Wednesday, June 5, 2013

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation : Part 2

Ready for Part 2?  We have at least two more parts after this. It gets deep. There’s an entire day for Results and there are a lot! I may even have to split up the Discussion into two days because wow. Just wow.

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation : Part 2
Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.

Identity Disturbance in Borderline Personality Disorder

Several clinical theorists have attempted to describe the nature of identity disturbance in borderline personality disorder. According to Kernberg, identity diffusion in patients with borderline personality organization reflects an inability to integrate positive and negative representations of the self, much as the patient has difficulty integrating positive and negative representations of others. The result is a shifting view of the self, with sharp discontinuities, rapidly shifting roles (e.g., victim and victimizer, dominant and submissive), and a sense of inner emptiness. Kernberg also emphasized the way defenses that allow patients with borderline personality disorder to remain comfortable with remarkable inconsistencies inhibit the capacity to form a coherent view of themselves.
            So far so good. Simplified but just a summary really.

Adler and Buie described patients with borderline personality disorder as suffering from a sense of incoherence and disjointed thinking, feelings of loss of integration, concerns about "falling apart," and a subjective sense of losing functional control over the self and other forms of "self-fragmentation." From a self-psychological perspective, these patients lack an ability to internalize many aspects of their primary caregivers that would allow them to develop a cohesive sense of self. Fonagy and colleagues drew upon empirical data with both borderline patients and maltreated young children to emphasize the failure of patients with borderline personality disorder to develop the capacity to step inside the mind of another and to imagine the way the other experiences the patient. Historically, social identity theorists such as the symbolic interactionists (notably George Herbert Mead) emphasized the extent to which our views of ourselves result from the reflected appraisals of others—that is, from seeing ourselves in others’ eyes and hence learning about who we are. To the extent that patients with borderline personality disorder have difficulty seeing themselves in the mind’s eye of another, they should have difficulty in developing coherent identities.
This is quite interesting. I especially connect to the idea of self-fragmentation. I still feel like I’m trying to pull pieces of myself together to form a cohesive whole. The idea that I lack the ability to internal aspects of a primary caregiver that would aid in developing a more cohesive sense of self is also something that Therapist has mentioned to me before as well. That inability to see myself as another see me: that feels like a lack of object constancy to me in a way. That feels like how I can’t image other people remembering me. I can’t fathom other people holding onto me; holding me as significant; internalizing me; seeing me. I’ve mentioned this many, many times before in my blog. I never made an association between my lack of object constancy and my less than solidified identity. Hmmm. Understanding the connection between how others see me and how I understand how others see me. Something to ponder…. For you too maybe.

Systematizing the clinical and theoretical literature, Westen and Cohen summarized the major attributes of identity disturbance hypothesized to be central to borderline personality disorder. These include a lack of consistently invested goals, values, ideals, and relationships; a tendency to make temporary hyper-investments in roles, value systems, world views, and relationships that ultimately break down and lead to a sense of emptiness and meaninglessness; gross inconsistencies in behavior over time and across situations that lead to a relatively accurate perception of the self as lacking coherence; difficulty integrating multiple representations of self at any given time; a lack of a coherent life narrative or sense of continuity over time; and a lack of continuity of relationships over time that leaves significant parts of the patient’s past "deposited" with people who are no longer part of the individual’s life, and hence the loss of shared memories that help define the self over time.

I feel this is true on some level but is only a partial truth. I do feel like I have a sense of who I am, or at least who I want to be, but depending on who I’m with, their values can often override or overshadow who I am/want to be and I lose myself which leads to the inconsistencies. It's not intentional or even necessarily noticeable, but it happens. Often gradually and to appease a person to avoid abandonment. So it’s not that there is just an empty shell to begin with, I do have a sense of myself, but I allow others in and they tend to take over.  

The clinical literature on identity disturbance in borderline personality disorder provides a rich conceptual foundation for understanding identity disturbance, but empirical research remains limited. A central issue in understanding identity disturbance in patients with borderline personality disorder is the relationship between identity disturbance and a history of sexual abuse. Research suggests that 30%–75% of adult and adolescent patients with borderline personality disorder have reported histories of sexual abuse. In addition, sexual abuse history and dissociative experiences are either common in, or diagnostic of, both borderline personality disorder and dissociative identity disorder. Given the association between sexual abuse and dissociation, the high percentage of borderline personality disorder patients with sexual abuse histories raises questions about whether identity disturbance is really characteristic of borderline personality disorder or rather of a history of severe and pervasive sexual abuse.

