In reference to: https://essayforum.com/dissertations/lit-review-show-critically-analysed-studies-5908/
Hi All
Warning - this is going to be long. I'd really appreciate people's feedback about what I've written so far. Particularly would you think about whether or not the information I'm providing is actually relevant given my research question. Please let me know what bits are relevant and why and which bits aren't relevant and why. Also would you see if you can identify areas of research that I need to explore that I haven't yet. I'm too "over it" to be able to step back and see this...
CHAPTER 1 - INTRODUCTION
The purpose of this thesis is to challenge the validity of the diagnosis of Borderline Personality Disorder as meeting the criteria for a personality disorder.
Personality disorders are defined in the DSM-IV as "...an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment". As the definition of personality disorders stipulate that the inner experience and behaviour of the person is pervasive, inflexible and stable over time the diagnosis of a patient with a personality disorder indicates the patient is unlikely to significantly improve even with treatment. The patient diagnosed with a PD is perceived as having a fundamental and irreparable flaw in their personality.
BPD is defined in the DSM-IV as "...a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity". The diagnostic criteria for BPD consist of nine criteria, only five of which are required to be met in order to be diagnosed with BPD. The latitude in diagnostic criteria results in their being 256 unique combinations of criterion that allow for a diagnosis of BPD. The hypothesis of this study arose from research which indicates that a child who is a victim of parental incest is more likely to have difficulty maintaining and sustaining healthy interpersonal relationships , has difficulty maintaining positive self-image , has emotional instability , and engages in impulsive behaviour (mirroring the definition of BPD as above)
It is expected that sustained, positive interpersonal relationships found outside the family of origin in adulthood combined with the opportunity to engage in psychotherapeutic type interventions (one on one counselling, support groups, group therapy, personal development courses etc) the victims of childhood parental incest can experience the interpersonal support and skills necessary to sufficiently heal the wounds created by the incest to no longer meet the criteria for BPD.
The aim of this research is to demonstrate that female victims of childhood parental incest perceive themselves as having been able to have met the diagnostic criteria for BPD in their late teens to mid twenties, and that those same subjects are less likely to currently perceive themselves as meeting the diagnostic criteria for BPD, thus demonstrating that someone can meet the diagnostic criteria of BPD but not the definition of a personality disorder (i.e. inflexible and stable over time).
CHAPTER 2 - BACKGROUND TO THIS THESIS
Borderline Personality Disorder is a relatively new diagnosis in the history of psychological disorders. There exists significant controversy within the psychological profession regarding the validity of BPD as a diagnosis. This chapter aims to provide an overview of these controversies and covers the history and development of personality disorders as a distinct Axis in the DSM-IV, the more specific history and development of BPD as a diagnosis within this Axis, the etiology of BPD, the relationship between trauma and BPD, other concerns with BPD as a diagnosis, and the research on the effectiveness of psychological interventions in treating BPD.
THE HISTORY AND DEVELOPMENT OF PERSONALITY DISORDERS AS A CATEGORY OF PSYCHOLOGICAL DISORDERS
One of the two Axis in the DSM-IV is dedicated to psychological disorders known as "Personality Disorders", however, the use of clear diagnostic criteria to define personality disorders as a whole, and clear diagnostic criteria to differentiate between individual personality disorders is only a very recent development in the history of psychology.
Personality theory and research into personality within the discipline of psychology began to flourish in the mid 20th century with the work of those such as Freud, Allport and Eysenk (Hall & Lindzey, 1970 ). At this stage the work on personality was based on decades of clinical observation (Fowler, K.A., O'Donahue, W., and Lilienfield, S.O., 2007 ). Work in the area of personality then became less of a focus in the field of psychology as it moved towards what Cloninger defines as more categorical, behavioural biological approaches to psychological disorders. Whilst some personality disorders (such as schizoid personality and paranoid personality) were included in earlier versions of the DSM it was not until the DSM-III that the construct of "Personality Disorders" was created to reflect the belief that personality disorders were considered to be significantly different from the range of other disorders included in the DSM. The DSM-III was the first version of the DSM which created two separate diagnostic Axis to differentiate between "clinical conditions" (Axis I) and personality disorders (Axis II) (Fowler, K.A., O'Donahue, W., and Lilienfield, S.O., 2007 ).
