BPD/HPD overlap

[ClinPsycMasters]

A few days ago I saw a patient for neuropsych assessment who displayed both histrionic and borderline traits. It got me thinking about the diagnostic validity of each personality disorder and the areas of overlap. Do you guys find it difficult to tell the two apart? And do you think they should be kept apart?

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[whopper]

The DSM mentioned that while there is large combordity with both disorders, and they appear similar, the data points to them being separate disorders.

Both disorders can elicit strong feelings of countertransference in therapists. My wife, who understands borderline much better than I do, and has more training in DBT mentioned that DBT is not geared towards the treatment of histrionic personality disorder, and the theory as to how DBT works is based on several theories on borderline PD that do not apply well to histrionic PD. She said the more she learned about DBT, the more she was able to distinguish between BPD and HPD.

Histrionic PD appears to be more focused on a person's need for attention based on their own insecurities such as feelings of inadequacy. BPD is more about a person's own internal conflict, based on conflicting emotional drives that were not resolved as they were growing up. E.g. someone molested by her father may feel a conflicting combination of hate against her father but also love because she is still in the emotional developmental phase where she needs her father's approval. These two drives are in direct opposition to each other, creating confusion and an inability of the woman to emotionally mature until these two conflicting areas can be resolved. It's actually much more complicated than that because in borderlines, there's usually several areas, not just two that are in direct conflict.

 

[ClinPsycMasters]

yes, that's a good way to tell them apart. I also find histrionics to be similar to dependents though people with DPD do not sexualize every single relationship.

Millon makes the following comparison between HPD and BPD, which I find confusing:

"borderlines and histrionics exhibit rapidly shifting emotions, and both experience
feelings of profound emptiness. Both may attempt to manipulate others with
suicidal gestures. However, actual self-destructive behaviors, such as cutting, are more
frequently seen in borderlines. Despite their contrasts, the two disorders do shade into
each, as histrionics may develop borderline traits. Developmentally, histrionics enjoy a
special relationship with their opposite-sex parent that stops short of actual incest and
develop repression as a means of keeping such forbidden desires out of consciousness.
In contrast, for borderlines, incest or other sexual abuse is often a reality."

In addition, not all borderlines cut themselves. I don't know how valid BPD subtypes are but some distinguish between higher-functioning externalizing and lower functioning internalizing BPD (the classic BPD). Higher-functioning BPD is the one most difficult to distinguish from HPD, I think. Again, my clinical experience is quite limited so perhaps experienced clinicians can pick up on the difference much more quickly, maybe in the overtly erotic and sexual way HPD present themselves to them.

 

[Manicsleep]

I think the overlap is seen in a lot of disorders, hence the clusters of the disorders.

Having worked with a lot of antisocials and borderlines, they can appear very narcissistic and histrionic but if you look at the core features of the disorder you can usually tell which is their primary disorder.

That said, a BPD may have strong antisocial, histrionic and narcissistic traits or perhaps traits from another cluster. ASPDs commonly have cluster A traits as well as cluster B traits. The final answer of course is that the DSM is a guide and clinical judgement should prevail. Can a person be BPD and HPD or some other chimera, I think so, but I would venture to guess that it isn't that common.

 

[ClinPsycMasters]

I think the overlap is seen in a lot of disorders, hence the clusters of the disorders.

Having worked with a lot of antisocials and borderlines, they can appear very narcissistic and histrionic but if you look at the core features of the disorder you can usually tell which is their primary disorder.

That said, a BPD may have strong antisocial, histrionic and narcissistic traits or perhaps traits from another cluster. ASPDs commonly have cluster A traits as well as cluster B traits. The final answer of course is that the DSM is a guide and clinical judgement should prevail. Can a person be BPD and HPD or some other chimera, I think so, but I would venture to guess that it isn't that common.

Reminds me of my classmate's saying:

borderline in women is antisocial in men
Indian yoga in Japan is zen

or something like that....

 

[billypilgrim37]

The push for DSM-V is to get rid of these labels because they aren't useful. There may be some mild clustering in factor analysis that made sense for DSM-III to try to craft these things. But it hasn't been helpful. DBT (effectively) targets specific symptoms in people who we call borderlines and in many other diagnoses. But that doesn't mean BPD is a meaningful concept unto itself.

It would take me 20 paragraphs to fully qualify what I just said, and let it just suffice to say that I very much agree with Whopper. However, I think instead of "BPD" vs "HPD," I think his wife is picking up on "people who will get a lot of help from DBT" vs "people who will not get a lot of help from DBT." And that latter construct is probably more helpful (and more globally applicable) than the former.