The present study represents an empirical examination of identity disturbance with two aims: to clarify the construct of identity disturbance and to try to discern the features of identity that distinguish patients with borderline personality disorder from other psychiatric patients.


(I took out some of this information for the sake of brevity. If you want all of the methodology feel free to go to the original article.)


Respondents for this study were experienced psychologists, psychiatrists, and social workers. The use of clinicians (rather than patients) as respondents is a growing practice in psychiatric research. Aside from substantially increasing the numbers of patients who can be included in a study (and hence increasing generalizability and power), the use of clinicians has several advantages. Clinicians tend to be sophisticated observers, who see a patient longitudinally and can often offer more informed and potentially less biased judgments than patients themselves or interviewers who see the patient for 90 minutes or less. Clinicians can, of course, be biased by their theoretical preconceptions; however, all observers have theories and hence potential biases, such as the intuitive theories patients hold about themselves (that is, their conscious self-concepts, through which their answers to the standard questionnaires and structured interviews are always filtered).

The question, then, is whether, in a given research domain, self-report biases or clinician-report biases are likely to be greater.

 Four factors led us to prefer trained observers as our informants: 1) the absence of shared theories about the multidimensional nature of identity disturbance that could produce bias; 2) the possibility of drawing from clinicians with diverse training experiences (psychiatrists, psychologists, and social workers) who would not likely share the same biases; 3) prior research that had used this method and demonstrated that clinicians do not tend to rely on diagnostic prototypes in describing their patients but instead tend to describe what they see clinically ; and 4) the problematic nature of asking patients about phenomena such as their conflicts over ethnicity, gross inconsistencies between what they say and what they do, and the tendency to define themselves in terms of extreme groups or roles.

Clinicians were given a diagnostic/demographic/developmental history form adapted from previous studies and an identity disturbance questionnaire designed expressly for the purpose of this research.

We solicited data from clinicians at The Cambridge Hospital/Cambridge Health Alliance at Harvard Medical School by contacting staff and trainees and expanded our criteria by 1) eliminating gender and age restrictions, 2) including patients seen up to 2 years in treatment, and 3) not predetermining whether the clinician should describe a patient with borderline personality disorder. In addition, we added a second cohort of clinicians (N=45) who completed questionnaires at a workshop on personality organization in Washington, D.C. With these modifications, we obtained our intended study group size, which we had preselected based on power considerations. Clinician respondents were, on the average, quite experienced, with mean of 18.13 years (SD=11.09) of clinical experience. They also knew the patients well; the median length of treatment was 30 sessions (mean=53.27, SD=78.59). Clinician respondents included psychiatrists (N=17), psychologists (N=41), and social workers (N=32).

Identity Disturbance Questionnaire

This assessment tool included 35 items rated on a 1–7 scale (1=not true at all, 4=somewhat true, and 7=very true). We included a mixture of items that required some inference (e.g., "sense of identity revolves around membership in a stigmatized group") and items that described relatively manifest aspects of the patient’s life. In general, the questions were written to require minimal interpretation on the part of the clinician and hence to minimize room for unreliability as a result of idiosyncratic reading of the items.

The item set assesses multiple possible indices or manifestations of identity disturbance, such as unusual name changes (other than marriage), contradictory beliefs and behaviors, frequently changing values, feelings of inner emptiness, and confusion over sexual orientation. We developed items by examining the relevant theoretical, clinical, and research literatures. For example, Erikson posited the existence of a negative identity, in which a person chooses a label or persona for the self that seems inappropriate given his or her socioeconomic status, gender, or ethnicity; often this identity focuses on being "bad." Thus, we operationalized the concept of a negative identity with items such as "sense of identity revolves around membership in a stigmatized group (e.g., child of an alcoholic, sexual abuse survivor)." Also derived from Erikson’s theoretical work and Marcia’s research on identity were various questions regarding professional commitments, political beliefs, and changes in sexual orientation.

