I've talked before about the diagnostic role of countertransference - the "feel" in the room when sitting with particular groups of clients. This type of reaction can be quite useful in distinguishing between diagnostic groups with similar symptoms. One population where the countertransference can be particularly strong is with clients with personality disorders.
Now, I have encountered people across the spectrum of personality disorders, but don't have the same level of exposure to this population that I do to, say, mood and eating disorders. As a result the "radar" of my countertransference is not always precise enough for a clear diagnosis. However, my supervisor has extensive experience with Borderline Personality Disorder (BPD), and has a finely tuned radar, at least with Cluster B (the "dramatic, emotional, or erratic" personality disorders).
Therefore, although I suspected a particular client had BPD, she suspected something related but different. It took her some time with the DSM, but she came to an understanding that I though was useful and insightful, so I thought I'd share it with you. Specifically, it concerns the distinction between BPD and Histrionic Personality Disorder (HPD). Both may include a similar intensity of affect, and similarly provocative behavior (of all shapes and sizes). However, the driving force behind these symptoms seems to be the key distinction between the two diagnoses.
Here is what the DSM says about this differential diagnosis: although both can "be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, BPD is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness anad loneliness" (p. 709). Looking further at the diagnostic criteria, HPD is based on a need to be the center of attention, while BPD is based on dysregulation stemming from an unstable sense of self, both independently and in relationship to others.
My supervisor suggests that these different driving forces manifest in the intent behind the client's "dramatic, emotional, or erratic" behavior. Specifically, it is more characteristically erratic in BPD - the emotionality is not typically planned or intended, but the result of the client feeling like s/he is out of control, or even dissolving. In contrast, the behavior seems more instrumental (i.e., goal directed) in HPD - it is in service of gratifying the need for attention, with more calculation as to the effect the behavior will have on others. Thus, clients with BPD may be much more likely to experience unintended effects of their behavior, but still be unable to choose more adaptive behavior. My supervisors suspected that our client had HPD because she seemed more in control and calculating in her behavior than one would expect from BPD.
What do you make of this distinction? How would you think about or describe the differential between these client presentations?