To further clarify without writing a thesis, Kernberg's Borderline Personality Organization is an incredibly useful concept. BPD is less so.

If you pub med the DSM-V white papers on personality disorders and track down some of the writings of the Iowa psychologist who is heading the work group (blanking on the name), I'm basically just reiterating what they've been saying for a while (although I have no idea if the DSM people appreciate Kernberg).

 

[whopper]

I think his wife is picking up on "people who will get a lot of help from DBT" vs "people who will not get a lot of help from DBT." And that latter construct is probably more helpful (and more globally applicable) than the former.

You are very right, in fact you're so right it shows to me that you and I probably agree on the things we didn't write about this.

Like what was written above, people's individual diagnosis often exist on a spectrum. The actual DSM diagnosis is more of an archetype, though most people do exist within a specific diagnosis.

That said, the histrionic and borderline archetypes, IMHO, are different enough to the point where they should be distinguished because they appear to be the result of different phenomenon.

 

[ClinPsycMasters]

You must be referring to Lee Ann Clark. It looks like they're still keeping BPD but getting rid of HPD in DSM-V.

I agree with you that Kernberg's "borderline organization" is a useful concept. Of course it can also apply to the more pathological NPD.

 

[ClinPsycMasters]

The push for DSM-V is to get rid of these labels because they aren't useful. There may be some mild clustering in factor analysis that made sense for DSM-III to try to craft these things. But it hasn't been helpful. DBT (effectively) targets specific symptoms in people who we call borderlines and in many other diagnoses. But that doesn't mean BPD is a meaningful concept unto itself.

It would take me 20 paragraphs to fully qualify what I just said, and let it just suffice to say that I very much agree with Whopper. However, I think instead of "BPD" vs "HPD," I think his wife is picking up on "people who will get a lot of help from DBT" vs "people who will not get a lot of help from DBT." And that latter construct is probably more helpful (and more globally applicable) than the former.

To further clarify without writing a thesis, Kernberg's Borderline Personality Organization is an incredibly useful concept. BPD is less so.

If you pub med the DSM-V white papers on personality disorders and track down some of the writings of the Iowa psychologist who is heading the work group (blanking on the name), I'm basically just reiterating what they've been saying for a while (although I have no idea if the DSM people appreciate Kernberg).

You are very right, in fact you're so right it shows to me that you and I probably agree on the things we didn't write about this.

Could either of you elaborate or else refer me to pertinent articles/books?

 

[whopper]

From my very pathetic level of study of Linehan. Borderline appears to respond to DBT much better than histrionic PD. The theories as to what's going on are also different. In borderline PD, the person has several conflicting dynamics including a desire to be loved, but also sense of worthlessness that drives a person to sabotage relationships. There's also a conflicted identity, emotions, etc.

In histrionic disorder, a theory is the person is acting in their manner out of a need for attention, and possibly a feeling of enjoyment from the chaos that person creates. Several borderlines do not enjoy the chaos.

In a theoretical sense, they are 2 very different disorders, yet the symptoms can present as very similar, and a person could have both or be on a spectrum between both.

 

[TenaciousGirl]

Could either of you elaborate or else refer me to pertinent articles/books?

http://www.amazon.com/Personality-Disorders-Modern-Theodore-Millon/dp/0471237345

This is a great book. It goes into what Whopper is talking about ... where the label of the PD is more of a archetype and how we as clinicians can look deeper into the personality and see how the PD can be different depending on the person's personality. So like others have said, it's more of a spectrum approach. It's important not to use absolutes with PD's like, "HPD ALWAYS have a sexual element to their interactions with others..." because although this is USUALLY a characteristic it is not ALWAYS the case.

 

[ClinPsycMasters]

http://www.amazon.com/Personality-Disorders-Modern-Theodore-Millon/dp/0471237345

This is a great book. It goes into what Whopper is talking about ... where the label of the PD is more of a archetype and how we as clinicians can look deeper into the personality and see how the PD can be different depending on the person's personality. So like others have said, it's more of a spectrum approach. It's important not to use absolutes with PD's like, "HPD ALWAYS have a sexual element to their interactions with others..." because although this is USUALLY a characteristic it is not ALWAYS the case.

I have read that book and to be honest, it hasn't been that helpful. If you look up further in the thread, I actually quoted from the book as basis for my confusion.

