Breaking Down The DSM

After being inspired by someone else, I thought tonight I would take a look at how the DSM criteria fits me - both now, and how it fitted/impacted me pre-DBT. (I'll apologise now, I'm retyping each of these as I go, so you'll need to forgive me for changing the spellings to the accepted Australian equivalent!)

The DSM-IV criteria for Borderline Personality Disorder states that there must be "a 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". Before I elaborate on the indicators, I'll make a few comments on this. I still don't think the psychiatrists had enough information about me to diagnose me when they did, but I have to admit that it's certainly true that I was exhibiting signs of poor mental health by at least the time I was 3. That, I think, certainly falls under "by early adulthood".


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

To me, this depends how much meaning we're attaching to the term "frantic efforts". What does that even mean, anyway? Are we talking physically holding on and begging them not to leave? I've never threatened to do anything drastic because someone was thinking about leaving. I don't recall screaming or pitching a fit to keep someone from leaving. I did, however, cling desperately to my friend's husband's hand when he had to take me to the doctors, and again when he had to take me to the hospital. I've made attempts to reduce the likelihood of abandonment by doing things like not admitting to liking something, or wearing the guilt for something they might have done wrong, or going back on my values, though. That one, I have to admit, is accurate for both now and the past - but I'm pleased to report that, post-DBT, I'm now less likely to resort to these behaviours.


2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.

I freely admit, I've always been terribly guilty of placing people upon pedestals that are far too high, and becoming devastated when they eventually tumbled. I'm not sure I would categorise myself as having a pattern of unstable relationships characterised by that, though - some, certainly, but I believe that the majority of my relationships with people were fairly stable pre-DBT, and even more now. One thing I've come to understand is that, pre-DBT, when I idealised someone, it took quite a bit for them to fall. Usually if there was anything that might have knocked them from their perch, I took responsibility for that, and thus kept the other person "pure". Post-DBT, I've become more able to hand responsibility where it belongs, and so people are falling from their pedestals a little more frequently. Interestingly, the pedestals I'm building now also seem to be shorter.


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

All my life I have been a chameleon. Whoever I was with, that's who I became. If someone wanted a certain type of person, I would do my best to fit that mould. My self-image in that time has remained fairly stable, but my sense of who I am has not. Having done a full course of DBT, I'm finding myself a little less unstable in my sense of self - I'm beginning to find a niche for myself that feels right; beginning to get an idea of who this person who goes by [dawni] actually is. Feedback from others still helps make up the basis of what I know about myself, but I'm slowly learning to match that feedback with what others have told me, with what 'feels right'. I have learnt that I like photography a lot, that I am avoidant and that I am a difficult read. I have decided for myself that my favourite colour is blue and my favourite animal is the giraffe; I have given myself permission to choose these things for myself.


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 behaviour covered in Criterion 5.

Impulsive? For a long time, that seemed more like something that would apply to my ex husband than to something that applies to me. In general, I'm not a particularly sexual person and I don't drive at all, so I think we can safely leave those two aside for now.
I am quite impulsive with my spending, probably more now than pre-DBT, but I've never spent so wildly that I've put myself in serious financial hardship.
My eating has been pretty shocking for years. Particularly in the lead up to my diagnosis, I occasionally binged, but more often starved myself. Admission to hospital set me back on the path of eating, but this time I moved back into binge eating. Post-DBT, my eating disgusts me. Despite knowing that it is a choice, I seem to have little control over my binging, and I am mortified at the amount of weight I have gained. This, too, is a side effect of my medication: extreme cravings, particularly for carbohydrates and food binges - one of the reasons it is described by those who've taken it as "legal marijuana".
As for substance abuse, I suppose it's time I admitted it. I was well on the way to becoming a drunk, pre-DBT. I'm ashamed to admit that I probably turned up at work still slightly drunk on more than one occasion; ashamed to realise how many times I went with what would have been a hangover, if I got them. During DBT I got this one, at least, under control. I went from several times a week drunk to drinking only once every month, or couple of months. Unfortunately, when DBT ended, the first thing I did, was to go back to drinking heavily. (I'm pleased to note, though, that in 8 hours, I will have been alcohol free for 9 days. It may not sound like a lot, but it's something, and that counts.)


5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.

This one rings true both pre and post DBT, but the suicidal thoughts  and attempts have lessened. In the six months before I began DBT, I had about a dozen hospital stays of varying length either after a suicide attempt, or to circumvent suicide urges. Post DBT, the hospitalisations have lessened (in fact, I've only had a few one or two nighters in the entire 13 months since DBT began). One thing that does both fascinate and frighten me, however, is that although at this point, my self harm has decreased slightly in frequency, there has been a marked increase in the severity of incidences. (And I'm pleased to note that although I have had one possible slip [that I am choosing not to count], and three minor wound interferences, I am coming up on 9 days since my last incident of "real" self harm.)


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).

Ah, finally, one that actually doesn't apply to me, either pre or post DBT. One of the reasons I fought the BPD label so long was that I lack the short term see-saw of emotions I feel this describes. My moods don't up/down that way, for the most part, and I don't really believe they ever have. When I experience an emotion, it tends to stick around for a long time - and here I'm talking more like weeks than hours. That said, I do struggle with emotion identification, so it's possible I may be way off base saying this one doesn't now, and never has, applied to me.


7. Chronic feelings of emptiness.

I denied this one, in the past, but I'm starting to wonder if it may have fitted after all. How do you define or describe a feeling of emptiness? I currently link it, in my mind, to that unstable sense of self: but is that accurate? Is it that search for self, that search for something that will complete you? Because if that's what they mean by feelings of emptiness, I'm already on board that train.


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

Difficulty with anger is certainly something that I struggle with, but in my case, it takes the opposite form: I struggle to allow myself to feel or express anger at all. Pre- or post- DBT, I think this is another one I can just cross off the books.


9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

I've heard 'psychotic' symptoms included in this box, as well, so I'm going to include that in my response. Dissociation is certainly applicable, both now and pre-DBT, though, again, the dissociation has lessened since DBT. I do suffer a small amount of paranoid ideation, and minor 'psychotic' symptoms such as hallucinations and 'voices' during times of particular stress; all of which has lessened since doing DBT.


In all, I can see from this that DBT has made a difference. It's hard to see, with just the criteria looked at in this way, how huge the changes have been for me, because the biggest ones have been in areas that aren't really covered by the DSM criteria. Things like learning how to ask for things, and building confidence. Things like being able to look someone in the face, or tell someone, "I feel angry today"; they don't show on the DSM criteria.

I'm considering making this my focus for the next week and going back over each criterion a day at a time, in order to highlight what I am doing, and what I can do, in order to continue minimising the effects of each on my life. I'll sleep on it and see how I go tomorrow.

In the meantime, I welcome those of you who knew me prior to DBT, and those of you who know me now, to share thoughts on what I have written, or what you may or may not have seen change in me regarding these criteria.


Today's thought challenges/cheer-leading statements:
I am not drowning. I am adjusting, and I am doing fine. I will be okay.
I am not a bad person.
My husband and I had some good times, and we had some bad times, and that's okay. Those times are over now and that's okay. That's how life works.
I am not responsible for someone else's emotions or choices. I am only responsible for mine.
It's okay to feel whatever I'm feeling. No emotion is wrong or bad.


Take care of yourselves until next time and may we all find our fence eventually.