HISTORY AND DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER AS A DIAGNOSIS
"Borderline" was a label first used by Stern (1938 ) who did not fit neatly into the then current psychiatric categories of neurotic or psychotic. At that time psychopathology was viewed as a continuum from normal to neurotic to psychotic (Linehan, M.M. 1993 ). Stern used the term borderline to refer to patients who generally appeared to fit the criteria for neurotic but demonstrated brief psychotic periods (Freeman, A., Stone, M., Martin, D., and Keinecke, M. ). Kernberg (1967 ) created the term borderline personality organization. He used the word personality to reflect the enduring nature of these patients thoughts, feelings and behaviours. Patients who were categorised as having borderline personality organization tended to respond to unpleasant realities with immature and drastic responses such as cutting or denial, and whilst not acutely psychotic became significantly disorganised cognitively when under stress with psychotic like symptoms such as splitting (Bradley, R., Zittel Conklin, C., & Westen, D. 2007 ).
Kernberg's work was the basis of much of the future work on BPD including the eventual description of BPD in the DSM-III. According to Bradley et al (2007 ) Grinker, Werble, and Drye (1968) were the first to attempt to create empirically grounded diagnostic criteria for what they referred to as the borderline syndrome. The Diagnostic Interview for Borderline Personality Disorder was then developed by Gunderson and his colleagues (Gunderson & Singer, 1975 ; Gunderson & Kolb, 1978 ; Kolb, & Austin, 1981 ). The definition and diagnostic criteria for BPD as set out in the DSM-III was overseen by Spitzer, the editor of the DSM-III who reviewed clinical and research literature, and consulted with clinicians specialising in the treatment of patients with borderline personality characteristics. He then created a set of potential diagnostic criteria which was evaluated by a national survey of psychiatrists. It was the resulting set of diagnostic criteria that was identified via this process which became the basis of the DSM-III (Spitzer, Endicott, & Gibbon, 1979 ).
Many researchers (i.e. Cloninger, R.C. 2007 ; XXXX; XXXX) have serious concerns about the validity of BPD as a diagnosis and this will be explored in greater detail further in this chapter (NB. I will flesh this sentence out as I continue writing this chapter and am better able to summarise these concerns).
ETIOLOGY OF BORDERLINE PERSONALITY DISORDER
One of the difficulties with BPD is that there is no clear path which leads towards the development of BPD. Many researchers (Paris 1999 ; XXXX; XXXX) believe that BPD occurs as a result of the interaction between genetic, biological, social and psychological factors. Whilst looking at each of these factors separately is useful for obtaining a grasp on how each of these factors may contribute to the development of BPD, the interaction of these factors is complex. For simplicity each of these factors will initially be explored individually and then the interaction of these factors will be discussed.
Genetic Factors
Research has shown that various emotional characteristics which are associated with BPD such as affective lability, impulsive behaviour, and neuroticism, are at least in part inheritable (Jang, Livesley, Vernon, & Jackson, 1996 ; Livesly, Jang, Schroeder, & Jackson, 1993 ; Paris, 2000 ; Plomin, Defries, McClearn, & Rutter, 1997 ; Silk, 2000 ) and that personality traits are heritable (Plomin, Chipuer, & Loehiin, 1990 ). However, to date, studies using linkage and adoption have not identified specific genetic vulnerabilities towards the development of BPD (Freeman, A., Stone, M., Martin, D., and Keinecke, M. ).
White, Gunderson, Zanarini, and Hudson (2003 ) reviewed the research on psychological disorders within the BPD patients family of origin. They found little support to link schizophrenia or bipolar disorders in family of origin with the development of BPD, some support for a familial link between depression and BPD, and a stronger level of support linking impulse spectrum disorders (including BPD) with the development of BPD. However, this does not identify how these familial links result (or don't result) in the development of BPD. Teasing out which part of this is due to genetics, which is due to biology (i.e. neurological development of the brain as effected by instability in the family of origin) and which is due to social and psychological factors is a significantly harder task.
Biological Factors
Studies which use positron-emission tomography (PET) indicate that patients with BPD may have decreased metabolism in their prefrontal cortex (Adams, Bernat, & Luscher, 2001 ; Paris, 1999 ) which is the area responsible for executive function, affect regulation and behavioural inhibition. This may well be linked to some of the characteristics of BPD such as impulsive behaviour, emotional lability and disorganisation (particularly when under stress). However, the cause of this decreased metabolism is not clear and could be as a result of social/psychological factors such as severe or chronic abuse or neglect as a child, a chaotic home environment, disorganised attachment or separation/early loss.