 

[TenaciousGirl]

you quoted millon, but did not cite the book. Millon has several published sources: books, articles, etc. If you haven't found it to be helpful then I don't have any further recommendations for you.

 

[ClinPsycMasters]

you quoted millon, but did not cite the book. Millon has several published sources: books, articles, etc. If you haven't found it to be helpful then I don't have any further recommendations for you.

You are a psych student, right? Do you do therapy on your own? Have you had clinical experience with BPD and HPD?

 

[TenaciousGirl]

You are a psych student, right? Do you do therapy on your own? Have you had clinical experience with BPD and HPD?

yes, yes (with supervision), and yes.

 

[ClinPsycMasters]

yes, yes (with supervision), and yes.

Okay, assuming you're a few years into the program and seen more than a few BPD and HPD patients, can you tell me how true the Millon quote is--the one I posted in the thread--based on your clinical experience?

 

[TenaciousGirl]

Okay, assuming you're a few years into the program and seen more than a few BPD and HPD patients, can you tell me how true the Millon quote is--the one I posted in the thread--based on your clinical experience?

In my experience, what Millon says is fairly accurate. HPD and BPD are definitely similar and share some of the same characteristics. I also agree they can be quite tricky to tell apart, depending on how symptoms and characteristics present. The only part of that quote that I haven't seen significantly first hand is the part where he said, "developmentally, histrionics enjoy a special relationship with their opposite-sex parent that stops short of actual incest ..." Individuals with HPD often do sexualize relationships and I have seen this, but the way it reads it sounds like this type of sexualization towards the parent is a very common occurrence (as if they all do it towards a parent) and I can't speak for that based on my clinical experience so far.

One of the above posters (i can't see it on the page right now) mentioned how some PDs, particularly ones of the same cluster, can look similar and how it's important to look at the root cause of the presentation/behaviors/symptoms. I think this is the trickiest part about the PDs. For example, some patients with BPD can come off VERY narcissistic, but sometimes when you strip the behavior down, the "activating ingredient" of the behavior isn't really about a grandiose sense of self at all. But, of course, it is completely possible to have a diagnosis of "Axis II: BPD with narcissistic features" it just depends on the person. (am I making sense? it's like 330 am here.)

 

[ClinPsycMasters]

In my experience, what Millon says is fairly accurate. HPD and BPD are definitely similar and share some of the same characteristics. I also agree they can be quite tricky to tell apart, depending on how symptoms and characteristics present. The only part of that quote that I haven't seen significantly first hand is the part where he said, "developmentally, histrionics enjoy a special relationship with their opposite-sex parent that stops short of actual incest ..." Individuals with HPD often do sexualize relationships and I have seen this, but the way it reads it sounds like this type of sexualization towards the parent is a very common occurrence (as if they all do it towards a parent) and I can't speak for that based on my clinical experience so far.

One of the above posters (i can't see it on the page right now) mentioned how some PDs, particularly ones of the same cluster, can look similar and how it's important to look at the root cause of the presentation/behaviors/symptoms. I think this is the trickiest part about the PDs. For example, some patients with BPD can come off VERY narcissistic, but sometimes when you strip the behavior down, the "activating ingredient" of the behavior isn't really about a grandiose sense of self at all. But, of course, it is completely possible to have a diagnosis of "Axis II: BPD with narcissistic features" it just depends on the person. (am I making sense? it's like 330 am here.)

Yes, you make very good sense. 🙂

In fact, it was Millon's assertion that "developmentally, histrionics enjoy a
special relationship with their opposite-sex parent that stops short of actual incest" that had perplexed me the most. I suppose if one is to take a depth psychology perspective, searching for root causes in early development, sexual abuse in BPD and an eroticized relationship in HPD, seem likely, at least in theory. However, there is no history of sexual abuse in a significant portion of BPD patients (though trauma--loosely defined--is present in all of them). I haven't read any studies on HPD and "special" father-daughter relationship. Though I think it maybe present in a significant portion of them, it's causative role, akin to BPD and sexual abuse in childhood, needs further study.

And as for your example of narcissistic traits and BPD, I think there was epidemiological survey--I can't remember which--showing that one third of patients with NPD also had BPD. Of course this makes me question the validity of each diagnosis a bit, but also reminds me of Kernberg's assertion that borderline personality organization is the structure of psyche in both narcissistic and borderline patients.

 

[TenaciousGirl]

if you remember the survey, can you let me know? I'd be interested in reading it. It will be interesting to see what happens with the DSM V research and how the DSM will change.