Monday, March 28, 2011

Axis I vs. Axis II: Controversy in BPD- Part 4

Where does Borderline Personality Disorder belong?

I’m referring to the DSM criteria for Axis I and Axis II designation. Let’s start off with, what’s the difference between Axis I and Axis II.

* Axis I: major mental disorders, developmental disorders and learning disabilities. Axis I disorders are predominantly mood disorders.
 * Axis II: underlying pervasive or personality conditions, as well as mental retardation. Axis II disorders are personality disorders.

For or Against?

[For Axis 2] Personality disorders are classified as Axis II disorders.
Personality disorders in general have their own list of general criteria that must be satisfied. They’re a class of personality types and behaviors that the American Psychiatric Association (APA) defines as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it”.
“These behavioral patterns in personality disorders are typically associated with severe disturbances in the behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior is ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in the client adopting maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress and depression in clients.”
The behaviors cause serious interpersonal and social difficulties as well as general functional impairment. I don’t think anyone can argue that BPD fits this criteria, which is a large part of why it is considered Axis II. It also has a sub-designation as Axis II, Cluster B which is characterized by dramatic, emotional or erratic behavior. No argument there either.

[For Axis 1] Both Axis I and Axis II are psychiatric disorders. Only personality disorders and mental retardation are segregated onto Axis II. All other psychiatric disorders are Axis I. Does it really make sense to segregate these if they are essentially the same type of thing?
[For Axis 2] However Axis I disorders are generally treatable with medication. While some presenting symptoms of Axis II disorders may be treatable with medication, it’s not shown that medication can ‘cure’ a personality disorder and correct all presenting symptoms.
 [For Axis 1] Moving BPD to Axis I would have economic benefits. Many insurance companies don’t recognize BPD as a treatable condition and use it as an excuse to withhold payments. I know for a fact that my therapist classifies me as Major Depressive when billing my insurance company. I am pretty certain my psychiatrist does as well. This is certainly true, but not completely accurate.  I’m not going to complain though.
I think the major debate lies here:
[For Axis 2] Axis II BPD is pervasive to a person identity, characterlogical in nature.

[For Axis 1]: But…There’s some debate about whether BPD should be considered a ‘personality disorder’ at all because it has such a high rate of co-morbid symptoms that fall into the Axis I designation.
Axis I disorders are primarily for mood disorders that are reactions to atypical situations which are not part of a person’s character. “Mood disorder is the term designating a group of diagnoses in the DSM IV TR classification system where a disturbance in the person's mood {not their character} is hypothesized to be the main underlying feature. The classification is known as mood (affective) disorders in ICD 10.”

[For Axis 1] There are many disorders that are just as pervasive as BPD such as bipolar, anxiety, and depression that are not caused by atypical situations, and are classified as Axis I disorders.
Two groups of mood disorders are broadly recognized (though not limited to these two); the division is based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, of which the best known and most researched is major depressive disorder (MDD) commonly called clinical depression or major depression, and bipolar disorder (BD), formerly known as manic depression and characterized by intermittent episodes of mania or hypomania, usually interlaced with depressive episodes.”

People with Borderline Personality Disorder almost always have a history of long term, pervasive depression.  I’ve never heard of anyone that didn’t, but I’m not a clinician. Hypomania is not always present. If you have manic phases though, that is the definition of Bipolar and while you can have bipolar disorder and BPD, I think you would then have both Axis I and Axis II designations, not just one or the other. From here it could be argued that the mood regulation disorders are the underlying cause for all the other disorder manifestations.

[For Axis 1] There’s also the stigma that a personality disorder just means that a person has a flawed personality that can’t be changed.  Except there has been plenty of research to support the idea that this is an emotional regulation disorder.  Which means it would technically be a mood disorder and qualify it for Axis I.
I can see how the mood disorder aspects can affect a lot of the behaviors and symptoms of BPD. I'm not sure it can explain all of them though. Things like a tendency towards impulsive behavior, identity disturbance, fear of abandonment, etc... these are not necessarily dependent on mood alone.

