What is Identity and Why do I Even Need One?

So before we get more into identity disturbance maybe we should establish exactly what Identity is.

"First, most experts view identity as your overarching sense and view of yourself. A stable sense of identity means being able to see yourself as the same person in the past, present, and future. In addition, a stable sense of self requires the ability to view yourself in one way despite the fact that sometimes you may behave in contradictory ways. Identity is quite broad, and includes many aspects of the self. Your sense of self or identity is probably made up of your beliefs, attitudes, abilities, history, ways of behaving, personality, temperament, knowledge, opinions, and roles. Identity can be thought of as your self-definition; it’s the glue that holds together all of these diverse aspects of yourself."

I often contemplate why people fuss so much about having a solid identity. Having a sense of identity probably serves many different functions. First, if you have a strong identity, it allows you to develop self-esteem. Without knowing who you are, how can you develop a sense that you are worthwhile and deserving of respect? According to other sources, a strong identity can help you to adapt to changes. While the world around you is constantly changing, if you have a strong sense of self, you essentially have an anchor to hold you while you adapt. Without that anchor, changes can feel chaotic and even terrifying.

Amusingly, being able to quickly adapt to change and rapidly fluctuating circumstances and people is exactly what I think having a flexible sense of self and a lack of a solid identity serves to do for people with Borderline Personality Disorder. Except as is stated, it leaves a sense of chaos and instability in its wake.

Sometimes I think it’s not so much that we lack an identity so much as that we are willing to allow our identity to flex and meet what we think others will approve of. There is a core there. The expression of them gets muddled though. Often we find ourselves acting ‘in character’ or being ‘someone else’ for someone else to gain their approval or maintain their approval in an attempt to avoid abandonment. Reaching down and telling ourselves that we will be who we are not bend and flex to the needs of others can be scary.

We do this to protect ourselves. It’s a shield to the world. A wall. A guard. A barrier and a buffer. If they reject a pseudo-you, that’s not so bad. When you show people who you really are, that’s potentially a real rejection. A real abandonment. So often those of us with BPD are living within this fragmented sense of self. We’ve been so wounded by abandonment trauma that it gives rise to a Borderline sense of false self which surrounds our wounded psyche.

As Dr. A.J. MMahari says, “Without really being consciously aware of it most with BPD are living in and from this false self. A pseudo self that exists only to express in what are known as repetition compulsions a loss that sits outside of the borderline's conscious awareness and a loss that has left them without the self that they were meant to be and know and live from.

It takes having a self, and then a connection to that self, to be able to form an identity that can be authentic. Borderline Personality Disorder exists in the space of that evacuated authentic self. - where it would have otherwise been. It rises up from the ashes of the core wound of abandonment and it is the very definition, in so many ways, of a brokenness that is this loss of self and along with one's identity.

Without a sense of self and of one's identity that is understood within a framework of object constancy a person, a borderline, cannot be expected to know what they want, what they need, who they are, what their goals are, what kind of job or career they'd like, who they want as friends, or who they would like to love because his or her sense of being is only known through the "object other" of the day, so to speak. It is that fragile. It is extremely painful.”

She goes on to state that a lot of that traditional Acting Out behavior, that rage, the abuse, the neediness the punishment, revenge, etc is evidence of a persons struggle to stave off the reoccurring re-living of the core wound of abandonment that “psychologically killed the burgeoning authentic self”.  It’s ironic that often people with BPD are the last to realize that they don’t know who they really are. It’s the finding of this authentic aspect of ourselves that we need to work on in order to help break this destructive cycle and then maintain this authentic aspect in the presence of those we might otherwise lose ourselves in. Easier said than done, I know.

A phrase I had to learn was, “This is me; what you see is what you get.” It shouldn’t be scary, but it can be. And unfortunately I’m still not completely perfect with it yet. I’m not even close yet. But I’m getting there. I have to actively stop myself sometimes and ask myself if I actually like something or if I’m simply attempting to ingratiate myself. Or if I’m being permissive of someone’s behavior when normally I’d be extremely angry about it.

