acceptance by the sufferer.

The question is - and forgive me if this was explained already but I want to make sure I understand - by this system, would it be more likely that treatment would be covered by insurance?

Thanks!

Matt

[Skip]

I really wish they would change the name!

A name change got lobbied pretty hard by the patient community.

My guess is that they didn't want to lose the connection to the recently completed large studies (and studies in process), the advocacy work done with Congress in declaring BPD awareness month, and the gains made with the insurance industry.  In fact, it seems that they are trying to leverage these gains to help with the other PDs that were previously classified separately.

It may have been just a very practical decision.

[Randi Kreger]

So, now there is a formula for rating impairment.  I find this proposal quite interesting.  It tackles the subjective nature of trying to diagnose these personality disorders, and the difficulty of even defining what the traits are.

The people who I talk to assume there will be lots of professional education to help people with whatever system they come up with. There has to be. Probably various books and seminars and such.

I'm not surprised the name wasn't changed. I didn't like the alternatives because they focused on emotion and made it seem like a mood disorder, and we all know it's more complex than that!

Randi
 

[Skip]

Summing it up...

Good comments, all.  

In summing up what we have learned so far, here is how the pieces fit together.  To be BPD all three must be true.  Anything less is not BPD per se' but rather "BPD leanings, or BPD style, or subclinical BPD, or "high functioning BPD".

(1) A rating of mild impairment or greater on the Levels of Personality Functioning

(2) A “good match” or “very good match” to a Personality Disorder Type (see BPD type)  

(3) Relative stability of (1) and (2) across time and situations, and excludes culturally normative personality features and those due to the direct physiological effects of a substance or a general medical condition.

[sandpiper]

I think there will be a lot of failings in the revised criteria until the psychiatrists start listening to the families of the BPD. Until they do this, they simply won't get the real picture of what's happening with the BPD. All they are seeing is what presents in their office, or what presents for the studies.

I learned more about the illness from other adult children of a BPD when I found this place around five or six years ago. What shocked me was that one of us would open up a topic about something we thought could never have happened to another human being, and suddenly there would be an outpouring of 'Oh My God!  My BPD mother/father did exactly the same thing.'

It frustrates me that there's no mention of what goes wrong when they have children. The change - and by change I mean deterioration - in my uBPDsister's behaviour after she had children - was something to behold.

I know they're trying, but they've got a long way to go to understand this illness.  They won't get it until they listen to the families.   Too much happens behind closed doors that the BPD's therapists would never DREAM was going on.

[Matt]

These are interesting thoughts, Sandpiper.

Most diseases don't have victims!  Doctors focus on helping their patients, and medical researchers often have that focus too;  you don't examine a family member to figure out what's wrong with someone's leg, or lungs.  You examine the patient.  But for BPD a reasearcher would have to be part doctor and part sociologist - not psychologist - because to understand it fully you have to look at the interactions between family members (or others close to the BPD sufferer), and I think that may be outside the scope of most medical researchers.

[UKannie]

These are interesting thoughts, Sandpiper.

Most diseases don't have victims!  Doctors focus on helping their patients, and medical researchers often have that focus too;  you don't examine a family member to figure out what's wrong with someone's leg, or lungs.  You examine the patient.  But for BPD a reasearcher would have to be part doctor and part sociologist - not psychologist - because to understand it fully you have to look at the interactions between family members (or others close to the BPD sufferer), and I think that may be outside the scope of most medical researchers.

That's interesting. I think there are some parallels here with conditions such as schizophrenia (which my Dad has; my mother is uNPD/BPD) where the patient's family can be left in a situation where they are living with a person whose symptoms are too severe for them to cope with. There were phases where my Dad was unable to be an effective parent (although he  never harmed us) and could not be left alone with us as children.

I think there are child protection implications when a parent has any kind of severe mental health condition. I hope the new DSM document recognises that when an adult is diagnosed with a PD, there is a significant risk that their children will be abused and/or neglected. Especially because so many adults with PDs seem to have a sadistic streak.

Annie xoxo

[Skip]

Just a small point  

The DSM is published by the American Psychiatric Association.

It provides definitions, symptoms and characteristics for mental disorders that are recognized by clinicians from around the world.  

It's simply a classification system.  The equivalent of "a heart attack is defined as" or "stroke is defined as".  This is really important for research, for example, so that a study of people with BiPolar I disorder at Harvard is looking at the same type of patients that a study of of BiPolar I at UCLA is.  This way the findings can be compared by clinicians and used by future researchers to design more advanced analysis.

The DSM does not discuss diagnostic methods per se', there is no discussion, for example, about the use of the SCIDII questionairre.  The DSM does not discuss treatment, social implications, the impact on families, etc.  All very important things - just not the charter of the DSM.

