5. Features & Criteria - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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5. Features & Criteria

Therapist Resources > Therapy Books > Ouch Borderline in Couples

Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy

From the Diagnostic and Statistical Manual- Fourth Edition are the definition and criteria for borderline personality disorder:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:  

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. identity disturbance: markedly and persistently unstable self-image or sense of self.

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. chronic feelings of emptiness

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. transient, stress-related paranoid ideation or severe dissociative symptoms (American Psychiatric Association, 1994, page 654).

The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

From the Diagnostic and Statistical Manual- Fifth Edition are the definition and criteria for borderline personality disorder:

A. Significant impairments in personality functioning manifest by:

1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.


2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

B. Pathological personality traits in the following domains:

1. Negative Affectivity, characterized by:
a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

c. Separation insecurity: Fears of rejection by –and/or separation from –
significant others, associated with fears of excessive dependency and complete loss of autonomy.

d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of
inferior self-worth; thoughts of suicide and suicidal behavior.

2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger.

3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last).  Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, and hypnotic phenomena) during times of stress.  Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships.  Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring mood disorders or substance-related disorders.  Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts.  Recurrent job losses, interrupted education, and broken marriages are common.  Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separations are more common in the childhood histories of those with borderline personality disorder.  Common co-occurring Axis I disorders include mood disorders, substance-related disorders, eating disorders (notably bulimia), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder.  Borderline personality disorder also frequently co-occurs with the other personality disorders (American Psychiatric Association, 1994).

Identifying or uncovering associated features can lead to clinical exploration that uncovers borderline personality disorder.  For example, certain problematic behaviors may be indicative of the disorder.  "Feminist and psychodynamic theorists have suggested that difficulties with intimate relationships, especially with men, are a central problem in bulimia… First, the bulimic has a tremendous desire to please others.  Second, bulimics expect to be rewarded by men for their strivings to fit the perfect feminine role and, thus, are very vulnerable to rejection.  Third, because the bulimic gains her sense of self-worth through others, her resultant over-dependence on others creates a self-perpetuating pattern of rejection.  Fourth, bulimics fear men because, although they seek self-validation from men, such dependence gives men the power to reject.  Finally, binging itself distances the bulimic from others, both through anxiety about eating with others and through the secretive nature of this behavior.  (Pruitt et al., 1992, page 472).  Bulimics have difficulty establishing intimate relationships.  "Bruch (1973) states that bulimics over-emphasize, idealize, and exaggerate romantic relationships" because of unmet family-of-origin love and acceptance needs.  This predicts failure for their relationships.

A different couple- Savannah and Liam had been dating for several years.  Early in their relationship, there had been infidelity on his part.  Liam had played college sports and traveled often to away games and tournaments.  Away from home and caught up in the freedom and hedonism of his teammates, he had gone beyond his limit drinking and both times, ended up doing some pretty stupid things.  He had gone to therapy to work on himself, stopping drinking, and had been "well behaved" every since then.  Savannah was worried whether he was "for real" or had been just "behaving good" for the last several years.  They were getting to their late twenties and both of them could see getting married and starting a family with children fairly soon.  Liam said he was "all in" for the next step.  He was worried that Savannah would obsess about his former excesses forever, no matter what he does or how committed he is.  And one other thing, Savannah was bulimic.  She binged on sweet desserts and purged by throwing up almost every day.  She was about 5'-1" average build and weighed about 125 pounds, which is well within an acceptable range for age, height, and weight.  She was also very fit from being a college athlete as well and working out regularly.  She rued coming from "stocky" Polish ancestry.  She was smaller and much more fit than her Polish-American aunts and girl cousins.  Despite that, she thought herself fat and disgusting despite reassurance from Liam.  A single pound of weight gain upset her.  Further, exploration of her background found a chaotic childhood, her parents divorcing when she was 3 years old, and being molested by her mother's brother for a year and half from when she was 8 years old.  Although, Savannah did not meet criteria for borderline personality disorder, she had definite borderline tendencies that affected the relationship.

Descriptions and associated features of bulimics often essentially mirrors descriptions and associated features of borderline personality disorder.  Bulimia is one of many associated features of borderline personality disorder that the therapist should be alert to.  The individual, the partner, and the couple usually do not first name borderline personality disorder as the presenting issue.  Bulimia, depression, unhappiness, or terrible luck with love, for example may be identified as an issue.  The therapist often finds that initially the array and intensity of the associated features rather than DSM criteria point therapy to the borderline diagnosis.  The therapist

Must become knowledgeable about associated features of borderline personality disorder;

Recognize features that may indicate borderline personality disorder in the individual;

Work with the individual and the couple to manage unproductive or harmful behaviors (bulimia, suicidal behavior or thoughts),  while also dealing with underling issues;

Educate both the individual and the partner of the relationships between behaviors and underlying issues.
3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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