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"Psych 101 -
What you didn't learn in nursing school."


by Kathi Stringer
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ISBN-13: 978-0615193137
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Disclosing Borderline Personality
Disorder to an Undiagnosed Spouse

Written by Kathi Stringer

July 29, 2003

This is great advice – it’s informative and the communication ideas are very helpful –

Cristina Cabrera, M.A.
Interpersonal Communication

Question

Should a person be told they have borderline personality disorder?

My wife is unaware she is a BP. The advice I had from the Psychologist is that it would not be helpful for my wife to know she is a BP and in fact it might be damaging. I find it difficult to withhold information as having been marriage 42 years I have always operated on sharing our lives in all ways. I can go on withholding this information if it is the wisest path to follow.

At different times I have tried to open the subject but there is always a reaction of hostility. I have attached a note I gave her in the hopes it would open the doorway to my being able to discuss the matter. It definitely got the thumbs down and only started a hostile reaction. The general reaction is to tell me I need fixing and that she is all right. Unfortunately over the years I have approached a number of professional people (who did not understand borderline personality disorder) and she subsequently came along. I think she is now at the stage of professional burnout after so much unhelpful information.

I have approached our local psychiatric unit and they have a program running to assist BP. It seems that it would be very helpful to her, but unless she knows she is a BP and approaches them they cannot help.

I believe that knowledge is power and it seems to me that if you know all that facts about yourself that you are in the best position to make decisions.

Have you any thoughts on this matter, as I would like your opinion. I realize it’s a knotty question.

Answer

The Undiagnosed Insult

There is quite a bit of information against disclosing a possible diagnosis of borderline personality disorder (BPD) to those we love and care about….and for good reason. The phrase “personality disorder” comes across as an insult, even in the kindest delivery. For example, imagine if you felt there was nothing wrong with your intelligence and someone empathetically tried to convince that you were in denial and that you are actually severely retarded. How would that go over? Perhaps you may recoil and shout, “I’m not stupid, you are the stupid one!” Then of course, things get escalated from there and any therapeutic window for discussion is now highly defended.

Identity Expansion

There is a second reason, however that may keep a treater from disclosing a diagnosis. Lets say for example through discussion with the treater it is agreed the client meets the minimum of 5 of the 9 symptoms for Borderline Personality Disorder [1]. Now lets say the client suffers from confusion and is lacking identity. Now we have a troubled client that is relived to meet the newly official diagnostic criteria to open a pathway toward individuality (upgrades to identity). Of course the client is excited to learn more about herself and studies all of the symptoms for a diagnosis of borderline personality disorder. Through research the client finds there are 4 more symptoms that she has managed to keep ‘in check’ but now realizes she has some latitude, a more extensive range to express her newly discovered identity. It is as though she has received a license to be complete, however maladaptive that may be. The reasoning maybe, “An maladaptive identity is better then no identity at all.” Now we have a treater that is frustrated with the extra symptoms that the client had previously been able to manage. So now what? Lets look at a few other items first and find out what a ‘disordered’ diagnosis amounts too.

The DSM-IV-TR

The DSM-IV is a dialogistic manual to aid treaters to formulate a diagnosis [1]. The DSM-IV views personality problems as ‘disorders.’ Therefore, it may be helpful to take a closer look at the DSM and understand how ‘disorders’ are rated.

The DSM-IV splits up a comprehensive diagnosis into five different categories referred to as “Axis”. Axis One is basically reserved for disorders that are treated with the ‘medical model’ such as Bipolar, Schizophrenia and Schizoaffective. Axis Two is reserved for the personality disordered such as NPD and borderline personality disorder. The primary difference between Axis One and Axis Two equates to the ‘medical model’ vs. ‘developmental model.’ In other words, Axis one in more likely to be treated primarily with medication, and Axis Two with talk therapy as a way to work though the arrested developments. (Note: Mental Retardation is also on Axis Two) Axis Three relates to prior or ongoing physical problems such as cancer, surgery or physical limitations. Axis Four relates to environmental or situational problems that may be giving rise to some of the symptoms. Axis Five (GAF) relates to the Global Functioning Scale that is rated from 0 to 100. Zero would be suicide and 100 would be perfect functioning.

A DSM-IV Diagnosis goes something like this:

Axis 1: Depression NOS [Not otherwise specified], rule out Bipolar

Axis 2: Borderline Personality Disorder, Severe

Axis 3: Lacerations of the wrist and diabetic

Axis 4: Relationship problems, job loss and legal problems

Axis 5: 10 (suicidal, liable, unpredictable and confused)

When it comes to care planning a doctor is required to make a diagnosis on each axis along with the driving symptoms.

Disorder vs. Organization

The word ‘disorder’ immediately suggests a defect. There are some grassroots’ organizations and individuals that are peeved at the notion of being labeled as disordered, and for good reason, because in some cases at the risk of annihilation they created these psychological structures to help them survive an abusive childhood. It comes off as a double negative. First, the individual is beat up in childhood and second, they are beat up again as being labeled disordered.

