Borderline personality disorder: a spurious condition?
journals.sagepub.com
journals.sagepub.com
What I love about this article is it makes us question the thing we all think we can't question: the validity of the diagnosis itself.
What if the whole thing is wrong? What if it is this "easy" thing clinicians invented because they just got frustrated with how insanely certain patients acted when their underlying neuroses became so severe that they progressed into something closer to psychosis? What if focusing on a BPD diagnosis masks underlying conditions that are much easier to recognize and treat? What if it is just underlying disorders advanced to the Nth degree, that all somehow converge on a similar behavior set (much like psychosis), despite a differing underlying cause, and that focusing on that similar behavior set rather than on those underlying disorders is what causes BPD to be so untreatable?
A BPD diagnosis is often hopeless. There are no good drugs for it, and talk therapy works poorly. Almost all the comments here on HN from people who have someone with BPD in their life reflect this reality, and how terrible BPD is.
This article actually gives me hope for my sister. It gives me a new perspective on how we have been trying to help her, and why it might not be working.
Note though that the people that were successfully treated (so it seems to me) were willing to be treated. They realized themselves that their emotional response appears different. A large part of it, as I understand it, is to recognize when the emotional feedback loops kick in, and break out of them before it becomes overwhelming, but this requires some introspective capability.
I'm basically trying to say: If a family member absolutely sees nothing wrong with their emotions and behavior, it might be hard.
The people I know that did "recover" (or at least seem to manage very well) realized themselves that their BPD needed to be dealt with. You say "I'd love to know how to escape the pain we all feel" as a family member, but know that for the affected person, it is hell as well. I don't think anybody likes spiraling themselves into overwhelming rage or feelings of abandonment for no good reason.
Sometimes it seems to actually work but the condition seems to adapt to any consistent mechanism to calm her down.
So if your mother is on top of the BPD someone who generally does not inspect and question her feelings, might not have helped...
With that in mind, what's "absurd" about the paper? Can you be specific? Did you follow the cites, and find them absurd as well?
One thing I noticed is that the popular stereotypes about people with BPD (which is unpleasant stuff) appears to not be true. Or rather, I bet it is true quite often, but not a direct result of BPD.
Rather, it seems to be what happens when people with BPD don't know how to deal with it. The underlying condition seems to be "emotions are really strong" and especially "internal emotional feedback loops", and if you don't know what's happening, I totally get how someone might confusingly react accordingly to what they are feeling in a bad way: Lashing out, paranoia, accusations, oscillating between thinking someone is a saint versus someone is terrible...
The two people I know both have been in talk therapy (not anymore), and they are generally very introspective. Knowing what they know, they seem to be perfectly able to separate their internal tumult from reality, and appear generally pleasant at least to me. A big part seems to be to recognize the feedback loops early and breaking out of them. That was different in the now distant past, but again, I totally get how their confusion back then led to that past behavior...
We consider narcissism a personality disorder, but we also reward narcissistic tendencies when one's extreme ego matches reality. Is there a single "correct" personality that we should all strive towards?
Your point about which behaviors are considered disorders (e.g. homosexuality) is also well-taken. I am primarily basing my take on DSM-5's definitions.
Functional
Interesting addition, and not one that a lot of people who had shitty childhoods would say is appropriate to include.
Only interesting in ~ 2023. Was a standard addition for millenia...
I don't know, it's not like we have some successful high ground as a society...
Post-WW2, the US as the new top dog going to grab its global spoils, went on to fight, directly (Korea, Vietnam, all the way to the modern invasions) and indirectly fuel all kinds of peripheral wars, and if the USSR was in better status and had a firmer grip globally, a major war could have been on the cards too, it came close at several times, like the Bay of Pigs. But they folded by themselves (plus there was this "mutual assured destruction thing").
So, it's more like senile people in some elderly hospice bragging how peaceful they are that they don't get into bar fights anymore - when neither their age and health, nor the conditions they're now in would make any sense for them to do so.
Do you think that's a reasonable expectation for everyone?
I just disagreed with what I perceived to be a knee-jerk aversion to a virtue because it doesn’t apply in some circumstances.
We keep trying the “strive for correct personality”; serf, slave, worker, and just end up with with ossified thinkers and banal brinksmanship; ho shit! he broke character! get ‘im!
Put automation to getting bulk materials to stores and let locals “job” be crafting their personal kit.
We’re just enabling rent seekers allowing the professional packaging industry buy up resources to sell us in cute cardboard boxes for high markup so their kids can play Xbox all day
We tried globalism and all these things to try and open the world and “free minds” and we’ve just created an on rails path to ecological collapse.
Longtermism is just religion trying to sound secular.
