Histrionics and High level Borderlines

Do any of you think that HPD's and Borderlines have similiar mentalities, motives, defenses etc.? When I say Borderlines I don't mean borderlines described by the DSM, Im talking about the little known High level Borderline. They are often mistaken by some therapists as being neurotic but underneath have similiar defenses and motives as their low level counterparts, only they're much less pronounced.

Jay -

You need to go back and read through some older posts on this issue. There is a continuim for all disorders. But borderlines have a different set of criteria in the DSM...There is a reason why we use the DSM and that is to diagnose and treat accordingly.

A high functioning borderline, as you call it, is more than likely a BPD...that is why HPD exsists. If someone fits the criteria of a BPD, than they are BPD....what that diagnosis does not tell us, is how severe the person is....nonetheless, they are still BPD.

One should never be given a BPD diagnosis unless they meet the criteria for BPD.

But yes, BPD's and HPD's have very similiar personality structures and defenses....That is why we have the Cluster B disorders.
Most of the Cluster B's have the same issues, they just present them and defend themselves in different ways.

There are neurotic people, and they are NOT bpd. A therapist would not treat a neurotic person in the way they would treat a BPD so that is the reason for distinction between the two. A BPD can be high functioning, meaning they have a job, education, relationship, etc....but still maintain the criteria necessary for a BPD diagnosis....AND if the DONT meet the criteria - they are simply not BPD. Its not that difficult. You just need to understand that there is a continuim for all disorders...

What I am saying is that WE ALL have personality characteristics - so if someone has some traits of BPD, that does not mean that they are BPD....it means they have traits of BPD.

I really get frustrated with people wanting to take the DSM subjectively ....one cannot kind of have cancer - they either have or not...and perhaps if they done have full blown cancer - they have Cin IV - the stage before cancer. It is the same with BPD - perhaps if they do not meet the full criteria for BPD, then they meet the criteria for HPD.

So, yes, there are high functioning BPD's but they are still BPD's they are just on the other end of the continuim. You must understand that there are only a few DSM diagnosis's that meet criteria for SPMI (severe and persistent mental illness). BPD is one of the them. There is no other PD that is considered a BPD. Now, that does not mean that EVERY BPD is so sick that they are considered SPMI...The range of BPD's is usually accordingly to each persons history of abuse, trauma, etc....

This is my personal story about BPD.

www.psychforums.com/viewtopic.php?t=162 ... c905c7b7f0

Well according to a study done by Weston and Arkowitz-Weston 60 percent of pateints who come to treatment with personality disorder pathology were not diagnosable on DSM-IV. The DSM diagnostic category for the Borderline Personality does not take into account the levels of functioning, object relations, nor the intrapsychic structure of the pateint. It is a descriptive diagnosis with criteria that focus on obvious symptoms and behavior. Higher level pateints are likely to be diagnosed as Neurotic. This why Masterson an many other psychoanalysts consider HPD to be part of the cluster of Borderline personality. Because they have problems with self activation and do not have a real sense of self. They have major problems with feeling entitled, self esteem, soothing their painful emotions, integrating their personalities, relationship commitment, creativity ie. repeating self destructive behavior, intimacy, and the ability to be alone and autonomous.

Not only that the intrapsychic structure of the HPD like the high level Borderline has two units that are split off from each other. In the first unit the mother is approving and rewards regressive immature self destructive behavior. The HPD feels like a special child that is loved and gratified by the feeling of being close to the mother.

In the second unit the mother withdraws, attacks and is angry and critical of the child for expressing it's own needs, thoughts and wishes which are contrary to the mothers and do not satisfy her needs. In other words when the child attempts to seperate and act capable and grown up. The HPD feels like a bad child and is empty, depressed and angry.

So like the high level Borderline the Histrionic is continuously projecting one of these two units. They do not see themselves or others for who they really are, as whole real people with both good and bad traits.

I worked with a girl who definitely met DSM-IV criteria for histrionic and possibly narcissistic and ASPD as well though not at all sure of those. The one I didn't see coming was bpd. It wasn't until she lost both parents, her job, her boyfriend, and other setbacks that the stress caused her to flip. She moved away from her remaining family support but came back a little over half a year later in shambles. She begged a friend to stay with her and the friend reluctantly agreed and the minute she set foot inside the house she took a box knife and opened her leg up to the tune of 18 stitches. Upon getting treated and getting some money she then proceeded on a drinking runner which consisted of going to the bars and partially removing her clothes to ellicit attention and drinks.