Otto Kernberg, a proliferated writer, theorist, and treater is a distinguished expert on borderline personality disorder. However, Kernberg refers to borderline personality disorder as “Borderline Personality Organization” [3],[4] which seems to relive the stigma somewhat, and recognize the personality as an adaptive organization at the time when higher levels of defensives were not yet constructed within the mind. Kernberg recognized that ‘borderline organization’ is an arrested developmental phenomenon that remained ridged in the personality because abuse or neglect road blocked expansion to age appropriate adaptive defensives.

Symptomology

Personally, I think I would rather be identified as relating to others with a certain ‘personality organization’ instead of ‘personality disorder.’ The mitigated descriptive use of ‘organization’ is helpful to invite self-examination of ‘symptoms’ rather then disorder – defect. The treater and the client have a greater advantage toward treatment if collaboration is focused on the acute symptoms rather then the pigeonhole disorder.

Treatment Considerations

Now lets move on toward disclosure of ‘personality organization’ to a loved one to facilitate treatment. Frankly, an accusation of an ‘undiagnosed’ personally disorder toward a loved one, no matter how well intended can stir up a tit-for-tat problem. Before proceeding we need to consider a few things first.

Have these symptoms always existed before a commitment to marriage?

Have the symptoms escalated over time during the marriage?

How likely is it that your spouse will accept the idea of treatment for their symptoms?

How important is the idea of having peace in your life?

Are you willing to make sacrifices to have a more rewarding life?

These are important questions, because when it comes down to it, you cannot help anyone if they are not willing to accept that help (Stringer) [4]. If your spouse gets into treatment, that is one thing, but refusal begs for another question to be asked of yourself. “Can I continue in this relationship the way things are going?”

To help answer this question, consider that all relationships are ‘value-for-value.’ Are you getting enough of what you need to stay in the relationship? If not, consider your option of leaving. If you decide to stay in the relationship, ask yourself what you are receiving emotionally or physically, and is it worth the trade-off?

Changing A Person

Often co-dependent couples are disillusioned with romantic love and there is a sense of “I can fix her, and change her, and make her whole” and on the flip side “he can save me, provide for me, and nurture me, and make me whole.” Then later down the road it dawns on the fixer that he is not able to fix or change his spouse. It was assumed by the fixer that once married and his gift of ‘fixing’ were engaged, the partner would heal and everything would be hunky-dory. Instead things may have gotten worse because the spouse cannot get fixed enough and will up the stakes to bring on more of an urgency to be fixed. So, things have indeed changed, but for the worse because the needy became more needy and burnout is just over the horizon. In essence, relationships are practically doom for failure if one or both partners are not happy at the point of marriage and are expecting ‘change.’ Basically, a person ‘marries’ what they agreed to marry when they say, “I do.”

Discussion Time

If you want to try and save the relationship, then set a time aside for discussion. Try it again. Make sure you toss the word “I” and use “Us – We – Our” to denote “we are in this together” For example, “Honey, I would like to spend some time with you and discuss something very important to us. Is there a time when we can do that?” Then later at that time “Thank you for making time for us, it is very important to me and I appreciate it.” Then… “I am very concerned about ‘our’ relationship. We are having problems communicating and getting our needs met. I’m afraid if we don’t get some outside coaching soon, we may not be able to survive our marriage.” Expand on this as much as you like, but make it about ‘we’ and it will increase your chances of getting treatment going. Accusatory statements such as ‘you made me’ or ‘you did it’ or ‘it’s not my fault’ will create setbacks and a defensive stance. Save those problems for your treater.

In Treatment

Once treatment has begun, begin with sessions together and also apart to express concerns. As things move along, hopefully the individual that needs the treatment the most can receive it and the other individual can decrease treatment or discontinue all together. Once in treatment the treater can make judgment calls as to the timely revelation of the full Axis workup for the client, whereby taking you off the hook.

Treatment Refusal

Now we are back to the phrase “value-for-value.’ Are you willing to live with a person that refuses to seek treatment? Do you think that getting treatment for yourself can help you continue to live with your spouse, and enhance your chances for happiness? I would suggest that you try it, or continue the relationship as usual, or dissolve the relationship.

These are hard choices for sure but the problem will not go away, only the remainder of your time on this earth toward a chance for happiness will go away. Something to think about.

Summery:

A suggestion of borderline personality can come off as an insult.

A diagnosis of Borderline Personality Disorder can provide an identity for those lost in emptiness and therefore may increase the symptoms.

A diagnosis toward care planning is categorized in 5 Axis’.

Kernberg’s borderline organization is less demeaning then borderline disorder.

Addressing symptoms has its advantages for getting a person into treatment rather than the tit-for-tat insult of ‘personality defect.’

Consider the value-for-value to remain in the relationship.

It is not fair to expect a person to change after marriage.

Setup a time for discussion

Enter treatment as ‘We’ rather than the accusatory ‘you’ to get things moving along.

Consider options if treatment is refused.

References

Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR - American Psychiatric Association (APA)
[Book Link]

Severe Personality Disorders - Otto F. Kernberg
[Book Link]

Borderline Conditions and Pathological Narcissism - Otto F. Kernberg
[Book Link]

Breaking Free from Co-dependence - Kathi Stringer
[Page Link]