Don’t be fooled. Identity issues are not a quick fix. They’re probably one of the harder ones to tackle. This takes a good deal of personal responsibility and self-awareness. Which, let’s face it, takes a hell of a lot of time and work to develop.  Especially if you’re not aware of them in the first place.

Thoughts on Identity and Borderline Personality Disorder

Identity is a funny thing. 

We make such a fuss about Who Am I? Who Are You?

It’s almost something that’s only important for other people.

When you’re alone it doesn’t matter who you are. You are who you are. You’re you and you don’t need to be anyone at all. It’s only when other people are around that it matters.

Maybe I’m wrong because I’ve spent so much of my life without a sense of THIS IS ME RIGHT HERE THIS IS WHO I AM that I feel this way.

I also know that identity changes. Who we are is constantly changing. It’s constantly evolving. Of course this isn’t what we mean when we talk about identity disturbance. That’s the big voids, the gross inconsistencies, and the major disruptions it causes in our lives.

I don’t know. I’m so many things. The Hollowness, the Emptiness, the Boredom, these things are painful for me. They go to my core some days and I feel like I’m nothing at all. No one. What makes a person? What composes a person’s identity?   

I know the things I like when I’m on my own and the things that I’m good at. I’m a PC gamer; specifically fantasy RPGs. I LOVE reading (my bookshelves are overflowing). I love to sew and costume. I like scary movies especially bad b-horror.  I’m a grade a science nerd. I’m exceptional at my job as an engineer. I’m a writer/Blogger. I cook and bake on a gourmet level. I dance. I snuggle my cat. 

Is this my identity?

I know the things I love to do for others. I’m a very outspoken advocate for women’s rights, GLBTQ rights, civil rights, equality, the environment, animals, the underprivileged, and of course mental health. For as dysfunctional as I am I do love to take care of people. Often to the exclusion of my own needs.  But even just in small ways. Cooking and baking for friends. Hosting all our gatherings. Nothing crazing. Being the one people can talk to. The one that listens. The person that has a couch they can crash one. That will be there in the middle of the night. That will pick up the phone. That remembers the birthdays and special events and throws the surprise parties and makes a big deal so they know they feel special. I like to do these things for people. I want the people in my life to know that they’re cared for.

Thanks to my therapy I can see where a lot of this comes from. I think I’ve just had so much pain in my life I don’t want the people around me to feel that, especially not from me. I know some of it is a need to not be abandoned either. But I also genuinely love to just do things for people. I also love to bake and cook. I simply can’t bake/cook the way I love to just for me. I need a crowd =) Fortunately I have a lot of friends that don’t mind one little bit.

How about this? Is this my identity?

But sometimes I’m not any of this at all. Sometimes I don’t care. Sometimes I’m angry and moody. Sometimes I’m sad and depressed. Sometimes I super happy and creative.

Is this all my identity? Pieces of it? Aspects of it? None of it at all? How about when I’m in a bad mood and it swings all over the place and I want nothing to do with any of this at all? Eventually I’ll come back to these things. I know these things will pretty much never change about me, no matter who I’m with. Then again, I never imagined the mood swings would change either. 

These are things I like. Things I do. Things I like to do for people or myself. But is that my identity? Especially when I feel nothing at all for long periods of time? Is the nothingness me as well? 

The thing that I think they don’t tell you about this flexible identity thing though. It can make you a GREAT partner as long as you manage to hold onto those things that make you, YOU. I am completely open to trying things that my partners are into. Hell I adopt them as my own interests like it’s nothing! As long as it’s not something that I’m morally opposed to like hunting or fishing (I’m strict vegetarian and live as cruelty free as possible).

More often than not I feel I’m merely consciousness sitting in a body waiting to do my next task.