Goodness I can think of multiple examples, and by multiple I mean vast swaths of time and probably dozens and dozens of instances of this just without putting much thought to it at all.  

From the clinical literature and our own clinical observations we derived a number of phenomenological items that described the patient’s own feelings and thoughts about his or her identity (e.g., "false self," "unreal") as well as descriptions of problems with identity that have been apparent to clinicians who work with borderline patients. From the research literature on dissociation, we drew items such as "has trouble telling life story; narrative accounts have large gaps or inconsistencies."

I think this would be helpful to keep for myself sometimes when I’m with someone or with a group of people and I feel like I’m acting differently that I would normally. Write down points of the night and put a note next to it labeled with “false self” or “unreal” when I felt that way.

Diagnosis, Demographics, and Developmental History

Given potential unreliability of clinician diagnoses and to maximize reliability, we measured diagnosis in a variety of ways. First, we asked if the patient had an axis II diagnosis and, if so, to name it. Later, clinicians rated by means of a 7-point scale (where 1=not at all and 7=very much) the extent to which the patient displayed symptoms of each of the 10 axis II personality disorders in DSM-IV. Because we were most concerned with the validity of borderline personality disorder diagnoses, we also included a list of the nine DSM-IV criteria and asked clinicians to make two determinations: 1) whether each symptom was present or absent and 2) the extent to which each item applied to their patient, again according to a 7-point scale.

We included four additional validity checks. First, we asked clinicians to report the patient’s Global Assessment of Functioning score. We then asked clinicians to report on the patient’s employment history, quality of peer relationships, and amount of social support (the number of close relationships or people in whom the patient feels comfortable confiding that the patient had described to the clinician).

We also asked for basic demographic information, including the patient’s age, sex, race, and socioeconomic status and the clinician’s sex, race, discipline, years of experience, and theoretical orientation. We inquired about clinician characteristics to investigate any possible clinician bias reflecting differential training or demographics. We also inquired about the psychotherapy setting (e.g., outpatient clinic or private practice) and number of sessions the clinician had seen the patient.

Finally, we assessed a number of aspects of the patient’s developmental history. The most important was information about the patient’s history of childhood abuse, particularly sexual abuse. Because sexual abuse history is of particular relevance to questions of identity disturbance, we asked clinicians not only to report no/unsure/yes to questions about abuse history but also to report the basis for the belief about the patient’s abuse history. To be coded as having been sexually abused, the clinician needed to report that the patient had conscious memories when treatment began or that the abuse had been confirmed by an outside source (e.g., Department of Social Services, police, or doctor).

Alright, all the checkboxes are check and all the ducks are in order. We get it. Good job. I’m cheeky today.

Statistical Analyses

Three questions were central to this investigation:

1) Whether identity disturbance is a unitary or multidimensional construct;

2) Which aspects of identity disturbance distinguish patients with borderline personality disorder; and

3) To what extent these aspects of identity disturbance continue to predict borderline diagnosis after controlling for history of sexual abuse.

To address these questions, we first subjected the identity questionnaire data to factor analysis to see which items [occurred] together. We then used tests to compare the mean scores of each item to determine which, if any, would distinguish patients with borderline personality disorder. We then ran a contrast analysis for each factor to test hypotheses about identity disturbance in patients with borderline personality disorder, patients with personality disorders other than borderline personality disorder, and those with no personality disorder. Multiple regression analyses were performed to predict diagnosis from identity disturbance scores after controlling for sexual abuse history. Finally, on the basis of recent cluster-analytic research that has suggested a distinction between two borderline personality disorder subtypes, characterized either by emotional dysregulation or histrionic features, we conducted additional analyses that assessed the relationship of histrionic features to identity disturbance holding borderline features constant, and vice versa.

Iiiiiiinteresting. Borderline Personality Disorder subtypes: characterized by emotional dysregulation or histrionic features. We’re often confused with histrionic personality disorder. I should do a comparison of at some point. I’ve been meaning to. That’s beside the fact.  This is an extremely thorough comparison between possibilities and causes. Next up…. The Results. This is a big one…… 

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