PYC4802 Psychopathology Assignment - Borderline Personality Disorder, University of South Africa, South Africa

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Essay Question - Provide a comprehensive discussion on problems/challenges experienced by clinicians in identifying and diagnosing Borderline Personality Disorder.

1. Introduction

The following essay will explore the criteria that are concerned with the identification and diagnosis of borderline personality disorder, and will also take into account, the major challenges and problems that are faced during the process. The issue, borderline personality disorder, is technically classified as being a complex personality disorder, which entails a significant amount of negative responses even from professional caregivers, despite it all, has contributed to being one of the most intensive fields for studies related to personality disorders.

2. DSM-5 diagnostic criteria for Personality Disorders

There are 10 kinds of personality disorders that are identified by the DSM-5 (American Psychiatric Association, 2013). They can be discussed briefly as indicated below -

Paranoid personality disorder

This condition is one where the patients suffer from paranoia, have a strong sense of mistrust, and are always suspicious of the intentions of others, even though there may be no reason to be so (Burke, 2014). This disorder commonly begins in early adulthood and is predominant among men as compared to women.

Schizoid personality disorder

This condition is characterised by a degree of indifference to social relationships, coupled together with limited emotional expressiveness, as well as experience. This condition usually manifests itself through social and emotional detachments in early adulthood, and although the patient can function normally in their daily life, there is a limited ability when it comes to forming meaningful relationships with others (Burke, 2014).

Schizotypal personality disorder

Schizotypal personality disorder manifests itself as odd and eccentric behaviour among individuals, who often have few close relationships with other people. They have limited understanding of how their behaviour impacts others, and also have the tendency for misinterpreting the behaviours and motivations of others, as they are significantly suspicious and distrustful.

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Antisocial personality disorder

This denotes an ingrained behavioural pattern where the individual has a persistent disregard for the rights of those around them, and often violates them (Burke, 2014). Its onset is usually during early adulthood and adolescence, and is characterised by a lack of remorse, impulsivity and recklessness, aggression and irritability, and an overall irresponsible behaviour.

Borderline personality disorder

This is a mental health disorder that has an impact on the way the individual thinks and feels about themselves as well as others, and it often causes problems when it comes to everyday functioning. Borderline personality disorder is characterised by intense and unstable relationships, impulsiveness, extremes of emotions, and a distorted sense of self-image (Burke, 2014).

Histrionic personality disorder

Individuals with histrionic personality disorder have a very unstable sense of self-worth, and their self-esteem is largely dependent on the approval of the others. It does not stem from a feeling of self-worth in the true sense (Burke, 2014), and they also inhibit this desire to be noticed by others, often resulting in dramatic or theatrical actions in an attempt to get the attention of the others.

Narcissistic personality disorder

People with narcissistic personality disorder have an inflated sense of importance regarding their own selves, and have an excessive need for admiration as well as attention. This disorder is characterised by troubled relationships, little or no empathy for others, and a fragile self-esteem that is masked by massive levels of confidence, which gets wounded at the slightest amount of criticism.

Avoidant personality disorder

Individuals with this disorder have a very poor sense of self-esteem, often marked by fear and nervousness. The fear of being rejected is extremely high, and they also have massive anxiety regarding negative judgement (Burke, 2014). This makes such people extremely uncomfortable in social situations, and they tend to avoid social contact and activities in a bid to elude being judged or criticised.

Dependent personality disorder

This is a personality disorder that is characterised by the inability to be alone, as the individuals get very anxious when they are not around people. They have a heavy reliance on the people for advice, reassurance, comfort and support, and often feel insecure in their relationships with others. They are by nature submissive, get hurt easily from disapproval, and feel extremely nervous and isolated when left alone.

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Obsessive-compulsive personality disorder

This disorder is characterised by extreme forms of perfectionism, cleanliness, neatness, and order. These individuals also have the persistent need to impose their personal standards or rules on others, and often find it difficult to express their feelings (Burke, 2014). They can also have disturbed relationships and are subject to social isolation.

