We’re coming to the end! And then we can move on to more topics on Ego/Identity Diffusion and Identity issues in general! I do like that I started with something solid to show that there is real research going on here though. I think that’s heartening for a lot of us to show that – No really, people do see that this is a real identifiable issue here. Even if scientific journals can be tough to gnaw through sometimes. With that…
Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 5
Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.
Previous research from our laboratory has found two distinct types of patients currently diagnosed with borderline personality disorder, one more distressed and emotionally dysregulated, and the other more histrionic.
I still don’t know if I agree with this subtype classification. I need more explanation because I find the histrionics are a mask for the emotional dysregulation and that emotional dysregulation is actually still there, it’s just being expressed differently.
The secondary analyses in this study provide suggestive data on differences in the types of identity disturbance characteristic of each subtype. Controlling for histrionic features, only the second and fourth factors, painful incoherence and lack of commitment, were significantly associated with borderline features.
In fact, each of these factors had a stronger association to borderline personality disorder ratings with histrionic features held constant. These factors appear to be more closely related to the emotionally dysregulated type. In contrast, when we held borderline features constant, the role absorption factor was significantly associated with histrionic ratings. The inconsistency factor appears to be associated with both kinds of patients, but particularly with the histrionic.
This paragraph is a mouthful. Let’s break this down so it’s more readable:
When studying the Borderline Groups but removing those with Histrionic features only the 2nd (painful incoherence) and 4th (lack of commitment) factors were significantly association with BPD features.
Each factor has stronger associations to BPD when the histrionic features was held as a constant, and not variable. These factors appear more closely related to emotionally dysregulated types of BPD this way. By contrast, when they held Borderline features as a constant, the role absorption factor (#1) was significantly associated with histrionic ratings. The inconsistency factor (#3) appears to be associated with both kinds of patients, but particularly with the histrionic.
Interesting. I may still have a bit of a histrionic streak. Hm.
This study represents a first empirical attempt to home in on what identity disturbance in borderline personality disorder really means, but several potential objections require discussion. The first is the question of diagnostic reliability, given that we did not use structured interviews. Recent research suggests that even with study group sizes as small as 20 subjects, the central tendency that emerges when clinicians make categorical personality disorder diagnoses tends to be robust. In addition, we measured the borderline diagnosis in four different ways. 1) Clinicians supplied a categorical diagnosis. 2) Clinicians indicated which DSM-IV criteria for borderline personality disorder were present in their patients. The list of symptoms was not identified as the criteria for borderline personality disorder and did not appear to deter many clinicians from rating five borderline personality disorder symptoms (including the identity disturbance criterion) as "present" in patients they had categorized as not having borderline personality disorder. 3) Clinicians rated the extent to which the patient showed features of each DSM-IV borderline personality disorder criterion. 4) Clinicians made a global dimensional rating of the extent to which the patient displayed symptoms of each of the 10 DSM-IV axis II disorders, including borderline personality disorder. In all cases, the borderline personality disorder group was clearly distinct from the other groups. No clinician who described a patient with borderline personality disorder endorsed fewer than five of the DSM-IV criteria; the average number exceeded seven. Secondary analyses that used level-of-functioning variables provided further evidence for validity. Finally, lower reliability among clinicians would foster type II, not type I, errors (i.e., null findings where positive findings are warranted). If clinicians were not diagnosing patients accurately, the borderline group would be more heterogeneous and thus less likely to show such robust differences from the other groups. The findings are even more striking given the less-than-optimal diagnostic reliability. Nevertheless, this is just an initial study, and future studies with more reliable diagnostic procedures are clearly warranted; one is currently underway.
I’m heartened to hear that there will be more in depth studies in the future and that there is, in fact, one going on now.
A second potential criticism is that since we relied exclusively on clinician reports, we were not testing the nature of identity disturbance in borderline personality disorder but rather clinicians’ implicit assumptions about it. In part, of course, we were attempting to assess what clinicians mean by identity disturbance. We generated a set of 35 highly specific items, of which 28 distinguished patients diagnosed by clinicians with identity disturbance from those without. Four factors derived from this item set accounted for much of the variance in clinician ratings of the presence as well as the severity of identity disturbance, which suggests the construct validity of the instrument.
This is one of my criticism actually as you may have noticed =P I really think these kind of studies need input influenced by people that actually have an understanding of what is happening so they have an idea of what to look for.
However I do like that simply by observation they found a very identifiable pattern of struggle. In general this is where I think pure Clinical analysis falls apart though. They can see patterns but then the Analysis and Resulting Conclusions tend to fall apart a bit or aren’t quite complete, at least not when read by someone that has an understanding from the side of actually having experienced it. There is validity in what they find, but it’s incomplete at best.
For several reasons, we believe these data provide meaningful information on the nature of identity disturbance in borderline personality disorder and do not simply reflect clinicians’ beliefs. First, all research relies on observation, and all observers have biases and intuitive theories. Most studies of psychopathology administer self-reports or structured interviews that ask patients to describe themselves and their psychopathology and then examine associations between these self-reported traits or symptoms and other self-reported variables. Our method is no different from this standard method, except that it uses expert informants rather than lay observers, for whom lack of insight into themselves is diagnostic. Given the subject of this study—identity disturbance—patients would likely have difficulty providing accurate information about their tendency to hold contradictory beliefs, their over absorption in particular roles, and so forth. We thus chose to rely on skilled observers who knew the patients well and used an instrument that asked very specific questions, most of which called for only minimal inference. Respondents were clinicians with an average of 18 years of experience who had seen their patient for an average of 53 sessions; they were thus likely to know the patients well and to be able to recognize clinically significant patterns. Ideally, studies such as this should use a combination of self-reports, interviews, clinician reports, and reports by family members and significant others to triangulate on the findings. Future studies should clearly rely on data from multiple informants.