Like we all said during Oceangate; there’s no escaping physics. Even if we reverse aging … enjoy cancer from wildfire smoke.
This is just puerile madness at this point; adults pouting their mom and dad lied to them.
We are all feeling guilty for all the literal harm and know the only real outcome is at best a massive die off, if not outright end of species.
We’re well into “War is peace” level of delusion.
The best path is intentionally reverse growing, and see what happens.
It is (and was) easy to see that homosexuality is not a personality disorder because it doesn't harm anyone.
On the other hand, narcissism and BPD are harmful to both the person exhibiting the associated behaviors and to the people around them.
Narcissists may be incredibly successful in some cases, but they also self-report feelings of emptiness, loneliness, and compulsion.
That kind of rewriting of history ignores the torture people like Alan Turing went through for being found out. It dishonors them by writing them out of the past.
I'm not at all forgetting the millions of people persecuted for something that harms no one.
My ex-GF was textbook BPD. Finding the survivor resources was so helpful - people who have never experienced someone who has BPD simply find it hard to believe what you say happened actually happened and those resources are almost as though someone has been dating your ex-GF as the experiences are so similar.
Either BPD doesn't exist and there's a grouping of consistent traits that many people have seen first hand or it does exist and either way the outcome is the same for those observing it.
After 25 years I could pretty well climb into her headspace. If I lived there, I don't think I could ever find my way out.
That seems to be exactly right. However, it also seems that, with some intelligence and introspection, people can totally learn how to deal with that and live a normal life.
It's hard for me to tell whether the symptoms actually subside, or whether they are just perfectly capable of dealing with them. From what I've been told, a big part of BPD is "internal emotional feedback loops" that become hard to break out of, but it's apparently possible to recognize them early and not build up.
Part of it is certainly that. It's not strange that some attempt to self medicate with strong psychedelics like mescaline, I heard a few successful stories but it can also go terribly wrong.
She couldn't progress by setting any of it aside because it could never be enough to improve her perspective. And whatever space she created would be quickly overwhelmed by the adjacent bad perspectives.
Progress needs trust (in the process) and trust needs progress. She couldn't generate enough of either.
She acts out in order to gain attention. From ruining the family finances like in the first example to engaging in affairs and luring men from the internet to appear at the house. She has made false claims against me to the police. Refuses to clean up after herself, leaving huge messes, while complaining about a single item I might leave out. She lies, a lot. She doesn't seem to understand that I don't trust her anymore after all the lies, to her that's in the past even if it was a few minutes ago.
I'm stuck due to my kid and family courts bias in favor of mothers. 14 more years.
We had 5 (all over 18 now). I got out of it because she started hanging with the nearby homeless community and found other guys go glom onto.
Then one night, while I was asleep on the sofa, she came home and emptied out her bedroom (hoarded to the ceiling). I was one door away and never stirred. I just work up and the room was completely empty.
I'm still kind of stunned by that.
Sorry, I don't mean to belittle what you go through, it sounds terrible. But I have to "defend" people with BPD against it, because I have people close to me with that affliction. What you describe sounds more like a very narcissistic person instead.
For example, where in that article do you see that people with BPD can be so straight up delusional that they think they "own the town"? Notice that the words "lie" or "lying" do not even appear in the article.
In my experience, presenting a BPD-afflicted person with definitive truth is actually calming them down, because it disperses the worries and fears they have about things that could be (however unlikely).
Again, I don't mean to belittle your experience. What you're going through sucks, regardless of what disorder your wife has.
However, you kinda have to be there but she didn't arrive at owning the town all at once but a series of escalations over years.
It all started a few years after we moved in. She started claiming the property line was further back and I corrected her. Unable to admit she was wrong she started going off on me, I let it go because it didn't matter. Then a few years after that the neighbors redo their backyard, cutting down a few old, mostly dead trees. This set her off. Those were "her trees" and they housed a cornucopia of wildlife (they didn't).
First it was the property line claim from before, so she hired a survey company, the neighbors property line is actually a few feet in from where I thought it was. So she was way off.
She then spent six months looking at pixalated maps and essentially having pareidolia. None of her claims about the maps made any sense but she argues they prove she is right and "Since in 1900 when this was built they forgot to add a line here so we own all of our town". She only has made that claim a few times and I think understands others find it odd, but I'm pretty sure she believes it.
BPD-afflicted people are terrified to be abandoned, for one thing. Why would someone who lives that way actively antagonize the people around them? Yes, the emotional feedback loop if not broken out of can make people with untreated BPD show strong emotional reactions (anger, depression, crying) in the moment, but they snap back out of it, are usually ashamed afterwards, and don't press on with what can only be described as nonsense.
It answers the antagonize question specifically it's just too much to type out for me now.