As far as the diagnostic criteria are concerned, the DSM-5 outlines several aspects, which form the general criteria that determine the diagnosis for a personality disorder. The most important feature is the impairment in the personality of the individual, and the external appearance of specific personality traits (Burke, 2014; American Psychiatric Association, 2013), such as those described above.

1. There must be some form ofimpairment in the trait expression and the personality functioning of the individual, which are typically stable over time and are consistent in different situations.

2. The normative understanding of the impairment of the personality trait and personality functioning is no better when correlated with the socio-cultural environment and the developmental stages for the individual.

3. The impairments in the personality trait and personality functioning are not the direct result of the physiological effects of any substance such as drugs, trauma and the like.

In case of borderline personality disorder, the DSM-5 criteria are the presence of specific pathological personality traits, and impairment in the overall personality. The impairments in terms of personality functioning can be either personal or interpersonal (American Psychiatric Association, 2013).

Personal (self): A poorly developed, often impoverished sense of self-image, that is highly unstable in nature, with a tendency to be excessively critical of oneself. It is also often characterised by high levels of self-criticism, feelings of chronic emptiness, and a dissociative state when under high stress. There can also be major instability in terms of goals, values, aspirations and career plans.

Interpersonal: Individuals are often characterised by a compromised ability to understand or recognise the feelings of other people, which is related to interpersonal hypersensitivity. In terms of intimacy with others, relationships with close people are often intense, dramatic and unstable, and are prone to neediness, mistrust, preoccupation with anxiety, abandonment (whether real or imaginary), and extremes of emotion (Von Krosigk, 2014). Such individuals often view relationships in a very ideal manner, and alternate between withdrawal and excessive involvement.

The pathological personality traits can be explained or diagnosed as per the following domains: negative affectivity, disinhibition, and antagonism.

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Negative affectivity -

1. Emotional liability:Emotional experiences are highly unstable, coupled with very frequent mood changes. Individuals have emotions that can be roused very easily and with a high amount of intensity, which is sometimes not in proportion to the circumstances or situations.

2. Anxiousness:Individuals are characterised by intense bouts of nervousness, panic or tenseness, which are mostly in reaction to interpersonal stress. They also have the tendency to be worried about the past negative experiences and the future possibilities, often feeling apprehensive, fearful and uncertain, with a fear of losing control or even falling apart.

3. Separation anxiety:This entails a fear of rejection, especially from a significant other, and is associated with excessive dependency, and loss of autonomy.

4. Depressivity:Individuals are frequented by feelings of misery, hopelessness and being "low" and find it exceedingly difficult to recover from such emotional bouts or mood. They are usually pessimistic about the future, have a rather low level of self-worth, and are often plagued with suicidal thoughts or behaviours (American Psychiatric Association, 2013).

Disinhibition -

1. Impulsivity:Individuals have the habit of acting impulsively in the heat of the moment, almost as a response to stimuli, and the action is usually momentary without any plan or regard for the outcome. There is also a marked difficulty in terms of following or constructing plans, together with a sense of urgency and sometimes a tendency to inflict self-harm.

2. Risk-taking: They engage in activities that are risky, dangerous and potentially life-threatening without much thought about the consequences. There is also a lack of concern regarding the thoughts of others, and the practical danger associated with the personal self.

Antagonism -

Hostility: Individuals are characterised by angry feelings on a frequent basis, along with irritability towards minor insults and slights.

The impairments as explained above are usually stable over a given time period, and are quite consistent across the numerous situations. They are also not the side-effects of any physical change, such as medications or drug abuse (American Psychiatric Association, 2013).

3. Problems related to identifying Borderline Personality disorder (BPD).

Borderline personality disorder has been previously indicated as ambulatory schizophrenia, or psychotic character disorder, or pseudoneurotic schizophrenia, and it was later officially termed as its current name (B.J. Sadock, V.A. Sadock,& Ruiz, 2015; Kernberg & Michels, 2009). This differentiation was necessary since it is very different from schizophrenia, as the psychotic episodes are a lot less prolonged, and the patients are quite stable as they undergo little or no change over time. Studies show that borderline patients do not degenerate towards schizophrenia, but the condition is associated with episodes of major depression disorder. This is one of the reasons why antidepressants are commonly used for controlling the condition.