Frankly I think this is the best way they could have handled this. It would have been interesting to have the patients also answer the questions separately to see how differently they answered and get a real idea of how great the identity disturbance is, but having a patients personal clinician of greater than 2 years is about as close a relationship as you can get for this kind of setting.
Second, and more important, shared theories could not have predicted the factor structure that emerged, the factors that correlated more strongly with borderline diagnosis, the factors associated with borderline personality disorder after controlling for sexual abuse, or the factors associated with particular subtypes of borderline personality disorder because there are no shared theories. The construct of clinical identity disturbance has been relatively ill-defined. No theory would have predicted the existence of four orthogonal factors in identity disturbance, or that subjective and objective inconsistency or incoherence would be uncorrelated with each other. These, we believe, may be important discoveries of this study.
That shared theories emerged is definitely important. Having correlations between a history of abuse, sexual abuse and the factors associated with the different subtypes when different variables were controlled may ultimately aid in more accurate Borderline diagnosis. It’s always exciting when shared theories emerge and you weren’t expecting them too. It tends to mean that things are related in ways that are significant but that had been overlooked previously… that you’re on the right track.
Third, we did attempt to assess the effects of clinician bias by examining the relationship between factor scores and clinicians’ theoretical orientation and discipline. Holding borderline diagnosis constant, theory did not predict any of the scores on any factors. Because most of the clinicians who participated in this study reported a primary psychodynamic orientation, however, we also investigated the role of discipline (psychology, psychiatry, social work) in predicting factor scores. Discipline failed to predict scores on any factors in any diagnostic group, despite the fact that clinicians from different disciplines have markedly different training.
No luck factoring in clinician bias. Hah. They’re good at scoring people with BPD, but not so hot at judging the judgers. Interesting. Professional courtesy? I can be less courteous if you need.
Fourth, dimensional and categorical diagnoses in this study produced identical findings. If clinicians were simply rating the 35 identity disturbance items on the basis of their beliefs about borderline personality disorder rather than on their actual knowledge of the patient, dimensional diagnosis would have produced much weaker findings than categorical diagnosis, since clinicians who described patients without borderline personality disorder would have systematically underdiagnosed identity issues. In fact, the regression analysis that predicted the number of borderline personality disorder symptoms from identity factor scores produced stronger findings than the comparable regression analysis that predicted categorical diagnosis.
Backwards and Forwards they got the same results. Asking the identity disturbance questions categorically to figure out if a patient had BPD or knowing that a patient had BPD and rating their responses to determine identity disturbance resulted cleanly. Good job.
Finally, as noted earlier, recent research suggests that when clinicians are asked to describe patients with various diagnoses, they do not tend to reproduce DSM-IV criteria or rely primarily on their intuitive prototypes. For example, when asked to rank order a list of 200 personality descriptors (which included DSM criteria) to describe a patient they were currently treating who had borderline personality disorder, clinicians in two studies did not tend to rank order the DSM-IV criteria the highest; rather, they painted a picture of borderline patients that tended to emphasize their subjective distress more than some of the more socially undesirable traits emphasized in DSM-IV. Indeed, cluster analysis of these descriptions led to the discovery of two replicable types of patients currently defined as borderline who do not, empirically, appear to fall into a single diagnostic category. Similarly, in the present study, clinicians rated 64% of all patients—including over half of the subjects without borderline personality disorder—as having identity disturbance as defined in DSM-IV.
In essence, Borderline Personality Disorder is a very complex disorder that is not limited to a mere checklist of criteria in the DSM-IV. This study lead to the idea that not only are there the 9 main criteria including identity disturbance, but there are also 2 subtypes (potentially more, but frankly I think they don’t have this quite right either, they definitely overlap). Not only that, 64% of all the patients in this study (including over half of the subjects WITHOUT BPD) had identity disturbance as defined in the DSM-IV. Remember they included people without personality disorders and people with personality disorders but not BPD with a history of sexual/abuse but still, that’s pretty significant. It’s not only us. That’s something to keep in mind. This is a serious issue and one with roots related to trauma at times, though clearly not always.
The data from this study suggest that identity disturbance is multifaceted, and that each of these facets is associated with borderline personality disorder. Identity disturbance in borderline personality disorder is characterized by a painful sense of incoherence, objective inconsistencies in beliefs and behaviors, overidentification with groups or roles, and, to a lesser extent, difficulties with commitment to jobs, values, and goals. These factors are all related to borderline personality disorder regardless of abuse history, although history of trauma can contribute substantially to the sense of painful incoherence associated with dissociative tendencies. Identity disturbance may manifest itself clinically in different ways depending on whether the patient is more emotionally dysregulated or more histrionic. Future research with a larger group of more carefully diagnosed patients will be required to make more definitive claims about these finer distinctions.
So what do you think? As I said back up at the top, I think it’s a good piece of solid research showing that identity disturbance is something that is clearly a struggle, a struggle that is noticeable and observable. That may or may not be reassuring but it’s a real thing.
Just because it’s all in your mind, doesn’t mean it’s not real. We don't have a 'Why', just yet, but maybe we'll get some clues as we go aloneg.