Other studies using neuroimaging indicate that those with BPD are hyperreactive to emotional stimuli as reflected by heightened activation of the amygdale (Donegan et al., 2003 ; Herpertz et al., 2001 ). However, other research has demonstrated decreased amygdale activity (Driessen et al., 2000 ). One explanation for this seemingly contradictory and mutually exclusive results could be that those BPD patients who are more prone to dissociation may indeed have decreased amygdale activity.
Social Factors
Research has indicated that some personality disorders are more frequently diagnosed in men, and others in women. The DSM-IV-TR (APA, 2000 ) stated that women are more frequently diagnosed with BPD, histrionic personality disorder, and dependant personality disorder, whereas men are more frequently diagnosed with antisocial personality disorder, narcissistic personality disorder, and obsessive compulsive disorder). However, other research (Golomb, Fava, Abraham, and Rosenbaum 1995 ) found no significant gender differences in the diagnosis of BPD, histrionic personality disorder, and dependent personality disorder.
In regards to the research which indicates patterns of gender and diagnosis - Is this because there are inherent personality differences between men and women that lead to observably different trends in psychopathology? Or is this a result of cultural biases towards the rearing of children which lead to differences in personality (i.e. the emphasis on certain personality traits - both functional and dysfunctional - that is gender specific)? Or is cultural biases in the way diagnosticians view behaviour (i.e. the angry man is antisocial, the angry woman is borderline)? At this point there is research which supports all of these possibilities but no clear answers.
Some research question whether there is a gender bias both in the diagnostic decision making process and in the diagnostic criteria itself. Warner (1978 ) provided clinicians with a patient profile identical in all aspects except gender. The patient profile was supposed to describe a patient with histrionic personality disorder. The outcome of this study demonstrated that when the patient's assigned gender was male the diagnosis was more likely to be that of antisocial personality disorder, and when the patient's assigned gender was female the diagnosis tended to be histrionic personality disorder. Other researchers (i.e. Caplan, 1987 ; Landrine, 1989 ) have argued that healthy individuals who meet extreme examples of gender stereotypes are labelled with psychopathology diagnosis unfairly.
Widiger & Spitzer (1991 ) reviewed potential sources of gender bias when diagnosis personality disorders and concluded that in order to protect against false positives due to gender bias it would be necessary for the DSM to make more explicit and concrete the threshold at which behaviours are deemed to be maladaptive.
Psychological Factors
The Interaction of These Factors
Hi All
Warning - this is going to be long. I'd really appreciate people's feedback about what I've written so far. Particularly would you think about whether or not the information I'm providing is actually relevant given my research question. Please let me know what bits are relevant and why and which bits aren't relevant and why. Also would you see if you can identify areas of research that I need to explore that I haven't yet. I'm too "over it" to be able to step back and see this...
CHAPTER 1 - INTRODUCTION
The purpose of this thesis is to challenge the validity of the diagnosis of Borderline Personality Disorder as meeting the criteria for a personality disorder.
Personality disorders are defined in the DSM-IV as "...an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment". As the definition of personality disorders stipulate that the inner experience and behaviour of the person is pervasive, inflexible and stable over time the diagnosis of a patient with a personality disorder indicates the patient is unlikely to significantly improve even with treatment. The patient diagnosed with a PD is perceived as having a fundamental and irreparable flaw in their personality.
BPD is defined in the DSM-IV as "...a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity". The diagnostic criteria for BPD consist of nine criteria, only five of which are required to be met in order to be diagnosed with BPD. The latitude in diagnostic criteria results in their being 256 unique combinations of criterion that allow for a diagnosis of BPD. The hypothesis of this study arose from research which indicates that a child who is a victim of parental incest is more likely to have difficulty maintaining and sustaining healthy interpersonal relationships , has difficulty maintaining positive self-image , has emotional instability , and engages in impulsive behaviour (mirroring the definition of BPD as above)
It is expected that sustained, positive interpersonal relationships found outside the family of origin in adulthood combined with the opportunity to engage in psychotherapeutic type interventions (one on one counselling, support groups, group therapy, personal development courses etc) the victims of childhood parental incest can experience the interpersonal support and skills necessary to sufficiently heal the wounds created by the incest to no longer meet the criteria for BPD.
The aim of this research is to demonstrate that female victims of childhood parental incest perceive themselves as having been able to have met the diagnostic criteria for BPD in their late teens to mid twenties, and that those same subjects are less likely to currently perceive themselves as meeting the diagnostic criteria for BPD, thus demonstrating that someone can meet the diagnostic criteria of BPD but not the definition of a personality disorder (i.e. inflexible and stable over time).