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The understanding of borderline personality disorder is rather poor, which makes it rather difficult to treat the condition. Accounts by numerous therapists and scholars state that it is difficult to treat patients with this disorder due to the low levels of response, and also because the chances of not developing a trustworthy and therapeutic relationship with the caregiver are quite low. There has also been a certain amount of stigma attached to the identification and the subsequent treatment of this illness, making it all the more difficult for the patients to avail quality care or aid in the form of professional help. This has also hampered the attempts to study more on the issue, and in discovering newer methods for more effective diagnosis (Gunderson, 2009).

Schizophrenia was believed to be the applicable category for borderline personality disorder, and it was treated as a form of psychopathology. It was definitive of characteristics such as identity diffusion, splitting, projective identification, and lapses in terms of reality testing. There were however doubts pertaining to the recognition and identification of the patients, as clinicians could observe specific patterns in terms of their behaviour, such as instability in a very stable manner, a desperate need for attachment to others, and the tendency to split or abandon those issues that were fearful or anxiety-inducing. The patients were typically very emotional, needy, and were not very psychotic except for certain isolated episodes or incidents. They had high risks of committing suicide, and were prone to escaping problematic situations in whatever way possible.

There has also been a certain degree of unconscious guilt associated with the behaviour of borderline patients (Kernberg & Michels, 2009), and the therapists' advice is sometimes interpreted as being malicious due to the patient's tendency to identify themselves with sadistic and primitive entities (Porr, 2010). This makes borderline patients extremely opposed to any form of therapy or treatment, and often exhibit negative results due to the counter-transference dislike or hatred. It was not until 1980 that borderline personality disorder was recognised officially by the DSM system, and subsequent research indicated that it was more like an internally persistent syndrome that was coherent in nature, and was majorly different from depression and schizophrenia by numerous parameters.

Another major issue that is associated with the identification of borderline personality disorder is that it is often linked to childhood abuse, both sexual and physical (Kernberg & Michels, 2009). Rebellious and defiant young teenagers can often be unidentified patients of this illness, and in more than 70 per cent of the cases, such instances have been unearthed. Furthermore, borderline has around a 30 per cent comorbidity with post-traumatic stress disorder (Gunderson, 2009), which is often misdiagnosed and thus results in unreliable and ineffective attempts of treatment.

4. Problems related to diagnosing Borderline Personality Disorder (BPD).

Psychotic patients often are characterised by defects in reality testing, chaos, and disorganisation, which is often absent for borderline patients, while they possess traits common with that of neurotic patients such as the lack of stability in relationships, and low levels of integrity (Kernberg & Michels, 2009). Goodman, Hazlett, New, Koenigsberg, and Siever (2009) even describe it as a variant of bipolar disorder, which is in fact a mood disorder and therefore quite different from personality disorders. Many clinicians view it as a disorder of impulse control, where the patient is often driven by impulses into aggression (Kernberg & Michels, 2009).

There are around 256 combinations of symptoms that can possibly arise when it comes to diagnosing a patient with borderline personality disorder, which can therefore make the task a very problematic and challenging one. Physicians have a very limited amount of time within which they have to diagnose the patients, which implies that they have to search for a few specific indicators that they can use for identifying the problem (Biskin& Paris, 2012). These factors further help the clinician get an estimate of how much care is required.

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Furthermore, the diagnosis of borderline personality disorder can be an overall difficult task as it is very similar to many mood disorders, among numerous other conditions. Biskin and Paris (2012) have stated that around 70 per cent of cases that were diagnosed were among women, and the prevalence becomes prominent during late adolescence. However, there is quite a disproportionate amount of patients who have still not been diagnosed with efficiency, or have been misdiagnosed in practice.