When I’m immersed in a task I forget to dwell on my existence for a while but that doesn’t really solidify my identity in that task. Unless it does make my identity that task for the moment. I identify with what I’m doing in that moment? Hm. I don’t think that’s how that works. Or maybe it is.

Here’s my problem with a group of clinicians telling me what identity is. Who’s to say that it has to be a certain thing? Who’s to say that – the act of saying that it’s supposed to be a solid steady thing – isn’t what’s causing us this intense anxiety about it being so flexible in the first place.

I’m at a point at the moment (this may change, who knows) that my sense of identity doesn’t really bother me. It is what it is. I actually like who I am even if I don’t feel particularly solid. I dig the things I’m into and the things I’m good at. I appreciate the things I like to do for people on a personal level and in a grander sense (my advocacy). 

Who’s to say that identity is one specific thing? That to identify with yourself has to be in a certain way? Maybe some people just can’t? Maybe some people aren’t supposed to? Maybe that’s our particular defense mechanism? I imagine that’s what it is in a way. But I also don’t subscribe to the idea that everything has to fit into a nice neat psychological check box. Maybe I’m being too abstract with this one.

I also can’t fathom how to fix it. I admit to being completely flummoxed here. Pretty much everything else I know to at least help correct and begin to fix. I think this probably has attachments to dissociations on some level, but it has to go deeper and begin earlier.

Identity is such a tricky, tricky little beast. It’s your beliefs, your attitudes, your history, ways of behaving, temperament, personality, knowledge, opinions, roles, etc. It can be thought of as your self-definition; the glue that holds together all of these diverse aspects of yourself. Which is why it can be so distressing when other people come into our lives and we pick up aspects of them and start to bleed and diffuse into them. Our sense of self is so malleable that we don’t hold together so well. Our self-definition isn’t so well defined.

It can be so poorly defined in fact that we lose our sense of self completely to the person or people we’re with. Or we can just lose aspects of ourselves. Or just adopt new aspects of other people. I actually thing this last aspect is pretty great (or it can be because it allows us to keep a very open mind to new things and opportunities).  Then again this doesn’t have to have anything to do with other people at all.

“. . . it is very difficult for me to let other people get close to me. I am simply too afraid that they will discover that I am nothing at all, that I am nobody, a shadow, a ghost. I am afraid that they will find out that I don’t have any opinion about anything, no attitudes, no ideology, that I don’t know anything about anything, and suddenly they will figure out how boring I really am.”

This is almost the opposite of me. I read like a librarian with a full storage of encylopedias in my head. I’m very knowledgeable. I’m extremely opinionated and outspoken. Though internally I do feel like a shadow speaking well drawn conclusions. Someone sayings things the person I want to be would say, not someone I am is saying.

I try on identities like hats and see which ones I like best. I’ve done it my whole life. See something new? Try it on. Do I like it? Is it fun? Does it continue to suit me? No. Take it off. Move on. Pick up a new one. It won’t necessarily be a whole new personality but I’d do it with religions, career ideas, social ideologies, personal values, etc. Something here, something there.  That was without the influence of a significant other. Well, sometimes it was. Just trying to figure myself out. I never really had an intuitive idea. Does anyone really have an intuitive idea of who they are without self-discovery? I just believe that sometimes things wear out and become out dated; no longer relevant. Of course sometimes these personal evolutions occur much quicker for me than others. I tend to make my mind up overnight and then they stick for year. Still….

Thoughts?

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 5

We’re coming to the end! And then we can move on to more topics on Ego/Identity Diffusion and Identity issues in general! I do like that I started with something solid to show that there is real research going on here though. I think that’s heartening for a lot of us to show that – No really, people do see that this is a real identifiable issue here. Even if scientific journals can be tough to gnaw through sometimes. With that…  

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 5

Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.

