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Borderline Personality Disorder: Proposal to include a supplementary name in the DSM-IV text revision
I received the following information from the National Institute of Mental Health. When I advised them I would be using an alternative name interchangeably for the BPD , I was encouraged. This lets people know that a more accurate term exists that describes this disorder.
If you would like to vote and you are up to date with what the BPD really is...
Also, please see the article "BPD - What's in a Name?
Patty E. Fleener M.S.W.
Borderline Personality Disorder (Emotion-Impulse Regulation Disorder)
To clarify, the name of the disorder would remain Borderline Personality Disorder, but the alternative name would appear in parentheses at the beginning of the BPD text section on page 650 on DSM-IV. It will not appear in any other location in DSM-IV (i.e., not in the classification or in the header for the criteria set). It would appear alongside the BPD criteria set in the “mini-D” (the criteria sets only version of DSM-IV). There is ample precedent for doing this as a way of introducing new terminology into the field. For example, an alternative name for Social Phobia, namely Social Anxiety Disorder, appears in parentheses on page 411.
Unlike previous textual revisions for DSM-IV to which you may have responded, this is not the type of proposal which lends itself to a review of the literature. I do have two sources of data based on unscientific, nonrandom surveys of opinion which I will discuss shortly. The main motivation for considering a supplementary alternative label for BPD is the fact that a number of clinicians have expressed concern that the term BPD is an impediment to explaining the disorder to patients, families, and the general public. This statement is based on my conversations with clinicians at professional meetings (most recently the ISSPD in Switzerland) and the recent surveys.
An additional motivation is the number of patients who have expressed objections to the label. It is my experience that fewer patients object to the label “antisocial personality disorder” than to the label “Borderline Personality Disorder.” If I explain the label “Major Depression” to a patient, family, or family practice doctor, the next time they encounter the term, the label evokes the description I gave them. If I explain the label, Borderline Personality Disorder, the next time they encounter the term they have frequently forgotten or confused my description. A number of other clinicians have indicated that they frequently clarify the term Borderline Personality Disorder by using an additional, more descriptive label. The problem is that each of us tends to use somewhat different alternative labels. This can lead to confusion when patients and their families talk with different clinicians.
Based on my informal conversation with colleagues, I have identified the following characteristics that would define an ideal supplementary label:
The label should be based on terminology that conveys the overall nature of the disorder in a way which is meaningful to clinicians, patients, families, and clinicians in training.
The label must be a useful alternative to the name “Borderline Personality Disorder” for clinicians representing a variety of different treatment centers.
The other characteristics consist of potential objections that need to be avoided. The alternative label must not::
Appear to suggest an etiology for Borderline Personality Disorder since the specific etiology is not known.
Convey a distorted picture of nature of the disorder (e.g., “Anger Disregulation Disorder” would fail to capture other key aspects of the disorder)
Suggest that Borderline Personality Disorder belongs in some other diagnostic category (e.g. “Affective Instability [Personality] Disorder” might suggest it belongs in the mood disorder section when there is no such consensus on this point.)
Convey that individuals with the disorder are highly deviant and should not be allowed to assume positions of social responsibility such as teacher, daycare worker, or parent.
I will briefly review some of the alternative labels that have been proposed and used. I will be referring to two surveys. Neither can be considered a true representative sample. The first survey (see Table 1) consists of 31 clinicians who responded to a survey by “TARA,” the public education/advocacy organization. Clinicians and researchers known to TARA as having an interest in Borderline Personality Disorder received a mailed survey and copies of the survey were also passed out to those attending the ISSPD meeting in Switzerland. The second survey (See Table 2) consists of 17 patients form Iowa who were invited to fill out the survey when they attended a meeting of our STEPPS Borderline PD Therapy group or when they came for an individual appointment during the month of November. Obviously patients at the University of Iowa may not be representative of patients at other centers and the sample was clearly biased towards alternative label we frequently use in Iowa. A copy of the survey form is included and clinicians at other centers are welcome to survey their own patients.