The most commonly identified symptom of borderline personality disorder is that of impulsiveness. This can be easily identified by most clinicians, but there are still problems with diagnosis. Most psychiatric wards and assessment centres are frequented by individuals, who have made suicide attempts. This can be further corroborated by the fact that around 78 per cent of borderline patients have a tendency to be suicidal, while more than 90 per cent of the people regularly engage in self-harm (Biskin& Paris, 2012; Oldham, 2009). One of the most noticeable characteristics of this disorder is persistent cutting, often together with recurring episodes of prescription drug overdose, all as coping mechanismsfor stressful situations. Repeated admissions to the emergency room due to suicide attempts is a strong indication for diagnosis, and more than 50 per cent of the patients meet this criteria.

Within this spectra of self-harm and impulsive behaviour are also included binge eating, spending excessive amounts of money, gambling, and sexual promiscuity. There are also several other symptoms that might make it easier for the psychiatrist to diagnose the personality disorder, such as substance abuse, and alcohol overuse or dependence. More than 50 per cent of borderline patients are prone to drinking in copious amounts. It also accounts for an increase in the chances of suicide attempts for the individuals.

The most important problem or challenge that is present when diagnosing an individual with borderline personality disorder is if the symptoms or difficulties have been persistent for a year, especially in the case of adolescents. Sudden changes in the personality functioning, or the occurrence of new symptoms, indicate lesser chances of the individual being borderline (Biskin& Paris, 2012).

The symptoms of borderline personality disorder often overlap with those of other numerous psychiatric disorders. This further toughens the challenge of diagnosing the problem correctly. It is necessary to conduct a careful evaluation for clarifying the clinical picture. Clinicians often focus on just one symptom and therefore end up with misdiagnosis, and this is very common as the illness cannot be verified or supported with the help of imaging or laboratory results.

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Another important facet is facing difficulties in multiple arenas. For instance, the chances of suffering from borderline personality disorder is less for those who have suicidal tendencies or harm themselves without any issues related to their moods, relationships, or emotions. On the other hand, a history of suicidal tendencies or attempts, together with chronic feelings of misery, emptiness or anger, and impulsive substance abuse, is more likely to point in the direction of a promising diagnosis.In case the diagnosis of the problem has been unsuccessful, there are chances that the individual would end up being diagnosed for multiple issues, which may not respond to common treatments (Biskin& Paris, 2012). This is yet another challenge that needs to be overcome in the diagnosis of this condition. However, the silver lining in this case is that there have been numerous new interventions that have sprung up in the past one to two decades, which have helped many patients suffering from this illness. Managing as well as diagnosing patients have become a lot easier with time, although there is a significant amount of progress that is yet to be achieved.

Recent studies indicate that a hyperactivity of the amygdala has a possible correlation with hypersensitivity in terms of interpersonal behaviour, which implies that it is possible to treat borderline personality disorder as being pathological in nature (B.J. Sadock, V.A. Sadock,& Ruiz, 2015). Furthermore, proof that prolonged psychotherapy acts as an agent that has the potential to modify the functioning of the brain in terms of memory and long-term learning exists, and although this might be effective for this disorder, the biggest obstacle that borderline patients face is their tendency to choose instant gratification rather than achievement that takes a little longer time.

5. Conclusion

It is quite evident that there has been a significant amount of criticism, both negative and constructive, associated with the research on borderline personality disorder, despite the many different connotations associated with the illness. What was once a misunderstood and misinterpreted personality disorder due to lack of research has now become one that can be identified, diagnosed and treated in a significantly better manner. Psychiatrists and psychologists have the responsibility to continue the research and unearth newer and more innovative methods of identifying and diagnosing patients, in addition to treating them in a more effective manner. Individuals suffering from this personality disorder have every right to get the assistance as well as guidance when it comes to professional help, so that they can improve their cognitive functioning and emotional behaviour in an attempt to achieve balance in their personal lives.

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