I Hate You--Don't Leave Me - Jerold J. Kreisman [7]
The categorical paradigm has stimulated controversy among psychiatrists, especially regarding the diagnosis of personality disorders. Unlike most other psychiatric illnesses, personality disorders are generally considered to develop in early adulthood and to persist for extended periods. These personality traits tend to be enduring and change only gradually over time. However, the categorical system of definitions may result in an unrealistically abrupt diagnostic change. In relation to BPD, a borderline patient who exhibits five symptoms of BPD theoretically ceases to be considered borderline if one symptom changes. Such a precipitous “cure” seems inconsistent with the concept of personality.
Some researchers have suggested adjusting the DSM to a dimensional approach to diagnosis. Such a model would attempt to determine what could be called “degrees of borderline,” since clearly some borderlines function at a higher level than others. These authors suggest that, rather than concluding that an individual is—or is not—borderline, the disorder should be recognized along a spectrum. This approach would put different weights on some of the defining criteria, depending upon which symptoms are shown by research to be more prevalent and enduring. Such a method could develop a representative, “pure” borderline prototype, which could standardize measures based on how closely a patient “matches” the description. A dimensional approach might be used to measure functional impairment. In this way, a higher or lower functioning borderline would be identified by her ability to manage her usual tasks of living. Another methodology would gauge particular traits, such as impulsivity, novelty-seeking, reward dependence, harm avoidance, neuroticism (capturing such characteristics as vulnerability to stress, poor impulse control, anxiety, mood lability, etc.) that have been associated with BPD.12,13,14 Such adaptations may more accurately measure changes and degrees of improvement, rather than merely determining the presence or absence of the disorder.
To understand the difference between these two definitional approaches, consider the way we perceive “gender.” The determination that one is male or female is a categorical definition, based on objective genetic and hormonal factors. Designations of masculinity or femininity, however, are dimensional concepts, influenced by personal, cultural, and other less objective criteria. It is likely that future iterations of the DSM will incorporate dimensional features of diagnosis.
Diagnosis of BPD
The most recent DSM-IV-TR lists nine categorical criteria for BPD, five of which must be present for diagnosis.15 At first glance, these criteria may seem unconnected or only peripherally related. When explored in depth, however, the nine symptoms are seen to be intricately connected, interacting with each other so that one symptom sparks the rise of another like the pistons of a combustion engine.
The nine criteria may be summarized as follows (each is described in depth in chapter 2):
1. Frantic efforts to avoid real or imagined abandonment.
2. Unstable and intense interpersonal relationships.
3. Lack of clear sense of identity.
4. Impulsiveness in potentially self-damaging behaviors, such as substance abuse, sex, shoplifting, reckless driving, binge eating.
5. Recurrent suicidal threats or gestures, or self-mutilating behaviors.
6. Severe mood shifts and extreme reactivity to situational stresses.
7. Chronic feelings of emptiness.
8. Frequent and inappropriate displays of anger.
9. Transient, stress-related