In this next addition, it appears that they want to simplify things - that maybe the 10 Axis II categories were too hard to work on a practical level - or there was too much overlap - and that appears to be what they have done.

[Matt]

The DSM-IV uses, if I remember right, nine criteria for BPD.  It's these criteria that are being discussed here, I think...

That is, the DSM defines disorders according to observable behaviors;  but the current criteria include some that aren't directly observable, but depend on the patients description of his or her feelings, state of mind, etc.  Maybe that's impossible to avoid in this field.

What I think is being suggested here - and I agree with it, I think - is that, as a scientist, the psychologist has access to other information, which may be as reliable, or more so, than the patient's description of his or her behavior and what's going on in their head.  In another scientific field, the scientist would look at any reliable information available to understand the phenomenon.  Because this is a medical field, and there is a strong tradition - and maybe considerations of "ethics" - in the way of the doctor talking openly with family members and others whose inputs might be meaningful - that make it tough for doctors to get it right.

[Skip]

Clinical Practices: There is nothing in the DSM that discusses how the information is to be gathered.   There is nothing in the DSM that precludes asking family member, co-workers, or friends.  And depending on the situation and the clinician this is often done.  Family therapy is not uncommon.  Nor are parent meetings with their child's clinician uncommon.  

Research Studies: Most research studies rely on patient surveys to determine the disorder. This is a significant aspect what psychology research - building of reliable diagnostic questionairres.  The questionairres themselves are tested against populations that have been diagnosed by in detail psychoanalysis to determine there accuracy.  Eventually, they find the right questions that can accurately reproduce what an detailed patient analysis can do (more or less).

This is why it is called the Diagnostic and Statistical Manual.  

Hope this helps  

[Matt]

There's nothing in the DSM preventing doctors from gathering information in a variety of ways.  My (minimal) observation suggests that there are traditions and role-definitions that can interfere with it though.  (So that's outside the scope of the DSM discussion per se, but related because the DSM definitions are in terms of behaviors which aren't entirely observable from testing or talking with the patient alone.)

Example:  The therapist views her role as helping the patient.  A diagnosis of BPD may not be in the patient's interest, because the patient is likely to reject the diagnosis and cease therapy.  So the therapist avoids objective testing and looks for ways to help the patient without fully understanding the disorder.  Meantime, family members are hurt by the patient's behavior, but have nothing solid to use to change the family situation - no diagnosis or clear input from the therapist.  By defining her role as "helping the patient" not "helping the kids" or "helping the family", the scientist comes to a different, or a more vague, conclusion and takes actions which may be less effective.  (This is a real example, by the way, not made up.)

I'm not condemning the DSM or saying it should be different - I really don't know - only building on some of the comments here that somehow the way BPD is diagnosed just simply doesn't always work in the real world.

[noahetal]

Great points raised by all-
I was told recently by a psycho analyst that they were considering changing the name from borderline to "emotional affect regulatory disorder" It's a mouthful but it is certainly more descriptive than "Borderline". I find it frightening that they are telling doctoral candidates( at least a few here in California ) to not code anyone as Axis II not only because of the potential stigma but because insurance won't pay for treatment. This throws the whole data collection  process and resulting statistics ( you know, 2-4% borderlines.3-5 % narcisssists,etc..)out the window. Without proper stats,we will never know the true scope of the problem. As many of you probably know or suspect , there are a lot more Axis II sufferers amongst us than the literature would have us believe and...no..I'm not paranoid         

[Nutts45]

By defining her role as "helping the patient" not "helping the kids" or "helping the family", the scientist comes to a different, or a more vague, conclusion and takes actions which may be less effective.

The latest trend in BPD treatment is to involve the family more and more.  The NEA-BPD Family Connections program is all about treating the BPD family and the BPD environment.

[Randi Kreger]

Great points raised by all-
I was told recently by a psycho analyst that they were considering changing the name from borderline to "emotional affect regulatory disorder"

I find it frightening that they are telling doctoral candidates( at least a few here in California ) to not code anyone as Axis II not only because of the potential stigma but because insurance won't pay for treatment. This throws the whole data collection  process and resulting statistics ( you know, 2-4% borderlines.3-5 % narcisssists,etc..)out the window.
  

Strangely, I have heard no wails from the typical people about the fact the name wasn't changed. I think people were too happy and the axis l and ll merger and the new stats.

But I disagree with the popular new name propositions that stress emotional dysregulation.  It would make it even harder for average folks to understand the difference between bipolar and BPD and that comes up in so many interviews I do. If we picked just one BPD trait it could just as well be identity disorder or fear of abandonment disorder.

The latest figures that raised the percentage of BPs from 2% to 5.9% were done by looking at large scale surveys, not hospital data. But the figures about BPD as a percentage of outpatients and inpatients ARE affected. Once wonders.

Randi Kreger
Author, "The Essential Family Guide to Borderline Personality Disorder "