Borderline Personality Disorder Diagnosis

DSM-IV Criteria for Borderline Personality Disorder
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Diagnostic Criteria for BPD. Image Source: Durham, Grube and Fuller, 2007[30]

Borderline Personality Disorder (BPD) is a dangerous mental disability that is often misdiagnosed or found to be comorbid with many other mental illnesses of similar attributes and symptoms. In order to correctly diagnose and eventually properly treat this mental disease, psychologists must take extra precautions to identify the symptoms associated with BPD and to make sure the symptoms involved are only present with the particular disorder in order to avoid a misdiagnosis. This is done using various questionnaires and tests in order to assess patients and correctly compare them to the symptoms associated with BDP. The symptoms that psychologists are looking for are outlined in DSM. The psychologists match the symptoms up to those presented in the DSM and make sure that a certain number of criteria are met in order to conclude that an individual has BDP as opposed to another mental disorder with slightly different, but very similar, symptoms. In order to properly observe this a number of studies were investigated in order to show examples of how patients are diagnosed with BDP using the criteria shown in DSM-IV. Although DSM-IV is now outdated since the release of the new DSM-5, the changes presented in the newly revised edition are very minimal. Diagnosing patients with a mental disease is never easy, but steps do exist in order to properly assess individuals and treat them for the correct disorders. [1] [2]

After a brief comparison of the two types of DSM, various studies were examined and focused on in order to get a better idea of how Borderline Personality Disorder is diagnosed in different scenarios, concentrating on its different pillars that make up the proper diagnostic criteria for the disease. Many cognitive symptoms exist with BPD and make up the main focus of this examination. One of the studies focused on in this category is that of Marion Robin and colleagues and their studies on adolescents and BPD. By examining a child’s response to identifying a person’s facial expression, adolescents diagnosed with BPD according to DSM IV criteria were found to be less sensitive to facial emotions (such as anger and happiness) and required far more intense facial expressions and cues.[24] Those suffering from BPD have also been found to exhibit irregular behavioural symptoms, such as self-harm and suicide.[27] The comorbidity of BPD and the problems of misdiagnosing it with other mental illnesses are also examined. Dangers such as those found in these studies must be examined immediately using DSM criteria in order to properly diagnose BPD and then to correctly treat it, so those suffering from this mental disease may live rich, fulfilling lives.

The Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, usually abbreviated as the DSM, is a tool used by the American Psychiatric Association (also known as the APA) in order to classify and diagnose different mental disorders and psychiatric diseases in patients. In order to properly diagnose and treat patients, psychiatrists compare the signs and symptoms found in the patients to different classifications found in the DSM. If a patient were to possess specific signs and symptoms relating to one particular disease more predominantly over the others, then it will be hypothesized that the patient possesses said disease and will be treated for it. Over the years the DSM is revised and edited in order to update its diagnostic and treatment criteria for the various different disorders discussed within its pages. The newest revision of the DSM is that of the DSM-5, which was published on May 18, 2013. In the field of personality disorders, this newly revised DSM retained much of the same categorical approach for the different types of personality disorders. The biggest change though implored in the new DSM-5 is that of the axes on which certain disorders are clinically assessed.[1] Until this newly revised model, the older versions of the DSM (such as DSM-IV) have relied on a axial system for organizing the assessments made by clinics. These axes were separated into 5 different areas in order to assess the different impacts disorders have. Axis 1 used to focus on major mental disorders, axis 2 was for personality disorders and mental retardation, Axis 3 was focused on actual medical illnesses, axis 4 was for psychosocial factors and axis 5 explored the global assessment of functioning.[2] DSM-5 changes this axis system by combining the first three axes into one, single axis.[1] The multiaxial system was in use before this singular one since not much was known about certain diseases in the past when the fourth edition was released.[2] As time went on, more and more was discovered about these mental disorders and prioritizing different diseases based on how much we know about them became a thing of the past. Combining the first three axes made sense as well since major mental disorders and personality disorders were already so common and similar.[1] [2] Besides these changes to the axial system, much of the past categorical approaches used to assess these personality disorders have remained intact. This is important for the studies discussed later for they made use of DSM-IV criteria of borderline personality disorder in their studies based on what was available at the time of research and writing.[1] [2] This diagnostic criteria for borderline personality disorder, and any other mental disorder, is a very useful tool for psychiatrists and truly aids in diagnosing and eventually treating certain individuals.

