DSM stuff

So according to the DSM, having a personality disorder means that you do not feel or behave the way you're supposed to ("as expected") in your culture. I guess it's just another way of saying that you deviate from "normal" in some ways, which is necessary for any psychiatric diagnosis. I don't know why it's emphasised for personality disorders. It's as if they're still thinking of these disorders as being a manifestation of moral weakness. But, they're only called "personality" disorders, I assume, because they are "pervasive and inflexible", have an "onset in adolescence or early adulthood", and are "stable over time". This means that the symptoms are always there, and they have been since a young age, and they are there in many different situations. Personality is supposedly like this, although you would call them traits, not symptoms. Also, a personality disorder must involve "distress or impairment", which is what makes it a disorder.

I went to borders to check out some books, and I found one called borderline personality disorder: a therapist's guide to taking control, by freeman and fusco. For every DSM criterion there were vignettes to demonstrate it and a series of questions to ask to see how much the patient has problems with that criterion. I found that the only ones I scored high on were impulsivity, suicidal thoughts and emptiness (the first mainly applies when I feel stimulated, the last two only apply when I'm depressed). I didn't even score that high on self harm or emotional instability. I have a little bit of all of the criteria, but not enough, I don't think. I have at times frantically tried to avoid abandonment, but this doesn't happen in every relationship and I think that I exhibit a pretty mild form of "frantic" compared to the vignettes. In my first ever relationship in high school I probably acted exactly like someone with BPD. I may still be a little bit like this. It doesn't mean I have BPD.

I don't idealise people as much as just become obsessed/fall in love easily. I certainly don't devalue anyone afterwards.

I don't have the identity disturbance that was described in the book. I definitely have a normal amount of identity disturbance for a young person.

I could relate to some of the questions about anger, but they only applied to when I'm feeling agitated.

I'm not that emotionally unstable since I can go through long periods of stability, and I usually have a general mood which lasts more than a few days.

I've experienced dissociation and I'm sometimes paranoid. I'm not paranoid about being abandoned as much as being judged, though. And mostly I've experienced dissociation randomly, not during stress. I think it's pretty normal to have experienced some sort of dissociation. It's not a problem for me, I don't lose time or space out. I think the paranoia is related to social anxiety, or maybe the agitation.

So the criteria I actually fulfill are impulsivity and irritability when agitated or stimulated, and emptiness and suicidal thoughts when depressed. I may experience some dissociation and some paranoia when I'm agitated. I do fear abandonment, but this only comes out when I'm depressed. My relationships improve as I get older. None of the criteria that I fulfill are constant for me. They are not stable over time. They're not pervasive and inflexible. The identity disturbance and abandonment fears have improved over time, like you would expect. I don't see any way that a personality disorder could explain my symptoms.

On the other hand, I looked at a book about understanding the DSM. The section on bipolar was interesting. Mania was described more clearly: elevated mood interrupted by irritable outbursts, increase in goal-directed activity which can appear like unrelievable restlessness (exactly what I experience), thoughts & mental activity speed up (for me, reading and writing fast), high level of verbal output (in speech OR writing), loosening of inhibitions, foolish ventures e.g. business decisions, spending, sex.

Instructions were given to confirm presence of mania or hypomania by looking for changes in: sleeping and eating patterns, energy levels, restlessness, increased activities especially risky or destructive ones, problems concentrating, easily distracted, instances of extreme feelings of happiness, laughing inappropriately (usually accompanied by agitation), increased talking, pressured talking, racing thoughts - unable to keep up with the influx, impaired judgment, grandiose ideas, inflated self esteem, increased irritability or impatience, easily excitable, lack of interest in personal relationships, hallucinations, incoherent speech, violence, disorientation. Also important is a history of alcohol and drug use, medical conditions and medications.

Hypomania was described as increase in energy or irritability, decreased need for sleep, increase in activities (including spending), increase in pressured verbalisation, and the tendency to become quite creative.

Cyclothymia was described as having milder mood episodes but being chronic, lasting at least 2 years with no symptom-free periods lasting more than 2 months.

BP-II patients have a strong family history of bipolar OR depression.

The book also had an interesting case study of a bipolar woman. She had a complicated history of social and behavioural problems. Her mania manifested as delusions, compulsions, being argumentative, paranoia, dissociation, anxiety and obsessions. Her symptoms started at age 16 but she wasn't diagnosed properly until she was 34 (she was diagnosed with depression at age 30). She has tried over 15 meds, none of which stabilised her. She apparently had depression, low self esteem and attachment issues since childhood. She has a history of childhood abuse and parental abandonment. She has been married 3 times and had multiple abortions. She has violent mood swings and deep depressions, which she always thought was caused by PMS. She self medicated with marijuana every day from age 16 tp 36. She has always felt inferior and continues to. She has casual sex and has had numerous troublesome relationships. She idealises men and feels rejected when relationships end. She has no social or recreational interests. She excelled in school when she applied herself but always had trouble with concentration, attentiveness and social skills. She is generally suspiscious of people. She dropped out of school, and later attempted further study, but couldn't complete the degree. She has had many types of jobs, and self doubt and social fears stop her from following through on career decisions. Compulsive shopping binges lead to financial trouble. She has had chronic insomnia problems, increased appetite and weight gain. At the time of the assessment she reported depressed mood but she seemed talkative and her speech was pressured and non-goal-directed. She has had inappropriate judgement in the past and reports poor concentration, although she was alert during the interview.

It's interesting that no one ever tried to give her a borderline diagnosis! According to this book for a proper diagnosis of bipolar you need to identify mood episodes and then see if they meet the criteria AND see if they affect many areas of functioning. Current and past behaviours must be considered.