Last edited Tue May 15, 2012, 07:35 PM - Edit history (2)
I don't have a history of sexual abuse or physical trauma. I have suffered from 7 of the remaining 8 families of symptoms used to diagnose borderline. My impulsiveness is often dismissed by psychologists as it has more to do with an inability to self-censor than reckless driving, reckless sex, or reckless handling of personal finances. Unfortunately most coworkers think it's pretty serious.
For those who aren't familiar with how the DSM works, many of it's diagnostic criteria go sort of like like this: must have five of the following nine symptoms, and the thing you use for item 3 can't be related to things in item 5 etc.
I understand this both conceptually and technically, multivariate statistics and principal components analysis in particular were included as part of my graduate systematics training. Someone has figured out how to create clusters of symptoms and give the clusters names.
Great...or maybe not.
Because of possible combinations of listed symptoms in the DSM for borderline there are nearly 300 possible combinations of qualitative symptoms. Think about that--296 qualitatively different clinical presentations!!!! Given the same name! We have too many names in the DSM?? What?
And worse than the nomenclatorial problems of diagnosis is the state of treatment for borderline--currently there are only 2 treatment programs that have been subjected to moderately critical clinical evaluation, 1 of them is based on 12 step programs and requires of it's patients acceptance of a spiritual higher power. Hmm. There is a bummer for atheist/skeptics. TWO?! treatment programs for 296 qualitatively different presentations of symptoms. Maybe if the psychiatric industry would give different names to say 4 or 5 subgroups of symptom clusters then psychologists could invent 2 or 3 more clinical approaches?
Well, you probably don't believe it but it gets still worse. The major metrics by which those 2 treatments are judged successful are 2 intimately linked symptoms--self-harm and attempted suicide. Setting aside the statistical issues assumed in the counting of such highly correlated symptoms as two qualitatively distinct features to measure, how is it that improvement of self-harm, one and only one of the required minimum of 5 symptoms for a BPD dx is considered such a great success that an entire industry has been created around DBT?
What if you are one of the folks who have borderline, whose dominant symptom isn't self-harm but borderline rage?? Well, there is NO treatment for borderline that has been clinically tested for effectiveness for rage...and you'll just have to have that wait until you do something to get sent into an anger management course--or prison. And that is how it comes to pass that borderline is considered to have a 3x higher incidence in women. Because rage is common in a borderline man. That symptomatic, some would say diagnostic, rage gets him sent to prison, while a borderline women's anger more likely gets her sent to a guarded room in a clinic.
I think that the editorialist's fear of widening diagnoses is more about fear of stigmatization than concern of bad science. Meaningful pathological evaluation wouldn't be based on social acceptability of diagnoses. It would be based on the presence of diacritical symptoms (those symptoms that are important in differential diagnosis). I get stigma, I face it. I can understand why every person with a mental health dx wants to avoid stigma.
Ignoring dx's or camouflaging them with a name change doesn't seem like the proper way to get people treated. I can't see how renaming borderline PTSD helps anyone advance understanding, treatment, and suppress stigmatization. It makes as much sense as believing that calling an abortion a D&C (which has been done quite a lot historically) is going to help the cause of Women's reproductive rights.
= new reply since forum marked as read
