Tuesday, June 4, 2013

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation - Part 1

I’m going to dive headlong into a huge article I discovered about Identity disturbance in Borderline Personality Disorder. This will touch on identity/ego diffusion at various points. When I first started looking at identity/ego diffusion I realized it was just too large of a topic to try and explain as a one off issue. It needs to be encompassed in a greater whole to understand it better and keep it in context and I don’t like presenting misinformation so let’s not do that! This is a really large article so as I usually do with articles I’ll break this one up into article sections + my own commentary over the coming days.

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation

Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.


Abstract

OBJECTIVE: Identity disturbance is one of the nine criteria for borderline personality disorder in DSM-IV, yet the precise nature of this disturbance has received little empirical attention. This study examines 1) the extent to which identity disturbance is a single construct, 2) the extent to which it distinguishes patients with borderline personality disorder, and 3) the role of sexual abuse in identity disturbance in patients with borderline personality disorder. 

METHOD: The authors constructed an instrument that consisted of 35 indicators of identity disturbance culled from relevant clinical and theoretical literature and asked clinicians to rate a patient on each of the items. The patient group consisted of 95 subjects diagnosed with borderline personality disorder (N=34), another personality disorder (N=20), or no personality disorder (N=41). Relevant diagnostic, demographic, and developmental history data were also collected. The authors used factor analysis to ascertain whether identity disturbance is a unitary construct and then examined the relation between dimensions of identity disturbance and borderline diagnosis after controlling for sexual abuse history. 

RESULTS: Four identity disturbance factors were identified: role absorption (in which patients tend to define themselves in terms of a single role or cause), painful incoherence (a subjective sense of lack of coherence), inconsistency (an objective incoherence in thought, feeling, and behavior), and lack of commitment (e.g., to jobs or values). All four factors, but particularly painful incoherence, distinguished patients with borderline personality disorder. Although sexual abuse was associated with some of the identity factors, particularly painful incoherence, borderline pathology contributed unique variance beyond abuse history to all four identity disturbance factors. The data also provided further evidence for an emerging empirical distinction between two borderline personality disorder types: one defined by emotional dysregulation and dysphoria, the other by histrionic characteristics. 

CONCLUSIONS: Identity disturbance is a multifaceted construct that distinguishes patients with borderline personality disorder from other patients. Some of its components are related to a history of sexual abuse, whereas others are not. Identity disturbance appears to be characteristic of borderline patients whether or not they have an abuse history.

Identity disturbance is one of the nine criteria for borderline personality disorder in DSM-IV, yet its precise nature has received surprisingly little empirical attention. The major theoretical and clinical descriptions of identity confusion in borderline personality disorder come from the psychoanalytic literature, in which theorists have used terms such as fragmentation, boundary confusion, and lack of cohesion to describe the experience of self in borderline personality disorder. These concepts are difficult to operationalize, however, and several questions remain, such as the extent to which identity disturbance is a unitary phenomenon, the extent to which it distinguishes patients with borderline personality disorder from patients with other personality disorders, and the extent to which it is reducible to dissociative experiences seen in borderline patients with a history of sexual abuse. The goal of this investigation is to explore the precise nature of identity disturbance in patients with borderline personality disorder by discovering what types of identity phenomena discriminate between patients with and without borderline personality disorder while controlling for history of sexual abuse.

Identity: Meaning and Measurement

The major theorist of identity is Erik Erikson who popularized the term in his discussion of identity crises in adolescence. According to Erikson, identity includes role commitments, a sense of personal sameness or continuity over time and across situations, a sense of inner agency, and some acknowledgment of one’s role commitments and views of oneself by the broader community. Erikson argued that adolescents in many cultures experience a period of identity crisis, from which they emerge with some balance between identity achievement and identity confusion. A healthy identity includes the ability to choose an appropriate avenue for industry, achieve intimacy with another, and find a place in the larger society.
           
I think adolescence is coming in well after the issue as already started, especially if you’re looking at BPD. The problem here originates in childhood. Fortunately this is taken into account….

The opposite pole of identity is identity confusion, which Erikson originally called identity diffusion. Identity confusion manifests itself in a number of ways: 1) in a subjective sense of incoherence; 2) in difficulty committing to roles and occupational choices; and 3) in a tendency to confuse one’s own attributes, feelings, and desires with those of another person in intimate relationships and hence to fear a loss of personal identity when a relationship dissolves. Some individuals escape this state by choosing a "negative identity" (i.e., a role that is inappropriate or unusual given the individual’s attributes, such as race or socioeconomic status) that often constitutes a role or group identification negatively viewed by the broader culture.

This often happens with me when the person I’m with doesn’t have a strong sense of themselves. I find myself subconsciously meshing with them in an unhealthy way.