I certainly don’t believe that a personality disorder just means you have a flawed personality. Calling it a flaw implies that it’s a minor issue, easily corrected. BPD is not minor, nor is it easily treatable. You might not be able to change everything about who you are (or want to), but if there is an aspect of your life that you do not value; if you are willing to put in the effort; if you have hope of living a better life or just a life different from what you currently experience– it is absolutely possible to make changes in yourself. Without hope for change there can only be resignation to the inevitable. But people do have control over their lives, what choices they make, how they want to live. It may not be easy, maybe everything can’t be ‘fixed’, but it is possible to heal from those things that we are willing to work to change.


  1. I think the key is in your last sentence.

    It may not be easy, maybe everything can’t be ‘fixed’

    People seem to think because you can't be "fixed" then you're a lost a cause or broken beyond repair. I think this type thinking with BD or BPD needs to change. I may not see the world like everyone else does but I can still see it.

  2. "I may not see the world like everyone else does but I can still see it."

    I love this sentiment. It's so very true.

    A lot of it goes back to the stigma against these disorders. It's a biased view that absolutely needs to change. Just because things are different for us doesn't mean there isn't hope for us.

  3. That is why I admire you and people like you. It's easy to stigmatize the zombie drooling in the corner, but when people see you, they see the PERSON behind the DISEASE.

    That is so important. By writing the way you do, you give a voice to those who can't speak. It's important for people to speak out because as long as the silence remains then so will the stigma

  4. I do not think multiple co-morbidities and hope of more funding are valid reasons to take BPD out of Axis II, especially if they are only going to restructure the entire personality disorder diagnostic method in the next revision. Somatoform, sexual, impulse, eating, and adjustment disorders are also frequently stigmatized/misunderstood, include co-morbitities, and require long-term therapy insurance does not want to pay for. That said, I also think bundling PDs with MR in Axis II makes no sense. I would like to see Axis I include clinical and personality disorders and Axis II retooled for "disorders first diagnosed in infancy, childhood, and adolescence"

  5. The most recent research on BPD indicates that this disorder is a treatable condition. It is not permanent and unchanging as is currently indicated under the AXIS II designation.The name should be changed to something more descriptive.There are biological components to BPD as there are biological components to bipolar disorder. It’s time to get rid of the Axis II classification of BPD and treat it like bipolar disorder.Please sign the petition to ask to change the BPD diagnosis to Axis 1 & to change the term “borderline” to something more descriptive.Thanks

    1. See I think it is sort of permanent but still definitely treatable. I also don't agree that the name should be changed to something more descriptive. I think a more accurately descriptive name would actually increase the stigma for the disorder.

      My psychiatrist has been trying to treat me as if I'm bipolar and it's done more harm than good. I don't disagree with the Axis II designation but I do disagree that it's an Axis I disorder.

  6. More info on why it should be changed to Axis 1 and other changes in the criteria can be found here:


  7. What improvements do you think could be made to the axis approach while still maintaining the important structure of care documentation?

  8. I am the eldest in a family of five. My next in line sister who is ten yrs younger than my self has been treated for depressions and anxiety since her early 20s. Most of the time she has had a short walk to a place that looks like "whatever normal is". two years ago she spiraled and nothing could get her back to a place where she had any happiness, could work and it became worse and worse with every passing month. The more meds they piled on her the worse it seems she became felt. Now she is in hospital for the 3rd time since Aug and this event s had them wean her off most of her previous meds and identify her with a Axis 11 disorder and Chronic Resistant depression. This is a new world and we are getting very little guidance other than some e-mails that have most of us very frightened for our sister.. One of the other siblings found this web site and I decided to write after reading much of this blog and the postings. Thank you for being here.

  9. the sister mentioned above is now almost 55.

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  12. just been diagnosed axis 1/axis 11 .... no wonder I've been confused the question being what caused this in the first place


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