Help with terminology

For #s 3 & 7, my clinical experience is that these manifest cognitively and behaviorally. From a cognitive perspective, they will often endorse not really knowing who they are, feeling empty inside, feeling "lost," and searching to identify who they are. However, one of my complaints about the diagnosis is that "feeling empty" is sensitive, but not specific to the diagnosis. For example, a good proportion of MDD patients may also endorse feeling empty inside. So if you just go off of that symptom (as a prior supervisor of mine once did), there is a risk of over-diagnosis.

Behaviorally, I've seen this manifested in BPD patients in that they will engage in behaviors to fill the emptiness (e.g., shopping, sexually acting out) or will try out several personas in order to derive a sense of self (e.g., become "goth," overidentify with an illness, suddenly switch careers).

As for dissociation - yes, the criterion is targeting true dissociation.

 

I had a friend in college who had a lot of borderline traits, including identity disturbance. He was Jewish but was an active part of the Catholic student center on campus and every year he would take the class to convert to Catholicism, then decide not to convert because he identified more as Jewish. He was also in the ROTC and wanted to make his career in the army except for those weeks when he decided he was a pacifist and killing was wrong.

 

Poety, you bring up a few good points.

1. The issue of a continuum of personality traits - several people can present with certain Axis II traits, without meeting criteria for a personality disorder. However, when the traits are so extreme/severe that they result in functional impairment and/or distress, that is when you'll probably see something at the threshold level.

For example, I definitely have some OCPD traits - I have a terrible time delegating, and have a tendency to get caught up in the small details of my work (e.g., making sure that the decimal points in my data tables are perfectly aligned). However, they aren't severe enough to interfere with my ability to accomplish things, and in some ways, I think they are adaptive in my work which is very detail-oriented. One of my grad school advisors always said that, to have a successful research career, we should always have a slight touch of OCPD and hypomania.


2. Developmental issues - Part of the reason why DSM specifies that we can't give BPD diagnoses to kids is that some identity disturbance and affective instability is part of the normative developmental trajectory. So something like switching from goth to preppy might be expected in teens.

I do think bjolly's example was a great one - you can see how, in adulthood, this kind of thing can result in a lot of chaos and life difficulty.

In addition, if an adult JUST had these identity disturbance issues (kind of like a teen, as you said) but didn't meet any of the other critiera for BPD, then they don't meet criteria.

 

Every Wednesday the patients on our unit get a didactic about Borderline PD. Without fail, a number of my depressed and/or substance dependent patients come up to me that day and say "I know what I am now!"

I usually tell them that I think that we ALL have a little Borderline in all of us, and that under times of extreme stress, our usual coping abilities can get eroded away such that we behave in that "frantic" manner. I still send them all for DBT, though!