I don't know that even that is sufficient for a diagnosis of bpd but the self-injury definitely fits the profile. The DSM isn't a finished work. It's true that if you meet the criteria for a particular disorder then you are technically diagnosed with having that disorder. But what does that mean? All it means is that those who developed the criteria used in the DSM have, after presumably analyzing mountains of information, studies, etc., concluded that some behaviors tend to lump together nicely and if there are enough people that exhibit those lumped together behaviors then there should be a name for them. What it doesn't address with specificity is the underlying mechanism driving those behaviors. The DSM-V is going to look very radically different according to those who are familiar with it's development. Considering how vastly different the DSM editions have been, I think it's safe to conclude that we're still quite a ways off from understanding what needs to be known in order to treat them with any degree of specificity. Personality Disorders in Modern Life by Millon has matrices that show the personality results of people with mixes of two different personaility disorders.

One last thing, the distinction between histrionic and hysterical are ambiguous as well. Supposedly the hysterical is considered to be higher functioning than the infantile histrionic. My observations of the above referenced girl suggested that the differences between hysterical and histrionic lie along the same plane and their differentiating behaviors might all present and someone moves from a stable situation to an unstable situation. The girl I first met was a confident and composed, slightly arrogant fem fatale with the quiet inquisitive exhuberant little girl persona made famous by Marilyn Monroe. The girl I last experienced had regressed into a completely uncontrollable child shrieking at the very top of her lungs for her friend to pick her up after she became involved in a fight with another woman. It seemed to me to be something akin to near complete regression which, along the way, might have presented any number of behaviors that would allow for a diagnosis of several of the histrionic variants as well as more than one of the Cluster B disorders and/or their variants. It all seems to be closely interrelated but the method by which they connect is not fully understood. Thus, reading the DSM verbatim yields an overly rigid perception of what's actually going on. That's my take on it anyway.

there seems to be a lot of disagreement regarding the use and usefulness of the DSM-IV. many recognize its inherent limitations while others refer to it as the Bible of the APA and seek its guidance as if the whole body of knowledge in the field of psychology is contained therein. its stated purpose is to facilitate consistent communication within the psychological community, which translates to applying labels precisely. it contains disclaimers that attempt to soften the inherently hard edges with respect to its pass/fail criteria. the concept of comorbidity seems archaic [in my opinion] when talking about overlapping cluster B diagnoses, often so closely related as to be virtually indistinguishable, as if they were completely separate issues. disordered personalities do not present in tidy packages ready to be barcoded, scanned, labeled and arranged in neat rows without so much as a thought toward etiology, biology or the uniqueness of each individual. DSM-IV is a rather simple checklist that seeks to establish uniform semantics in the highly imprecise and evolving field of psychology with the same degree of measurable precision that has benefited physical medicine and the other pure sciences. It relies on observable behavior to the exclusion of all other knowledge and experience, because practically speaking that is the only universally available input in the context of the clinical interview. the irony is that in practice, especially at the edges of differential diagnoses, its application is almost entirely subjective based on the astuteness, predisposition and judgement of the individual practitioner. Whether or not a particular behavior is observable to the degree of deserving a checkmark today is always a yes/no judgement. tomorrow, next door, or with two more cups of coffee the judgement might go the other way.

interestingly enough, Theodore Millon (Personality Disorders in Modern Life, and many more), preeminent authority on personality disorder, was instrumental in the development the DSM-IV. criteria is decided by committee, using logical and practical considerations as well as compromise, to facilitate consistent application, and defaulting to non-diagnosis (effectively indicating that existing observable behaviors don't exist) when some degree of doubt is present as to whether an individual meets the full criteria, both in quantity and severity.

I am posting Kernberg's chart (for about the 5th time) which takes into account the relatedness and variability within the realm of cluster B disorders. Kernberg believes that borderline personality organization underlies the entire spectrum. severity of neurosis/psychosis is graphed on the y axis and introversion/extroversion on the x axis. these factors coincide with certain expressions (diagnoses) within the realm of cluster B disorders, or borderline personality organization. I assume that characteristics would typically occupy ameba-shaped, irregular areas on the chart, large or small, and that some individuals might occupy discrete areas on the chart.

http://salparadise.net/images/kernbergrelations_480.jpg

I am not implying that this chart is the perfect model, just that it seems more representative than a checklist and describes the relativity of the diagnoses to one another as well as presenting a different point of view regarding borderline organization and cluster B disorders.