Cognitive Diagnosis of Borderline Personality Disorder

Disturbed Body Image Perception

Research has found that women who show signs of suffering from borderline personality disorder (BPD) also tend to suffer from a disturbed self-body image, which could be used as a diagnostic tool in diagnosing and treating individuals suffering from this mental condition.[3] In analyzing these body image disturbances in women suffering from BPD, it has been found that many of these women could be suffering from a comorbid case of a severe eating disorder or even that of a history of childhood sexual assault, which have been found with individuals suffering from BPD like symptoms.[4] [5] A study performed by Anne Dyer and colleagues attempted to link the cognitive and behavioural components of one’s self body image to those individuals suffering from BPD. This was done by comparing these components between both healthy women and those diagnosed with BPD. In order to assess the psychopathology of the women, as well as their perceived traumatic experiences, various surveys and questionnaires were given to the women to assess them mentally.[6] These questionnaires included the likes of The Borderline Symptom List (BSL-23), the Childhood Trauma Questionnaire (CTQ), and the Eating Disorder Examination-Questionnaire (EDE-Q), which all assessed the women for certain comorbid symptoms with their self-body images (like eating disorders and childhood sexual assault) and also diagnosed those women who were suffering from BPD using the criteria found in the DSM-IV.[2] [7] [8] [9] The cognitive and behavioural aspects of the two groups of women were then assessed using the Multidimensional Body-Self Relations Questionaire (MBSRQ) and the Body Image Avoidance Questionnaire (BIAQ).[10] [11] The results show that those women who were found to be suffering from BPD scored significantly lower on the MBSRQ and the BIAQ than that of the healthy women. Those women suffering from BPD were also found to be more concerned about their body image and weight, and many of them were seen to be suffering from eating disorders. Of all the women surveyed and tested, it was found that a significant proportion of women suffering from BPD reported a past experience of childhood sexual assault, which was confirmed to be associated with a more negative self body image. These results show that a disturbance in the cognitive and behaviour aspects of one’s own self image is prevalent in those suffering from BPD.[6]

The Amygdala
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Diagram of the human brain highlighting the amygdala in red. Image Source: Gholipour, 2013[31]

Extreme Sensitivity and Intense Reactions to Interactions

Individuals suffering from the effects of Borderline Personality Disorder (BPD) have been found to exhibit hyper sensitive emotions, great hostility and very impulsive behaviours.[12] Those suffering from BPD tend to have a more negative perception towards ambiguous faces and exhibit a strong initial attention to negative facial expressions.[13] [14]It has been found in other studies as well that patients suffering from BPD do not only suffer from great emotional disturbances through perceiving stimuli but they also exhibit greater emotional dysregulation when anticipating emotional stimuli.[15] Research has found that initial eye movements are a good way to measure one’s reflexes to changing facial expressions and stimuli.[16] Other research has also shown that patients suffering from BPD have increased amygdala responses compared to normal processing.[17] Oxytocin is a neuropeptide that has been found to enhance one’s ability to recognize facial expressions as well as promote positive information processing over negative information processing revolving around attention.[18] [19] It has also been found to reduce the amygdala’s activity to negatively emotional stimuli.[20] Using this information, Katja Bertsch and associates set out to observe these negative reactions and emotional stimuli and to test whether the administration of oxytocin would prove beneficial to these BPD patients in producing regular behaviour and neuronal functioning.[21] In order to study this, a double blind study was performed where either oxytocin or a placebo was given to either normal functioning women, or that of women suffering from BPD as outlined in DSM-IV.[2] [21] After administering either the placebo or the oxytocin, initial eye movements and amygdala activation were observed using eye tracking and fMRI respectively. The results from the study show patients suffering from BPD did indeed have a more immediate fixation on the eyes of an angry face and also showed increased amygdala activation towards an angry face when compared to people of normal functioning. The results of the oxytocin administration normalized the behavioural and neuronal patterns observed in those suffering from BPD. This research can be used to better diagnose those suffering from BPD when we observe their high levels of sensitivity to social stimuli and through the administration of oxytocin, it is possible to reduce these overt emotional responses and calm down the BPD patient.[21]