CHAPTER 2 - BACKGROUND TO THIS THESIS
Borderline Personality Disorder is a relatively new diagnosis in the history of psychological disorders. There exists significant controversy within the psychological profession regarding the validity of BPD as a diagnosis. This chapter aims to provide an overview of these controversies and covers the history and development of personality disorders as a distinct Axis in the DSM-IV, the more specific history and development of BPD as a diagnosis within this Axis, the etiology of BPD, the relationship between trauma and BPD, other concerns with BPD as a diagnosis, and the research on the effectiveness of psychological interventions in treating BPD.
THE HISTORY AND DEVELOPMENT OF PERSONALITY DISORDERS AS A CATEGORY OF PSYCHOLOGICAL DISORDERS
One of the two Axis in the DSM-IV is dedicated to psychological disorders known as "Personality Disorders", however, the use of clear diagnostic criteria to define personality disorders as a whole, and clear diagnostic criteria to differentiate between individual personality disorders is only a very recent development in the history of psychology.
Personality theory and research into personality within the discipline of psychology began to flourish in the mid 20th century with the work of those such as Freud, Allport and Eysenk (Hall & Lindzey, 1970 ). At this stage the work on personality was based on decades of clinical observation (Fowler, K.A., O'Donahue, W., and Lilienfield, S.O., 2007 ). Work in the area of personality then became less of a focus in the field of psychology as it moved towards what Cloninger defines as more categorical, behavioural biological approaches to psychological disorders. Whilst some personality disorders (such as schizoid personality and paranoid personality) were included in earlier versions of the DSM it was not until the DSM-III that the construct of "Personality Disorders" was created to reflect the belief that personality disorders were considered to be significantly different from the range of other disorders included in the DSM. The DSM-III was the first version of the DSM which created two separate diagnostic Axis to differentiate between "clinical conditions" (Axis I) and personality disorders (Axis II) (Fowler, K.A., O'Donahue, W., and Lilienfield, S.O., 2007 ).
HISTORY AND DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER AS A DIAGNOSIS
"Borderline" was a label first used by Stern (1938 ) who did not fit neatly into the then current psychiatric categories of neurotic or psychotic. At that time psychopathology was viewed as a continuum from normal to neurotic to psychotic (Linehan, M.M. 1993 ). Stern used the term borderline to refer to patients who generally appeared to fit the criteria for neurotic but demonstrated brief psychotic periods (Freeman, A., Stone, M., Martin, D., and Keinecke, M. ). Kernberg (1967 ) created the term borderline personality organization. He used the word personality to reflect the enduring nature of these patients thoughts, feelings and behaviours. Patients who were categorised as having borderline personality organization tended to respond to unpleasant realities with immature and drastic responses such as cutting or denial, and whilst not acutely psychotic became significantly disorganised cognitively when under stress with psychotic like symptoms such as splitting (Bradley, R., Zittel Conklin, C., & Westen, D. 2007 ).
Kernberg's work was the basis of much of the future work on BPD including the eventual description of BPD in the DSM-III. According to Bradley et al (2007 ) Grinker, Werble, and Drye (1968) were the first to attempt to create empirically grounded diagnostic criteria for what they referred to as the borderline syndrome. The Diagnostic Interview for Borderline Personality Disorder was then developed by Gunderson and his colleagues (Gunderson & Singer, 1975 ; Gunderson & Kolb, 1978 ; Kolb, & Austin, 1981 ). The definition and diagnostic criteria for BPD as set out in the DSM-III was overseen by Spitzer, the editor of the DSM-III who reviewed clinical and research literature, and consulted with clinicians specialising in the treatment of patients with borderline personality characteristics. He then created a set of potential diagnostic criteria which was evaluated by a national survey of psychiatrists. It was the resulting set of diagnostic criteria that was identified via this process which became the basis of the DSM-III (Spitzer, Endicott, & Gibbon, 1979 ).
Many researchers (i.e. Cloninger, R.C. 2007 ; XXXX; XXXX) have serious concerns about the validity of BPD as a diagnosis and this will be explored in greater detail further in this chapter (NB. I will flesh this sentence out as I continue writing this chapter and am better able to summarise these concerns).
ETIOLOGY OF BORDERLINE PERSONALITY DISORDER
One of the difficulties with BPD is that there is no clear path which leads towards the development of BPD. Many researchers (Paris 1999 ; XXXX; XXXX) believe that BPD occurs as a result of the interaction between genetic, biological, social and psychological factors. Whilst looking at each of these factors separately is useful for obtaining a grasp on how each of these factors may contribute to the development of BPD, the interaction of these factors is complex. For simplicity each of these factors will initially be explored individually and then the interaction of these factors will be discussed.