For several reasons, Emotionally Unstable Personality Disorder is an attractive option. It uses words that are descriptive and meaningful to the general population and it is the label used in ICD-10 for a personality type very similar to DSM-IV Borderline Personality Disorder. Congruence with ICD-10 is a worthwhile goal. The option received moderate support form a few consultants with a strong interest in nosology, however consultants who work with patients with BPD were not very supportive of this alternative. (This statement is based on private conversations since TARA did not include this as an option on the clinician survey.) In the survey of Iowa patients, the term was very unpopular (obtaining a mean of 1.9 out of a possible 7). It appears that many nonprofessionals few the term “Emotionally Unstable” as akin to terms such as “crazy” or even “dangerous.” (See criticism 4 above).
The alternative label we use most often at the University of Iowa is, “Emotional Intensity Disorder.” Therefore, it is not surprising that among the 17 patients who responded to our survey, this option was given the strongest support. However, this option received weak support from clinicians responding to the TARA survey with a mean of 2.6 our of a possible 5.0 (I should note that no clinicians from Iowa were included in the survey). Another limitation is that the label “Emotional Intensity Disorder” may also be subject to criticisms 2 and 3 above. A medical student or family practice doctor might have difficulty distinguishing how the label differs from the mood disorders.
Marsha Linehan has proposed the term Emotional Dysregulation Disorder and has more recently simplified this to Emotional Regulation Disorder. Besides removing an extra syllable, the latter may be a little less likely to be mistaken for a proposed etiology. Emotional Regulation Disorder received the strongest support in the TARA survey of clinicians with a mean of 3.8 out of a possible 5. Among the patients at Iowa, this alternative received the second highest level of support with a mean of 3.4 out of a possible 7. This is impressive in light of the fact that many of our patients had never heard this label before.
Early in my review, I noted that the proposed alternative labels usually omitted the word “personality.” Because of this, I sought an opinion from our Iowa patients on the statement “The term Personality Disorder should be avoided in any alternative name for Borderline Personality Disorder.” Aside from the fact that the supplementary label we usually use does not include the word “personality,” my colleagues and I have not generally expressed any opinion that the word “personality” is inappropriate to either patients or to each other. Our patients strongly endorsed the statement that the term personality should be avoided. The statement achieved a mean of 5.2 out of a possible 7 with 10 of the 15 responding patients giving the item a 7.
It might be more difficult to get wide support for a supplementary label which does not include the word personality. Reviewers not specializing in personality disorders might view the proposal as a major conceptual shift towards conceptualizing BPD as something other than a personality disorder (see criticism 3 above). If this were the case, the proposed alternative might be viewed as beyond the scope of a minor text revision of DSM-IV. Nevertheless, there are two strong arguments that the proposal does not imply a conceptual shift. The first is that the proposal only supplements and does not do away with the name “Borderline Personality Disorder” as the primary label for this disorder. The second is that most other sections of the DSM-IV do not use the title of the section in every label. For example, the Anxiety Disorders section does not incorporate the word “anxiety” in every diagnostic label in that section.
Based on the two non-random surveys and my discussions with colleagues thus far, “Emotional Regulation Disorder” appears to have moderate to strong support among many clinicians and is understandable and acceptable to many patients. A strong case can be made that , “Emotional Regulation Disorder” is the best candidate for a supplementary label in DSM-IV. However, I believe there are reasons to consider some minor variations on this label. First, the distinction between Emotional Regulation Disorder and some of the mood disorders is not immediately clear. This may be a source of confusion to both patients and clinicians in training. Second, some clinicians have expressed the concern that the emotional aspects are emphasized by this label at the expense of other key features of BPD such as impulsivity and interpersonal attachment difficulties. The term “emotion” encompasses a broader range of mental states than does the term “mood” but given the remarkable behavioral difficulties that bring these individuals to clinical attention, it seems less than ideal to focus only on emotion.
I believe it would be desirable to modify the proposed supplementary label to, “Emotion-Impulse Regulation Disorder.” While not explicitly mentioning interpersonal difficulties, the expanded label goes beyond feeling states. It might be argued that the reference to regulation problems which include both emotions and impulses more strongly hints at the types of interpersonal difficulties such individuals often have.
Prepared by Bruce Pfohl, M.D.
Univ. of Iowa Hospitals and Clinics
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