Decreased Sensitivity to Facial Expressions in Adolescents

Adolescents suffering from Borderline Personality Disorder (BPD) share many of the same traits found in adults as outlined in the DSM-IV.[2] The adolescents suffering from this mental disorder have been found to exhibit severe social problems, such as those mentioned in the previous section, which results in them experiencing fewer relationships with others their age, less confidence in their relationships, and less enjoyment of being around others.[22] [23] Most studies focusing on adolescents suffering from BPD observed how they were impaired in terms of their ability to accurately recognize emotion but not really whether one’s sensitivity to emotion was effected. In order to investigate this phenomenon, Marion Robin and colleagues went and studied the sensitivity to facial emotions adolescents with BPD exhibit.[24] In order to observe this, the researchers explored the ability of the adolescents suffering from BPD to recognize dynamic facial emotions, which included a range for these BPD patients to test their sensitivity from a very low level of emotion to that of a much higher, fully expressed level of emotion. The study compared the sensitivity needed for adolescents to recognize expression changes between the patients suffering from BPD and those individuals with normal processing (the control). The adolescents were presented with various facial emotions that were displayed progressively and continuously and asked to quickly identify them.[24] The results of the experiment show that adolescents suffering from BPD are far less sensitive to those facial cues of happiness and anger and require a far greater expression of emotion in order to correctly identify the emotions, as opposed to that of the control group. The BPD adolescents however showed no problems in recognizing fully expressed facial emotions. The results from the study show how adolescents suffering from BPD have a greatly impaired sensitivity to correctly identifying facial expressions.[24] These findings describing the ability to correctly identify facial expressions could even link back to that of the hypersensitivity to ambiguous facial expressions mentioned in the previous section.[21] [24] These findings involving the recognition of facial cues is a great sign in assisting psychiatrists in diagnosing children, and even adults, who are suffering from BPD.[24]

Behavioural Diagnosis of Borderline Personality Disorder

Relationship Between BPD Traits and Suicide Attempts
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Graph depicting the correlation of one's BPD traits their recurrent suicide attempts. Image Source: Stringer et al., 2013[27]

Recurrent Suicide Attempts

The risk of suicidal tendencies from individuals suffering from mental disorders is always an important topic to discuss. After many unsuccessful attempts at committing suicide and after many unsuccessful treatments to help the patient, the risk of suicide increases more and more.[25] Experimenters differentiated between single and repeat offenders for attempted suicide and have hypothesized that these two groups of people are considered to be different. Studies show that anxiety and depresstion increase one’s risk of suicide.[26] Patients with severe depressive symptoms and anxiety have been found to have more repeated suicide attempts than those with less severe symptoms. The presence of Borderline Personality Disorder (BPD), when its comorbid with anxiety and depression, has a terribly negative impact on the suicidal behaviours of patients. Evidence revolved around BPD and suicide attempts however has been mysterious with no clear answer to what specific BPD trait causes the repeat suicide attempts.[27] In a experiment performed by Barbara Stinger and colleagues, researchers attempted to study the role of BPD traits and compare them to recurrent suicide attempts.[27] The researchers made use of the Netherland Study of Depression and Anxiety (NESDA) in order to investigate depression and anxiety disorders over a long course of time with patients.[28] A univariable negative binomial regression analysis was used to assess the association between BPD and suicide attempts. Using four different categories (axis-1 disorders according to DSM-IV, BPD attributes, reasons for suicide attempts and socio-demographics) as reference, univariable and multivariable negative binomial regression analyses were used to identify different factors that could have contributed for the number of repeated suicide attempts found with the patients.[27] The statistical results show that for the entire sample of people observed, the suicide attempt rate showed an increase of about 33% for every additional BPD trait (according to DSM-IV criteria) observed with the patient.[2] [27] The results show that patients suffering from depression and anxiety, along with a comorbid observation of BPD traits, were significantly associated with the danger of repeated suicide attempts. These results are extremely useful for screening patients for BPD and BPD traits (especially aggression and anger) in order to look for any possibility of a suicidal intention which can hopefully be prevented by treating the mental illness before any irreversible damage is done.[27]

Misdiagnosing Borderline Personality Disorder

The use of these diagnostic criteria is crucial for differentiating between different disorders and their many similar attributes. Disorders, such as Borderline Personality Disorder (BPD), are found to share many similar concepts and attributes with other mental illnesses which could unfortunately result in a dangerous misdiagnosis if proper precautions and research are not taken into account. A misdiagnosis could result in an unsuccessful treatment and therapy to cure a mental illness that a patient may or may not even have. This could have dangerous side effects and possibly make the individual much worse than they originally were, as seen with the increased risks of suicide attempts in patients unsuccessfully treated in the previous study discussed.[27] [29] BPD has been found to be commonly misdiagnosed with such mental illnesses as bipolar disorder usually due to their similar symptoms. In a study performed by Camilo J. Ruggero, it was found that bipolar disorder is not only under-diagnosed in certain diagnoses, but may actually be over-diagnosed in certain situations. The study observed how BPD symptoms increase the odds of a bipolar disorder misdiagnosis. In using DSM-IV criteria and questionnaires, patients were assessed and asked if they have ever been wrongly diagnosed with a bipolar disorder diagnosis.[2] [29] The results of the study showed that those individuals who were suffering from BPD had greater odds of being misdiagnosed with bipolar disorder. This increased risk of a misdiagnosis shows how important it is to observe the correct diagnostic criteria associated with Borderline Personality Disorder so it may be better understood and better treated when the time comes.[29]

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