Are survival skills and coping mechanisms DSM-codable?
This post won’t be interesting to anyone who isn’t involved in social work or the mental health field, so feel free to skip it and refresh yourself on what’s been happening lately with Larry. As I was sitting in my Human Behavior: Disorders of Adults class this morning, I was once again baffled by the level of discourse that happens in the School of Social Work. Lately we’ve been discussing disorders that I just don’t believe exist, and it’s becoming more and more difficult to keep my mouth shut. I often feel as though I come off like the angry, irrational feminazi during class discussions…which I am, but I’m trying to keep my cool these days.
Borderline Personality Disorder. Probably nothing else withers a social worker’s resolve to do good quicker than getting stuck with a client who’s got BPD, an Axis II diagnosis for which there is no cure and no medication, and for which the only known form of semi-effective treatment is something called “dialectical behavioral therapy”–where the therapist commits to being on call for the client 24/7/365 should a crisis arise.
So-called borderline behavior is characterized by attention-seeking, wildly fluctuating moods, manipulative and self-serving behavior, selfishness, an extreme fear of abandonment, and other forms of intolerable tomfoolery. Unable to connect with others or form lasting significant relationships, borderlines are always in some kind of hugely dramatic crisis, may constantly threaten to kill themselves, may hate your guts one minute and the next scream for you to never leave them. These are generally pretty emotional folks. And big surprise: the disorder is vastly overrepresented among females, with women being diagnosed at a rate of 20 times the rate of men.
But don’t worry, men! There’s a personality disorder for you too. Particularly violent borderlines are given the diagnosis “Antisocial Personality Disorder”, which generally means that you are one ginormous asshole. The disorder is most often found among felons, prison inmates, and petty criminals (a whopping 75%, apparently, of the prison population at any given time). And if I were a betting woman, I would put money down that it’s diagnosed more frequently in African-American men than other ethnicities.
And here’s the most ridiculous part. According to Kaplan & Sadocks’ Synopsis of Psychiatry (2007), the rate of personality disorders in the general population is between 10-20%. (Even my professor thought this number was excessive.) That means AT LEAST one in ten of us has a disorder so pervasive, so stigmatizing, and so heinous that few therapists will consent to see us and our lives will always be characterized by high levels of acute psychological crisis. My problems with this are manifold:
Point 1: Any disorder in which the numbers are drastically skewed one way or the other in regards to gender: BPD in females, APD in males, etc.–should have its criteria seriously reconsidered. BPD is another way of reinforcing the 19th century stereotype that women are hysterical slaves to their hormones, as APD an outdated cliche of men as violent, unfeeling machines. The DSM may be a really heavy book, but it’s hardly a definitive and unbiased take on mental hygiene. (Some other disorders codable by the DSM: Caffeine Intoxication, Inhibited Female Orgasm, and Gender Identity Disorder Not Otherwise specified, i.e. cross-dressing.) It fails to account for the social context in which we live and which informs our behaviors, motivations, mental health, and the coping mechanisms we develop to adjust to our environments (whether socially sanctioned or otherwise).
2. To that end, we should be asking why Borderlines do what they do. A huge percentage of the Borderline population are survivors of child or adolescent sex abuse; perhaps “Borderline” behavior is a warped survival response to a totally warped childhood. Similarly, Antisocial Personality Disorder is most often observed in men of low socioeconomic status who have problems in school and some involvement with the judicial system by the time they’re teenagers. Hmm. Could it be that these young men are simply developing a survival response to the difficult neighborhoods or disadvantaged circumstances in which they’ve grown up?
3. Finally, 10-20% prevalence: wow. Say that the DSM controlled for both of the above points I’ve just made, and still found that these so-called personality disorders existed in a large portion of the general population. To that I say, perhaps 1 in 10 people is just an asshole anyway. Think about it. Of all the people you are likely to meet in a public place–a concert, the Coney Island Mermaid Parade, the School of Social Work–don’t you generally find that about 1 in 10 of them are unsavory characters? Either they’re boorish, or intolerant, or nerve-gratingly annoying, or just plain assholish. Maybe these are the borderlines and antisocials the DSM’s talking about. If so, you can’t classify “weird” as a mental disorder, just like you can’t classify “bitch” or “Republican”. Give it up, you old white men who determine what is appropriate behavior!
Addendum: During class discussion about BPD, several people invariably tell horror stories about experiences they’ve had with this population to try to convince me that personality disorders do in fact exist. Their stories carry no weight for me for two reasons. One, I worked in battered women’s shelters, a population in which personality disorder diagnoses are a blanket phenomenon. Live, work, or volunteer long enough at a DV shelter and someone will diagnose you with BPD. My belief is that this is a blame-the-victim mentality which pathologizes women for being in an abusive relationship instead of placing the blame where it belongs: with the guy who beats her. Two, I have, at two points in my life, lived with girls who fit the DSM criteria for BPD to a T. But that’s another post for another day.
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April 1st, 2008 at 1:01 pm
just wrote 15 pages about DBT. we need wine pronto. there are a few things about it that i really think you’d dig as it pertains to “BPD.” lovelovelove!
April 8th, 2008 at 6:43 pm
*waving hand in air* I can guess which girls!! Or rather, I can guess one of them. And personally, I’m willing to believe that BPD exists just for her. Or rather, my mother convinces me of its existence on a regular basis
I think there is a difference, though, between a true personality disorder and a diagnosed personality disorder. If they’re being diagnosed at the rate of 10-20%, clearly, there is something terribly wrong (and I’ve been out of mental health professions too long to speak with any accuracy on this subject).
Killing 42 to women because you are humanly incapable of feeling empathy or remorse (a true anti-social) and ignoring your conscience to do what you must in order to survive (75% of the prison population) are two very different things. For them to be clumped together as one “disorder” is a disservice by those changed with improving our mental health.
But the real question is *why* these disorders are being diagnosed at a rate of 10-20%. If insurance companies and Medicaid *require* a DSM diagnosis to pay for treatment, is it the fault of mental health professionals for over-diagnosing, or is it the fault of old, money-grubbing white men in suits forcing everyone into prescribed categories for their own financial gain? Maybe we should lobby the APA to add “general asshattery, otherwise unspecified” to the DSM-V.
(and sorry fir the diatribe - I’m at work and bored. This is what happens.)