The American Journal of Psychiatry, VOL. 157, No. 4

DISCUSSION  Continued…

Identity Disturbance and Borderline Subtypes

Previous research from our laboratory has found two distinct types of patients currently diagnosed with borderline personality disorder, one more distressed and emotionally dysregulated, and the other more histrionic.

I still don’t know if I agree with this subtype classification. I need more explanation because I find the histrionics are a mask for the emotional dysregulation and that emotional dysregulation is actually still there, it’s just being expressed differently.          

The secondary analyses in this study provide suggestive data on differences in the types of identity disturbance characteristic of each subtype. Controlling for histrionic features, only the second and fourth factors, painful incoherence and lack of commitment, were significantly associated with borderline features.

In fact, each of these factors had a stronger association to borderline personality disorder ratings with histrionic features held constant. These factors appear to be more closely related to the emotionally dysregulated type. In contrast, when we held borderline features constant, the role absorption factor was significantly associated with histrionic ratings. The inconsistency factor appears to be associated with both kinds of patients, but particularly with the histrionic.

This paragraph is a mouthful. Let’s break this down so it’s more readable:

When studying the Borderline Groups but removing those with Histrionic features only the 2nd (painful incoherence) and 4th (lack of commitment) factors were significantly association with BPD features.

Each factor has stronger associations to BPD when the histrionic features was held as a constant, and not variable. These factors appear more closely related to emotionally dysregulated types of BPD this way. By contrast, when they held Borderline features as a constant, the role absorption factor (#1) was significantly associated with histrionic ratings. The inconsistency factor (#3) appears to be associated with both kinds of patients, but particularly with the histrionic.

            Interesting. I may still have a bit of a histrionic streak. Hm.

Study Limitations

This study represents a first empirical attempt to home in on what identity disturbance in borderline personality disorder really means, but several potential objections require discussion. The first is the question of diagnostic reliability, given that we did not use structured interviews. Recent research suggests that even with study group sizes as small as 20 subjects, the central tendency that emerges when clinicians make categorical personality disorder diagnoses tends to be robust. In addition, we measured the borderline diagnosis in four different ways. 1) Clinicians supplied a categorical diagnosis. 2) Clinicians indicated which DSM-IV criteria for borderline personality disorder were present in their patients. The list of symptoms was not identified as the criteria for borderline personality disorder and did not appear to deter many clinicians from rating five borderline personality disorder symptoms (including the identity disturbance criterion) as "present" in patients they had categorized as not having borderline personality disorder. 3) Clinicians rated the extent to which the patient showed features of each DSM-IV borderline personality disorder criterion. 4) Clinicians made a global dimensional rating of the extent to which the patient displayed symptoms of each of the 10 DSM-IV axis II disorders, including borderline personality disorder. In all cases, the borderline personality disorder group was clearly distinct from the other groups. No clinician who described a patient with borderline personality disorder endorsed fewer than five of the DSM-IV criteria; the average number exceeded seven. Secondary analyses that used level-of-functioning variables provided further evidence for validity. Finally, lower reliability among clinicians would foster type II, not type I, errors (i.e., null findings where positive findings are warranted). If clinicians were not diagnosing patients accurately, the borderline group would be more heterogeneous and thus less likely to show such robust differences from the other groups. The findings are even more striking given the less-than-optimal diagnostic reliability. Nevertheless, this is just an initial study, and future studies with more reliable diagnostic procedures are clearly warranted; one is currently underway.

I’m heartened to hear that there will be more in depth studies in the future and that there is, in fact, one going on now.

A second potential criticism is that since we relied exclusively on clinician reports, we were not testing the nature of identity disturbance in borderline personality disorder but rather clinicians’ implicit assumptions about it. In part, of course, we were attempting to assess what clinicians mean by identity disturbance. We generated a set of 35 highly specific items, of which 28 distinguished patients diagnosed by clinicians with identity disturbance from those without. Four factors derived from this item set accounted for much of the variance in clinician ratings of the presence as well as the severity of identity disturbance, which suggests the construct validity of the instrument.