To butcher it, they feel great anxiety that you are going to leave and test that assumption by acting out. When you don't leave after they act out, they feel comfortable for a time until the cycle begins anew.
Yes. (We broke it off, but for reasons entirely unrelated to BPD. We're still friends. It's not my only experience with BPD.)
> To butcher it, they feel great anxiety that you are going to leave and test that assumption by acting out. When you don't leave after they act out, they feel comfortable for a time until the cycle begins anew.
I agree. Believe me, I am actually very familiar with that. But your storyline still does not fit. Imagining a shifted property line is way more than that, and claiming that she owns the town is straight delusional.
In all the "testing of the assumption that I am going to leave/abandon" them that I underwent, never did anyone come close to spending six months to "prove" a delusional claim. It was all highly emotional spur of the moment stuff. No lies or actual counterfactual realities involved.
Going back to the article you linked, that actually all rings very true to me. But it does not mention either lying, or delusional and counterfactual beliefs at all. If that was a common symptom, why would the article not list it, especially given what a bad symptom it is?
Especially because, for example, the articles on narcissistic or histrionic personality do mention it pretty clearly?
I'm not sure why this is so important to you. You obviously have to deal with someone who has a personality disorder. It's a lot to deal with. Why does it have to be BPD, specifically? Or why can't it be BPD and something else on top of it?
That, by the way, sticks out to me a lot. Read the article you linked, and see if you find anything that matches that. Then look at histrionic and narcissistic disorders instead, and see if it matches that.
When folks would ask me about what disorder she has, I'd answer All of them. When she drifts into psychosis she'll have symptoms common to schizoaffective and maybe dissociative.
I genuinely can't come up with one symptom group that she never dips into.
You might win here. Mine didn't have this kind of focus. Early on, maybe but her symptoms were much less pronounced in her 20s. In her 30s, psychosis started showing up along with the rest and with that came some persistent loopiness - which was a bit of a blessing.
People are going to read this, and then when they meet someone who they know has BPD somehow (for example when getting close in a relationship), they are going to think that that person can become that delusional. That's not what happens.
Both is more likely. There's tons of overlap between the symptom groups.
Did she develop it the minute after you put it in, or was it a "I can fix her/deal with this" sort of scenario?
I wish you the best of luck, and I hope you find a way out sooner rather than later.
Generally speaking men tend to get every other weekend, maybe a dinner on a off week. I can't risk my kid being subjected to her worst days alone.
That is awful if that is truly the case. You are a far kinder soul than I am -- I would be scheme and connive every way I possibly could to set this woman up.
> I can't risk my kid being subjected to her worst days alone.
I can tell you are a great father. A far better man than I am capable of being. If you ever need someone to vent to, shoulder to cry on, etc. never hesitate to shoot me an email (in profile).
Yep. That sounds familiar.
> She acts out in order to gain attention. From ruining the family finances like in the first example to engaging in affairs and luring men from the internet to appear at the house.
Yep.
> She has made false claims against me to the police.
Not exactly but in the neighborhood.
> Refuses to clean up after herself, leaving huge messes, while complaining about a single item I might leave out.
Mine was a hoarder. Otherwise, yep.
> She lies, a lot. She doesn't seem to understand that I don't trust her anymore after all the lies, to her that's in the past even if it was a few minutes ago.
...while she keenly remembers the smallest of slights from decades ago.
> I'm stuck due to my kid and family courts bias in favor of mothers. 14 more years.
By the time mine got thru a paragraph, the judge would be giving me that look. I know that because judges routinely gave that look. Criminal judges, that is.
That didn't happen. And if it did, it wasn't that bad. And if it was, that's not a big deal. And if it is, that's not my fault. And if it was, I didn't mean it. And if I did, you deserved it.
Luckily, nobody is doing that. The claim is that BPD is too broad. If there were separate, narrower diagnoses, we might also be able to treat them better.
My point is: it doesn't matter whether narcissism or BPD are useful mating strategies. It's slightly interesting in an anthropological sense, but it has no bearing on whether they should be considered disorders and treated as best we can.
I know three close people with a BPD diagnosis. They had both a similar constellation of personality traits and all three were first medicated with antidepressants to no avail (a common trait in BPD is that it is easy to confuse for major depression). They took BPD-specific drugs and after a few trials and errors their quality of life increased _tremendously_, and there is evidence that BPD and associated personality traits are highly inheritable.
It is completely possible that a combination of adequate diet, exercise and sleep and lifestyle changes may take away these symptoms as they may possibly manifest the weird ways in which our minds and bodies react to the difficulties of modern life. But for most people that's just an option.
People may debate the minutiae of the biological underpinnings and the quantification of certain classes of symptoms. But that doesn't change that I've seen people who had a monthly episode of behaving like complete trash who totally changed their lives after taking lithium or other medication.
