“How much do you know about Narcissism?” asked yet another female client, on the same day that a male client asked, “How much do you know about Borderline Personality Disorder?” It seems like therapists I supervise or I am asked a version of these questions at least weekly. I can confidently state that I likely know more about both of them than most of my clients do. I believe that these labels are used prematurely and inaccurately in short, because they simplify complex problems for people who are desperately trying to make sense out of the seemingly nonsensical. Here are some reasons why they are incorrectly overused:
Narcissistic Personality Disorder (NPD) and Borderline Personality Disorder (BPD) are labels that describe sets of behaviors and internal states identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This is a tome published by the American Psychiatric Association for the purpose of categorizing and typifying groups of mental health disorders in order to conceptualize diagnoses and treatment options for various clinical presentations. The book is the best we have for making sense out of mental health disorders. As a collaborative clinician for the most recent issuance (5th edition), I have respect for the amount of study and diligence that goes into refining the descriptors as an attempt at diagnostic and treatment accuracy. The problem is that the taxonomy is clumsy, largely subjective, politically influenced, and always controversial among mental health and medical professionals.
For example, one of the identifying specifiers for NPD is “Requires excessive admiration,” (p. 669). What? Who decides how much is “excessive?” Another feature is, “Shows arrogant, haughty behaviors or attitudes,” (p. 670). Do you see the problem? What exactly is “arrogant or haughty?” What is the context for such behavior? Many of the remaining identifiers are equally ambiguous. The lack of precision throughout the DSM is an enormous problem because it is so subjective and can vary tremendously from clinician to clinician.
Let’s look at BPD. The first listed criterion is, “Frantic efforts to avoid real or imagined abandonment,” (p. 663). So, what, exactly, is “Frantic?” Does that mean if a spouse is threatening to divorce and walks out the door, the panicky reaction of a partner is “BPD?” The 7th identifier is “chronic feelings of emptiness.” Huh? How empty? Does “emptiness” mean the same thing to different people? How about “Inappropriate, intense anger or difficulty controlling anger?” I have seen plenty of that in partners who experienced betrayal, or a number of other emotionally-laden events. This does not mean the individual has BPD.
Hopefully, most clinicians are very careful in using these labels. Unfortunately, I see way too many who are not. Many clinicians use the labels as a way to dismiss clients when they are overwhelmed with the behaviors, particularly in couple cases where the emotion is notoriously high, and the dynamics exceed the therapist’s competence and skill level. Personality disorders are by nature considered durable and nearly unchangeable. If a client has a legitimate personality disorder, in a sense, the clinician can just write off the case as untreatable. Many do. To be honest, sometimes I think it’s laziness at best and negligence at worst. This is a particularly egregious practice when a therapist has diagnosed a spouse based on the report of their client, without ever actually meeting that individual (and yes, this happens, not infrequently). I’m not a DSM expert, but as a licensed clinician with DSM training, I believe the actual prevalence of these cases in a population is far lower than they are diagnosed by mental health professionals, at least informally, behind closed doors.
Among the client population, the overpathologizing might be more pervasive. Currently, the ability to easily research anything on the internet has provided fertile ground for spouses to gain just enough information to be dangerous. Most of us are guided by confirmatory bias, meaning that we have a tendency to give more credence to information that supports what we already believe. If I think I’m married to a narcissist (or an autistic or a bipolar individual or…) then I will find all kinds of information supporting my viewpoint. Ditto for borderlines. Then, if I read that it is not very treatable, I might prematurely give up on the relationship.
Much of the highly emotional behavior observed in panicky, anxious pursuing partners (often wives who get labeled “Borderline”), is exacerbated by, if not a direct result of, the withdrawing or stonewalling behavior by spouses who are flooded. Likewise, the withdrawing husband who numbs himself because he doesn’t ever feel like he can calm down his wife’s emotions, may appear incapable of empathizing (Aha! Narcissism!), when the apparent lack of empathy is really a conditioned response generated from years of feeling helpless to impact a partner’s emotional reactions. The pattern becomes cyclical, more pronounced, and anticipatory until partners can and do appear to be Narcisstic and Borderline. In short, protective behaviors of stonewalling and withdrawal that make sense in an intense situation are incorrectly labeled, and desperate, clingy, panicky emotional behaviors that come as a result of not knowing what else to do to save a relationship are prematurely pathologized. Various trauma responses based on previous client history can also be prematurely lumped into a personality disorder.
I have no illusions about my self-indulgent blog post changing anything in general. That would require a readership larger than three people. However, I want to be on record somewhere articulating and highlighting this problem because it is endemic with therapists who don’t place behavior in a highly emotional couple context, and it is a problem with spouses who are desperately trying to make sense out of painful marriages they feel powerless to change.
Don’t get me wrong. I have seen clients who I believe meet criteria for both of these disorders. However, far more often, I see people who are very reactive to each other after years of feeling rejected, and their behaviors look like some of the personality disorder specifiers. In other words, I see more instances which are treatable than those which aren’t. If you think your spouse has a personality disorder, you could be right, but it is more likely that you are incorrectly labeling contextual, reactive behavior. Be very careful in your unofficial diagnosis.
Now it’s time to return to my real life of being mom to 7 children, or, as I like to call it, my “Acute Stress Disorder,” or my “Circadian Rhythm Sleep-Wake Disorder,” for which the recognized treatment is “birth control.” Oops….too late! Happy diagnosing!
Reference: Diagnostic and Statistical Manual of Mental Disorders, 5th edition (2013), American Psychiatric Association: Arlington, Virginia.
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