This is one of my criticism actually as you may have noticed =P I really think these kind of studies need input influenced by people that actually have an understanding of what is happening so they have an idea of what to look for.

However I do like that simply by observation they found a very identifiable pattern of struggle. In general this is where I think pure Clinical analysis falls apart though. They can see patterns but then the Analysis and Resulting Conclusions tend to fall apart a bit or aren’t quite complete, at least not when read by someone that has an understanding from the side of actually having experienced it.  There is validity in what they find, but it’s incomplete at best.

For several reasons, we believe these data provide meaningful information on the nature of identity disturbance in borderline personality disorder and do not simply reflect clinicians’ beliefs. First, all research relies on observation, and all observers have biases and intuitive theories. Most studies of psychopathology administer self-reports or structured interviews that ask patients to describe themselves and their psychopathology and then examine associations between these self-reported traits or symptoms and other self-reported variables. Our method is no different from this standard method, except that it uses expert informants rather than lay observers, for whom lack of insight into themselves is diagnostic. Given the subject of this study—identity disturbance—patients would likely have difficulty providing accurate information about their tendency to hold contradictory beliefs, their over absorption in particular roles, and so forth. We thus chose to rely on skilled observers who knew the patients well and used an instrument that asked very specific questions, most of which called for only minimal inference. Respondents were clinicians with an average of 18 years of experience who had seen their patient for an average of 53 sessions; they were thus likely to know the patients well and to be able to recognize clinically significant patterns. Ideally, studies such as this should use a combination of self-reports, interviews, clinician reports, and reports by family members and significant others to triangulate on the findings. Future studies should clearly rely on data from multiple informants.

Frankly I think this is the best way they could have handled this. It would have been interesting to have the patients also answer the questions separately to see how differently they answered and get a real idea of how great the identity disturbance is, but having a patients personal clinician of greater than 2 years is about as close a relationship as you can get for this kind of setting.

Second, and more important, shared theories could not have predicted the factor structure that emerged, the factors that correlated more strongly with borderline diagnosis, the factors associated with borderline personality disorder after controlling for sexual abuse, or the factors associated with particular subtypes of borderline personality disorder because there are no shared theories. The construct of clinical identity disturbance has been relatively ill-defined. No theory would have predicted the existence of four orthogonal factors in identity disturbance, or that subjective and objective inconsistency or incoherence would be uncorrelated with each other. These, we believe, may be important discoveries of this study.

That shared theories emerged is definitely important. Having correlations between a history of abuse, sexual abuse and the factors associated with the different subtypes when different variables were controlled may ultimately aid in more accurate Borderline diagnosis. It’s always exciting when shared theories emerge and you weren’t expecting them too. It tends to mean that things are related in ways that are significant but that had been overlooked previously… that you’re on the right track.

Third, we did attempt to assess the effects of clinician bias by examining the relationship between factor scores and clinicians’ theoretical orientation and discipline. Holding borderline diagnosis constant, theory did not predict any of the scores on any factors. Because most of the clinicians who participated in this study reported a primary psychodynamic orientation, however, we also investigated the role of discipline (psychology, psychiatry, social work) in predicting factor scores. Discipline failed to predict scores on any factors in any diagnostic group, despite the fact that clinicians from different disciplines have markedly different training.

No luck factoring in clinician bias. Hah. They’re good at scoring people with BPD, but not so hot at judging the judgers. Interesting. Professional courtesy? I can be less courteous if you need.

Fourth, dimensional and categorical diagnoses in this study produced identical findings. If clinicians were simply rating the 35 identity disturbance items on the basis of their beliefs about borderline personality disorder rather than on their actual knowledge of the patient, dimensional diagnosis would have produced much weaker findings than categorical diagnosis, since clinicians who described patients without borderline personality disorder would have systematically underdiagnosed identity issues. In fact, the regression analysis that predicted the number of borderline personality disorder symptoms from identity factor scores produced stronger findings than the comparable regression analysis that predicted categorical diagnosis.