Reviewing both the empirical and theoretical literature on self and identity,  Westen summarized the major components of identity as being a sense of continuity over time; emotional commitment to a set of self-defining representations of self, role relationships, and core values and ideal self-standards; development or acceptance of a world view that gives life meaning; and some recognition of one’s place in the world by significant others.
The major research on identity reflects the work of James Marcia who operationalized Erikson’s theories into "identity statuses" or types. Marcia distinguished four identity statuses: identity achievement, moratorium, foreclosure, and identity diffusion. For identity achievement, a person must have struggled with issues of family, profession, religion, and values and have come to some kind of committed resolution. (This is what a person would typically strive for.)  A person who falls into the moratorium category has put off resolution of identity issues and remains in an extended state of identity search. (Moratorium isn’t necessarily bad I don’t think as long as you continue to search.) Foreclosure is the label assigned to people who have made major role commitments without ever seriously considering alternative possibilities or experiencing any period of struggle; people with a foreclosed identity have chosen a kind of de facto identity. Finally, the most severe identity problems are found in people with identity diffusion, who may have had multiple identity crises, chosen a succession of careers or religions, or may not even be aware of their lack of a cohesive identity.

By multiple identity crises, the identity that the person finds themselves taking on isn’t who they necessarily would have chosen for themselves.  This doesn’t mean split personality disorder (DID) dissociative identity disorder. This is like the personality projections, mirroring, and slipping into different roles and personas and skins that don’t feel quite like you when you’re in a different crowd or person. Waking up one day to find that the life you’re living has been tailored to suit someone else’s ideals instead of your own. You can check in, it’s not like you’re not in control of your body. Again, this isn’t a multiple personality disorder (DID) thing, it’s a subconscious need to please projection that you just subconsciously twist your actions to suit your situation to keep the people around you there. Until little, by little, you change and you change until you’re not you anymore and you look into the mirror and you see someone that looks familiar but you no longer recognize.



Tomorrow: Identity Disturbance in Borderline Personality Disorder……




7 comments:

  1. "Some individuals escape this state by choosing a "negative identity" (i.e., a role that is inappropriate or unusual given the individual’s attributes, such as race or socioeconomic status) that often constitutes a role or group identification negatively viewed by the broader culture."

    i wonder what this means. it seems to be completely different than the hellish chaos that eventually comes from mirroring.

    erikson means that some people with 'identity diffusion' hold onto identities typically viewed as 'negative' because they can feel solid?

    identity categories/labels like 'queer' or 'muslim' or 'feminist' come to mind as being seen as relatively negative in broader us culture. theyre also some of the few ids that i get a sense of stability and pride from. so i dont know how i feel about his pathologizing this.

    it feels like something a white man would say.

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    1. Hi There... Yeah so far I don't like what Erickson has to say much either. He feels very incomplete. Fortunately there are others to round this out. And after this article there will be more to come to further this idea and really get into the idea of ego diffusion.

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    2. Needless to say, Erickson was not what my Therapist was referencing when she mentioned it to me.

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  2. I live in Brazil. Here the public health service sucks and it is very expensive to make a particle psychological treatment. Psychologists and psychiatrists are also very unprepared, they do not like to give diagnoses, they only prescribe any medication and they have no commitment to the improvement of the patients. I've already been diagnosed with bipolar disorder and post-traumatic stress, but do not agree with these diagnoses. I see myself in every little word of your posts. I really liked your blog, while reading all this leave me worried. In Brazil have a psychological illness is a shame, my family does not believe in my pain, they say I'm inventing problems. I swear to god that I try so hard to get up every day.

    My identity is what disturbs me most, I feel I'm not enough, I'm not anything that i want to be, I do not know who I am, I am what is needed for people like me, I'm almost invisible, feel disappearing. I'm really tired. Reading all this makes me understand that I am not so guilty, I'm not so crazy.I need treatment for this disease and not take any remedies undiagnosed. Unfortunately for me it is impossible at the moment.

    I apologize if my English is bad. I like your blog very much.


    And a tip for everyone: never come to Brazil. Here is a den of corruption. Someday I'll get out of here.

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    1. I'm sorry to hear about that Thaís. I know from experience that the health system is awful here in Ireland too. Just wanted to say you're not alone and I hope one day you can move away from Brazil and things will get so much better. Everyone deserves to be happy and get treated correctly for their illnesses whether metal or physical. And your English is great!

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  3. Great article! I'm glad your focusing in this because I find identity disturbances and that 'lack of self' to be one of the most interesting things about BPD. Fascinating stuff. Can't wait for more!

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  4. I really like what you are doing with this blog. I am fascinated by the advances in diagnosis and treatment of BPD. I was diagnosed in 1986, and was in therapy until I and my shrink both retired in 2010. I still struggle with my symptoms, although as I have aged, it is not as life threatening a situation. (I am now 71.) The part of this article about identity diffusion comes as close to my experience as could be. It is comforting (sort of) to know that I am not so very different from some others, that I am not alone in my role playing to cover the fact that "no one is home).

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Leave me a comment! It makes me feel good and less paranoid about talking to myself =)

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