It seems that almost every patient who has issues with chronic depressive symptoms gets diagnosed with BPD at my hospital by clinicians who have just met the patient. It sometimes seem that asking severely depressed patients about the DSM-5 symptoms for BPD is like reading them their fortune. They find ways that the criteria apply to them and agree that they are meeting it.
For example, we had a patient in their early twenties who had been married for 6 years but dated several different people as a teenager in early high school and middle school. This was described as having a history of unstable relationships. Who didn't date multiple people as a teenager (assuming they were dating at all)? If changing partners frequently as a kid is a criterion for BPD then 80% of the people I went to high school with meet it.
When does a desire to avoid abandonment become pathological? I think a lot of people work hard to save relationships or might make heroic or romantic gestures if they felt they were losing a valued connection.
And how does one delineate chronic feelings of emptiness from generally feeling bad about life and one's self?
Also what is the difference in unstable self image and poor self-esteem and what questions can you ask a patient to really distinguish these two?
Is it appropriate to label someone you have only known for 10 hours (and have directly interacted with for less than an hour) with a personality disorder? I thought a longer term clinician-patient relationship was important for appropriate diagnosis.
Obviously one can be diagnosed with BPD, PDD, and a major depressive episode but I see BPD way more than PDD with PDD almost never being considered.
Obviously BPD and MDD can co-exist, and I do think it's important to have a proper diagnosis for each, because different treatments and approaches work for different things and treatment preferably needs to be tailored for the individual and the individuals symptoms at any one time. To me a good psychiatrist should be able to tease out the differences between the way MDD and BPD might manifest within the same person on not only a check list type symptomatic level, but an observable, emotional level as well (the sort of stuff that is not necessarily reliant on a DSM list of symptoms, but which more typically comes from experience of knowing what subtleties to look for outside of strict diagnostic criteria). I do think the biggest problems in treatment can happen when there is a presumption that once a person has a diagnosis of BPD that everything else has to somehow relate back to that one particular diagnosis, and things like MDD get missed, or mistreated, because everything is being viewed through this lens of, 'this patient has borderline personality disorder, ergo the symptoms of depression/anxiety/'pseudopsychosis'/etc they are experiencing can only be attribute to their borderline personality disorder'.
At this point I should probably point out, for those who aren't already aware, that I'm not a psychiatrist, nor am I medical or healthcare professional of any description, although I am currently studying to hopefully enter the mental healthcare field. I have also been in long term therapy for a little over six years now, and I do have a former diagnosis of BPD (I no longer meet full diagnostic criteria), as well as a current diagnosis of MDD (recurrent), which does also occasionally manifest with psychotic features.
You asked some questions on when does X feature of BPD become pathological. Obviously I can't speak for all patients who have received a diagnosis of BPD, but I can at least try to answer those questions based on my own experiences. In my particular case it was very, very obvious that I had BPD, blind Freddy himself could have seen it. I was so obviously borderline in my early 20s that I might as well have just walked around with a flashing neon sign above my head saying, "Hello, I have borderline personality disoder". I should also mention that I remain extremely grateful for the fact that I was diagnosed with borderline personality disorder in my early 20s, and that I was able to access treatment specific to this diagnosis at the time.
...a history of unstable relationships. Who didn't date multiple people as a teenager (assuming they were dating at all)? If changing partners frequently as a kid is a criterion for BPD then 80% of the people I went to high school with meet it.
For me it wasn't so much the number of relationships I had, but the quality of those relationships. It wasn't like someone just going on a few dates, enjoying the time they're spending with someone, but ultimately deciding a relationship in the longer term isn't what you're both looking for, and then moving on to dating someone else. The 'relationships' I had at the time always had a sense of urgency and desperation about them, like the person I had literally just met and spent less than a few hours with (and usually also just slept with as well) was the most attractive, wonderful, and amazing person ever (besides the last person I had literally just met and slept with) and I was so very lucky to have this person in my life, and now we could look forward to a long and happy future together, and I *had* to make sure that happened. I feel in love at the drop of a hat, repeatedly and with the same level of intensity as all the other times I had also fallen 'in love'.
When does a desire to avoid abandonment become pathological? I think a lot of people work hard to save relationships or might make heroic or romantic gestures if they felt they were losing a valued connection.
The very first actual long term, and relatively stable, relationship I ever had both of us made what might be considered heroic, or romantic gestures to try and keep that relationship going when we both knew deep down that it had come to an end (including deciding to purchase a block of land and build a house together). Considering we had been together for over six years, were essentially living in a defacto (or common law) marriage, and whilst we were no longer 'in love' we did still care very deeply for one another, then under these circumstances any 'heroic' or 'romantic' gestures made to keep the relationship going might well be considered at least somewhat understandable. Compare that to the desperate, and often manipulative, lengths I would go to keep hold of a 'relationship', any 'relationship', when I was in full flight borderline mode. At that time it wasn't at all uncommon for me to meet someone on a Friday night, have fallen madly in love with them within a few hours, spent the weekend with them, and then have them leave for work on Monday morning only to then be met by a phone call not even 5 minutes after they'd walked into their work place, and it's me on the other end of the line asking if they missed me and bursting into tears if they said they hadn't even had time to miss me yet - 'what do you mean you don't miss me, I miss you, have I done something wrong, don't you like anymore?' (and no that isn't hypebole to make a point either, I was quite literally this full on, and this clingy). If I didn't send the poor sod running for the hills right then and there, then woe be tide anyone who made it past the first week with me and bought up the subject of perhaps slowing things down, or wondering if things were becoming a bit too intense too soon - more often than not that would be met by my going into complete hysterics and threatening suicide. I spent many a night sitting in a darkened room, listening to tragic break up songs on repeat, slugging vodka straight from the bottle and slicing my arms up, because, 'OMG, they've left me, my life is over, you don't understand we were together for 2 whole weeks!!! *baaawwwlll*'.
And how does one delineate chronic feelings of emptiness from generally feeling bad about life and one's self? Also what is the difference in unstable self image and poor self-esteem?
I think everyone goes through points in their life where they experience feelings of emptiness, feel bad about their lives and/or themselves, and have a poor image of themselves, and low self esteem. With MDD these feelings can obviously become magnified to a degree. The difference for me, in terms of experiencing these types of thoughts and feelings from a borderline perspective, was, again, more in the intensity and degree in which I experienced them. I took feelings of chronic emptiness to a point where I felt like I didn't even really exist in my own right, an unstable self image manifested itself to the degree that I barely even registered that I was actually human; and as for poor self esteem, I didn't just not like myself, I quite literally hated myself with a passion. In my experience of having BPD there wasn't really ever any middle ground, everything was experienced in a very 'all or nothing' type mode of thinking and feeling. All of this is vastly different to the feelings of emptiness, poor self image, low self esteem, etc, that I've experienced during episodes of MDD since no longer meeting full diagnostic criteria for BPD.
Like I said these are just my own experiences, and I can't speak to the experiences of others, but I hope this has still perhaps given you some measure of insight into the ways in which different emotions/emotional states might be experienced by someone in terms of BPD vs MDD.