Backwards and Forwards they got the same results. Asking the identity disturbance questions categorically to figure out if a patient had BPD or knowing that a patient had BPD and rating their responses to determine identity disturbance resulted cleanly. Good job.

Finally, as noted earlier, recent research suggests that when clinicians are asked to describe patients with various diagnoses, they do not tend to reproduce DSM-IV criteria or rely primarily on their intuitive prototypes. For example, when asked to rank order a list of 200 personality descriptors (which included DSM criteria) to describe a patient they were currently treating who had borderline personality disorder, clinicians in two studies did not tend to rank order the DSM-IV criteria the highest; rather, they painted a picture of borderline patients that tended to emphasize their subjective distress more than some of the more socially undesirable traits emphasized in DSM-IV. Indeed, cluster analysis of these descriptions led to the discovery of two replicable types of patients currently defined as borderline who do not, empirically, appear to fall into a single diagnostic category. Similarly, in the present study, clinicians rated 64% of all patients—including over half of the subjects without borderline personality disorder—as having identity disturbance as defined in DSM-IV.

In essence, Borderline Personality Disorder is a very complex disorder that is not limited to a mere checklist of criteria in the DSM-IV. This study lead to the idea that not only are there the 9 main criteria including identity disturbance, but there are also 2 subtypes (potentially more, but frankly I think they don’t have this quite right either, they definitely overlap). Not only that, 64% of all the patients in this study (including over half of the subjects WITHOUT BPD) had identity disturbance as defined in the DSM-IV. Remember they included people without personality disorders and people with personality disorders but not BPD with a history of sexual/abuse but still, that’s pretty significant. It’s not only us. That’s something to keep in mind. This is a serious issue and one with roots related to trauma at times, though clearly not always.

           

CONCLUSIONS

The data from this study suggest that identity disturbance is multifaceted, and that each of these facets is associated with borderline personality disorder. Identity disturbance in borderline personality disorder is characterized by a painful sense of incoherence, objective inconsistencies in beliefs and behaviors, overidentification with groups or roles, and, to a lesser extent, difficulties with commitment to jobs, values, and goals. These factors are all related to borderline personality disorder regardless of abuse history, although history of trauma can contribute substantially to the sense of painful incoherence associated with dissociative tendencies. Identity disturbance may manifest itself clinically in different ways depending on whether the patient is more emotionally dysregulated or more histrionic. Future research with a larger group of more carefully diagnosed patients will be required to make more definitive claims about these finer distinctions.

So what do you think? As I said back up at the top, I think it’s a good piece of solid research showing that identity disturbance is something that is clearly a struggle, a struggle that is noticeable and observable. That may or may not be reassuring but it’s a real thing.

Just because it’s all in your mind, doesn’t mean it’s not real. We don't have a 'Why', just yet, but maybe we'll get some clues as we go aloneg. 

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 4

Hey check it out I'm posting on a Monday again! 

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 4

Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.

The American Journal of Psychiatry, VOL. 157, No. 4

DISCUSSION

The aim of this study was to formulate a more precise conception of identity disturbance, particularly in patients with borderline personality disorder. The 35 items on our identity disturbance questionnaire discriminated 1) patients with and without identity disturbance across the entire cohort, and 2) patients with and without borderline personality disorder. Four factors emerged from the factor analysis, each encompassing a distinct facet of identity disturbance.

1.      The first factor, role absorption, describes over-identification with a specific role or group membership, such that a limited role or label defines the person’s whole identity.

-          This is what happens when I talk about mirroring the actions of others or groups. Subconsciously or purposefully taking on the identity of the people around you, to garner their favor. I’ve never really done this to the extent that it’s taken over my whole identity, but I’m sure it could for some.