Genetic Factors
Research has shown that various emotional characteristics which are associated with BPD such as affective lability, impulsive behaviour, and neuroticism, are at least in part inheritable (Jang, Livesley, Vernon, & Jackson, 1996 ; Livesly, Jang, Schroeder, & Jackson, 1993 ; Paris, 2000 ; Plomin, Defries, McClearn, & Rutter, 1997 ; Silk, 2000 ) and that personality traits are heritable (Plomin, Chipuer, & Loehiin, 1990 ). However, to date, studies using linkage and adoption have not identified specific genetic vulnerabilities towards the development of BPD (Freeman, A., Stone, M., Martin, D., and Keinecke, M. ).
White, Gunderson, Zanarini, and Hudson (2003 ) reviewed the research on psychological disorders within the BPD patients family of origin. They found little support to link schizophrenia or bipolar disorders in family of origin with the development of BPD, some support for a familial link between depression and BPD, and a stronger level of support linking impulse spectrum disorders (including BPD) with the development of BPD. However, this does not identify how these familial links result (or don't result) in the development of BPD. Teasing out which part of this is due to genetics, which is due to biology (i.e. neurological development of the brain as effected by instability in the family of origin) and which is due to social and psychological factors is a significantly harder task.
Biological Factors
Studies which use positron-emission tomography (PET) indicate that patients with BPD may have decreased metabolism in their prefrontal cortex (Adams, Bernat, & Luscher, 2001 ; Paris, 1999 ) which is the area responsible for executive function, affect regulation and behavioural inhibition. This may well be linked to some of the characteristics of BPD such as impulsive behaviour, emotional lability and disorganisation (particularly when under stress). However, the cause of this decreased metabolism is not clear and could be as a result of social/psychological factors such as severe or chronic abuse or neglect as a child, a chaotic home environment, disorganised attachment or separation/early loss.
Other studies using neuroimaging indicate that those with BPD are hyperreactive to emotional stimuli as reflected by heightened activation of the amygdale (Donegan et al., 2003 ; Herpertz et al., 2001 ). However, other research has demonstrated decreased amygdale activity (Driessen et al., 2000 ). One explanation for this seemingly contradictory and mutually exclusive results could be that those BPD patients who are more prone to dissociation may indeed have decreased amygdale activity.
Social Factors
Research has indicated that some personality disorders are more frequently diagnosed in men, and others in women. The DSM-IV-TR (APA, 2000 ) stated that women are more frequently diagnosed with BPD, histrionic personality disorder, and dependant personality disorder, whereas men are more frequently diagnosed with antisocial personality disorder, narcissistic personality disorder, and obsessive compulsive disorder). However, other research (Golomb, Fava, Abraham, and Rosenbaum 1995 ) found no significant gender differences in the diagnosis of BPD, histrionic personality disorder, and dependent personality disorder.
In regards to the research which indicates patterns of gender and diagnosis - Is this because there are inherent personality differences between men and women that lead to observably different trends in psychopathology? Or is this a result of cultural biases towards the rearing of children which lead to differences in personality (i.e. the emphasis on certain personality traits - both functional and dysfunctional - that is gender specific)? Or is cultural biases in the way diagnosticians view behaviour (i.e. the angry man is antisocial, the angry woman is borderline)? At this point there is research which supports all of these possibilities but no clear answers.
Some research question whether there is a gender bias both in the diagnostic decision making process and in the diagnostic criteria itself. Warner (1978 ) provided clinicians with a patient profile identical in all aspects except gender. The patient profile was supposed to describe a patient with histrionic personality disorder. The outcome of this study demonstrated that when the patient's assigned gender was male the diagnosis was more likely to be that of antisocial personality disorder, and when the patient's assigned gender was female the diagnosis tended to be histrionic personality disorder. Other researchers (i.e. Caplan, 1987 ; Landrine, 1989 ) have argued that healthy individuals who meet extreme examples of gender stereotypes are labelled with psychopathology diagnosis unfairly.
Widiger & Spitzer (1991 ) reviewed potential sources of gender bias when diagnosis personality disorders and concluded that in order to protect against false positives due to gender bias it would be necessary for the DSM to make more explicit and concrete the threshold at which behaviours are deemed to be maladaptive.
Psychological Factors
The Interaction of These Factors