Typically in Victoria, The Diagnostic Statistical Manual (the DSM-5 is), used to diagnose BPD. The DSM is produced by the American Psychiatric Association. BPD first appeared in the DSM in 1980. Since then there have been some changes, the most recent move to change to 'emotional dysregulation disorder', was unsuccessful
The last DSM, no 5, was issued in 2013.
What are the criteria? The DSM-5
Patients must meet five of nine criteria in order to be diagnosed with BPD. Patients who partially, but incompletely, meet this criteria set may be considered to have borderline personality traits or features.
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
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).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Another way to diagnose:
The ICD-11 Classification of Mental and Behavioural Disorders, World Health Organisation, Geneva was first compiled in 1992 and is updated annually.
The International Classifications of Disease (ICD) is the work of the World Health Organisation. The ICD-11 uses dimensional criteria to diagnose BPD. It looks at the ability of the person to function and allows for a level of severity to be specified. The level of severity ranges from subthreshold personality difficulty to mild, moderate, or severe personality disorder.
This is a dimensional approach. The five dimensions are:
1. Negative affectivity - a tendency to experience a broad range of negative emotions.
2. Detachment - a tendency to maintain interpersonal distance and emotional distance.
3. Dissociality - a tendency to disregard the feelings of others, self centredness and lack of empathy.
4. Disinhibition - a tendency to act rashly without consideration of consequences.
5. Anakastia - a tendency to focus on one's narrow standards of perfection, right and wrong, controlling one's own behaviour and the behaviour of others.
What causes BPD? It's nature and nurture of course.
It is commonly accepted that there are genetic risk factors and environmental risk factors. However there are a range of differing theories about how BPD develops. A study of the data indicates that BPD appears to be moderately heritable and to involve a complex interplay between biological and environmental factors.
Interestingly, “Social factors in BPD are suggested by indirect evidence. Thus far, there have been no cross-cultural studies of BPD, although characteristic symptoms such as recurrent suicide attempts are less common in traditional societies, in which there is little change from one generation to the next, but are on the increase in modern societies and in societies undergoing rapid change.” (Paris, Dr Joel: CMAJ June 7, 2005 vol. 172 no. 12 doi: 10.1503/cmaj.045281)
What does Borderline mean?
The term was first coined in 1938 with a description of the diagnostic criteria by the American psychoanalyst Adolph Stern. He described the people with BPD as being on border of neuroses and psychosis.
There is much debate about the appropriateness of the name, which will probably continue. While the DSM 5 continues to use the descriptor Borderline Personality Disorder, so will we here in Victoria.
How common is BPD?
The research data is out of date and inconsistent, however it suggests a range from 1% - 6%. Currently BPD is not even counted in the national health and wellbeing data, and the last prevalence research done here was in 1980.
A person with BPD commonly has other mental health issues, for example anxiety, depression, drug abuse disorder, eating disorders, PTSD and other personality disorders are amongst the most common. Patients with BPD need treatment specific to the disorder, whatever comorbidities they have. Unless the BPD is treated, the other mental illnesses cannot be successfully treated.
Is it hard to diagnose BPD?
There are a number of diagnostic tools for BPD and it does not have to be difficult to diagnose. Often however, BPD is misdiagnosed as Complex Post Traumatic Stress Disorder or Bi Polar. Sometimes a person is said to have BPD traits. Sometimes a diagnosis is made and not disclosed. All these factors cause unnecessary distress to people with BPD and their families. For these people getting a diagnosis and understanding what it means is the first step towards recovery.
Is a cure possible? Yes.
To talk of a ‘cure’ vs ‘recovery’ is to engage in semantics. If we consider that our brains are plastic and we can change our brains, then what would be considered a cure, is a realistic possibility.
Is recovery possible? Yes.
There are many people who have recovered from BPD and live full and happy lives. Some of these people suffered immensely from the disorder and from mistreatment. An especially famous person who had BPD is Marsha Linehan who developed Dialectical Behaviour Therapy (DBT).
What treatment works?
Effective structured therapies share the following characteristics:
The therapy is based on an explicit and integrated theoretical approach, to which the therapist (and other members of the treatment team, if applicable) adheres, and which is shared with the person undergoing therapy.
The therapy is provided by a trained therapist who is suitably supported and supervised.
The therapist pays attention to the person’s emotions.
Therapy is focussed on achieving change.
There is a focus on the relationship between the person receiving treatment and the clinician.
Therapy sessions occur regularly over the planned course of treatment. At least one session per week is generally considered necessary.
Structured psychological therapies are effective when delivered as individual therapy or as group therapy.
For the psychological approaches shown to be effective in randomised clinical trials, the duration of treatment ranged from 13 weeks to several years. In clinical practice, some therapies are usually continued for substantially longer periods. For further information please follow the link.
What are the names of successful treatments?
Evidence shows that the following types of treatment can be successful:
Dialectical Behaviour Treatment (DBT)
Dialectical Behaviour Therapy Standard Treatment (DBT ST)
Cognitive Behavioural Therapy (CBT)
Dynamic Deconstructive Psychotherapy (DDP)
Manual Assisted Cognitive Therapy (MACT)
Mentalisation Based Therapy (MBT)
Motive Oriented Therapeutic Relationship (MOTR)
Schema Focussed Psychotherapy (SFT)
Systems Training for Emotional Predictability and Problem Solving (STEPPS)
Transference Focussed Psychotherapy (TFP)
The treatments below have not been compared with treatment as usual in a randomised clinical trial (as at 2012), however they are believed to be successful treatments:
General Psychiatric Management (a form of structured psychological therapy)
Cognitive Analytical Treatment
Good Clinical Care (an Australian form of standardised, structured, team-based clinical care)
What does BPD Community do?
To support recovery, BPD Community focuses on the concept of 'relational' support.
Relational Dysregulation is a core domain of BPD. At BPD Community we use the techniques that support personal change and empowerment to address 'Relational Dysregulation'. Our focus is to build resilience to address emotional regulation which will lead to behavioural regulation, the principles of Dialectical Behavioural Therapy and Positive Psychology inform this work. Acceptance and Commitment Theory underlies our work addressing issues of identity regulation.
Creating community to support recovery is an essential component of this work. Many people with BPD are estranged from their families, and many families struggle in their relationships with their loved ones with BPD. The sense of belonging to a community of people who support each other can help create a sense of connection with people who understand and care can never replace a loving, supportive family but it can ease the burden. To this end we make group peer support a priority and aim to supplement this with individually tailored support. Sadly lack of funding has limited our capacity to develop this.
Providing up to date, accessible and evidence based information is also a key component of our work. There is much misinformation on BPD. Our website is rich with well resourced information targetted for all levels and needs. Covid permitting we will again hold Info Nights, a standard of our work since 2015. Those who join our community are kept abreast of all things BPD in a monthly email update.
BPD Community offers training programs, face to face when Covid permits. Our Family & Friends Group which meets monthly via Zoom, has a twelve month training program on the techniques we can use to build a positive, supportive relationship with loved ones.