Thursday, June 7, 2012

Differentiating Borderline and Histrionic Personalities

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?

6 comments:

  1. What if someone were to have BPD, as in "stemming from an unstable sense of self, both independently and in relationship to others", but "seem more in control and calculating in their behavior than one would expect from BPD"? That is often the case.

    I stumbled across this article hoping for an answer to that, but now I'm even more confused.

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  2. Thanks for your comment. I think the key is what specific behavior is in control or out of control. While individuals with BPD are in control much of the time, and often choose maladaptive behaviors to achieve a specific outcome, due to the lack of more adaptive skills, there are times when they experience themselves as out of control, "disintegrating," and feel and display a high intensity of distress in a quite chaotic way. In contrast, individuals with HPD seem much more in control DURING an episode of distress, and may rapidly shift what emotion they are expressing (from crying to smiling, for example) based on factors in the environment.

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  3. in practicing you find borderline with moral, borderline with hi histrionic traits, borderline with obsessive traits,this all make difference......but borderline really suffering.....this is the key......pure histrionics do believe that they suffer, but they will not be have the same degree of the strength ,long of the period like boderline

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  4. HPD seems to me like "BPD-lite" or "NPD-lite" in some cases. HPD seems to be characterized by what BPD and NPD -lack-.

    BPD has the attention seeking like HPD, but like you pointed out from your supervisor, the latter is more calculated...not as "reckless." Also, fear of abandonment is not a hallmark of HPD.

    NPD also has attention seeking as well, but they are trying to feed their narcissistic identity. People with HPD don't necessarily think they're a "god."

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  5. Correction on the first part: HPD seems to be characterized by what is -lacking- from BPD and NPD.

    (wish there was an Edit button. :) )

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    Replies
    1. ARGHHH!!! "HPD seems to be characterized by what is -lacking- from it in comparison to BPD and NPD."

      (sorry it took three dang posts to convey that!)

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