At least in women I suspect more than a few BDP diagnosis mask autism.
It wouldn't surprise me if stimulants improved Austism in some individuals because, if I recall correctly, I think 60%-70% of people with Autism have ADHD as well.
I have a family member (by marriage, I didn't know her when she was young) who sounds an awful lot like your description. Unfortunately for her getting her "misdiagnosis" "corrected" (her words) seems to have made things a lot worse, at least for family members dealing with her. Splitting behavior doesn't help matters at all. This stuff is so complicated and so hard that we really barely have any handle on any of it. It's important to remember that diagnoses are just words; the map is not, is never, the territory.
But I'd never heard of Ritalin as an option here, so thanks for bringing it up. I'll mention it to that side should it be appropriate....
(Tangent: I need a family with better general mental health, myself included. Anyone know where I can get one? Do they sell them at Amazon or do I have to risk AliExpress?)
We don't have affirmative biomedical tests for these conditions. Until we do, they are just constellations - funny imagined shapes - that we're drawing in a galaxy of traits on display in that person's life. Your picture of a "tree" overlaps about 30% with my picture of a "mushroom". But it's not the case that "First it was identified as a tree but later turned out to be a mushroom".
We pretend that these things are distinct biomedical disorders because it makes it easier to talk about them, easier not to literally murder the person displaying them, and (bizarrely) because it's legally required to classify them in order to bill a therapist/psychiatrist for their treatment, but in reality they're parts of a maladaptive personality that just look very roughly similar to other maladaptive personalities we've seen in the past.
sometimes a tree can't function without a mushroom and vice versa, a true symbiosis
The fact that you've known people whose lives were changed by medication would tend to strengthen the authors point, right?
We're all cognitively adept at identifying patterns and giving them names, but that doesn't make our intuitions about those patterns science.
I've got the impression that BPD, unlike other personality disorders (or things labelled as such), isn't actually considered essentially untreatable, at least not nowadays. BPD probably has a notorious reputation, possibly because of the potentially emotionally taxing nature of living with or treating emotionally unstable people, and perhaps because it could be difficult to treat. But no modern factual source I've come across has considered it untreatable.
Even a superficial source such as Wikipedia says the majority of those who have been diagnosed achieve recovery over time [1]. I've also read from reputable sources [2] that in 5 or 10 years the majority of patients no longer fulfil the diagnostic criteria.
That doesn't invalidate what you're saying, of course. The symptoms do overlap with a lot of other disorders (which is also true of many other psychiatric diagnoses, which is why differential diagnosis is important). And the very fact that just about every other thing that's called a personality disorder is considered nearly untreatable (and stable over time), while BPD isn't, is probably a reason to consider whether it should belong in the same category.
[1] https://en.wikipedia.org/wiki/Borderline_personality_disorde...
[2] the ones I remember are non-English but I haven't got the impression that they differ from Western mainstream
Is there any good evidence that there are BPD-specific drugs?
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2015: Pharmacotherapy for borderline personality disorder--current evidence and recent trends
> Abstract
> Drug treatment of patients with borderline personality disorder (BPD) is common but mostly not supported by evidence from high-quality research. This review summarises the current evidence up to August 2014 and also aims to identify research trends in terms of ongoing randomised controlled trials (RCTs) as well as research gaps. There is some evidence for beneficial effects by second-generation antipsychotics, mood stabilisers and omega-3 fatty acids, while the overall evidence base is still unsatisfying. The dominating role SSRI antidepressants usually play within the medical treatment of BPD patients is neither reflected nor supported by corresponding evidence. Any drug treatment of BPD patients should be planned and regularly evaluated against this background of evidence. Research trends indicate increasing attention to alternative treatments such as dietary supplementation by omega-3 fatty acids or oxytocin.
https://pubmed.ncbi.nlm.nih.gov/25413640/
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2021: Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis
> Results
> Of 12,062 unique records, we included 21 randomized controlled trials (RCTs) with data on 1768 participants. Nineteen RCTs compared pharmacotherapies with placebo; two RCTs assessed active treatments head-to-head. Out of 87 medications in use in clinical practice, we found studies on just nine. Overall, the evidence indicates that the efficacy of pharmacotherapies for the treatment of BPD is limited. Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD. Low-certainty evidence indicates that anticonvulsants can improve specific symptoms associated with BPD such as anger, aggression, and affective lability but the evidence is mostly limited to single studies. Second-generation antipsychotics had little effect on the severity of specific BPD symptoms, but they improved general psychiatric symptoms in patients with BPD.
> Conclusions
> Despite the common use of pharmacotherapies for patients with BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity of BPD.