2.      The second factor, painful incoherence, deals with patients’ subjective experience of their own identity. This factor conveys distress or concern about identity incoherence or lack of a coherence sense of self.

-          This is often our traditional sense of Emptiness, Hollowness and Boredom. That utterly distressing sense of nothingness. At the same it could also be the sense that we can feel torn between being so many different things depending on where we are.

-          This was the most highly recorded. #1.

3.      The third factor, inconsistency, includes items such as "beliefs and actions often seem grossly contradictory."

-          This is something I know a lot of our Loved Ones are confused by. We can often send mixed messages and do things that seem wildly out of character from one minute to the next. Sometimes I think this is an attempt to figure out who we are, sometimes I think it’s dependent on who we’re with, picking up on the whims of others.

-          This was second most. #2.

4.      The final factor, lack of commitment, is a fundamental element of Marcia’s conception of identity. This factor includes patients’ difficulties in committing to goals or maintaining a constant set of values.

-          This one isn’t actually my issue but I know it is for a lot of people. Especially when it comes to those of us that don’t function so highly and Act Out with less control over our mood swings and temper.

-          This was third most. #3.

All four factors were associated with clinicians’ present/absent ratings of identity disturbance, further corroborating validity of the measure. Painful incoherence was most highly associated with presence of identity disturbance, followed by the inconsistency factor, and then by the lack of commitment factor. The four factors together (R=0.61) predicted more than a third of the variance in presence/absence of the DSM-IV identity disturbance criterion (36.7%). When a continuous rating of identity disturbance was used, the four factors predicted almost half of the variance (47.3%).

While these are the 4 factors that were measured, these are by NO means the only things that contribute to identity disturbance in BPD. Scientific studies need to be limiting in nature in order to be study-able.

Oddly of the he one that distresses me the most is the one that ranks last.

Identity Disturbance in Borderline Personality Disorder

Each of the identity disturbance factors distinguished patients with borderline personality disorder from those with other personality disorders as well as those with no personality disorder. In general, subjects with borderline personality disorder had higher scores on all of the factors, which suggests that each type of identity disturbance is more severe in patients with borderline personality disorder than is seen in other nonpsychotic psychiatric disorders. Furthermore, the contrast analysis indicated a linear relationship, such that identity disturbance on each factor was greater for patients with borderline personality disorder than for those with other personality disorders, and greater for patients with other personality disorders than for patients without personality disorders.

It’s probably not surprising but results show that compared to people with other personality disorders people with BPD have a greater disturbance of identity. Even greater than that is the difference in identity disturbance when compared to people with not personality disorder at all. This will definitely contribute to why it’s so difficult for our non personality disordered loved ones to relate to the plight we deal with sometimes. Our perspectives are really just completely differently on a different plane of existing at times.

Patients’ experience of their own identity incoherence is central to identity disturbance in borderline personality disorder; this factor was the most strongly related to borderline personality disorder in every analysis. Some theorists characterize patients with borderline personality disorder as being unaware or unconcerned about their own identity disturbances, whereas others describe these patients as being distressed by their lack of coherence. Our data support the latter point of view, although this may depend on whether the patient is more emotionally dysregulated or histrionic.

This I find interesting. Even the results of their analysis is a bit ambivalent! How Borderline! How a person experiences their own identity incoherence or coherence is crucial, plain and simple. Some people are completely unaware of their identity disturbances at all. Where others are aware and are in utter distress about it. How a person manifests their distress though is going to depend on whether they’re more emotionally dysregulated or histrionic.

The weakest of the four factors in predicting borderline personality disorder was the fourth, lack of commitment. This may be an important finding, given the heavy emphasis most identity research (as well as DSM-IV) has placed on this construct. For example, DSM-IV describes identity disturbance in borderline personality disorder as being "characterized by shifting goals, values, and vocational aspirations" (p. 651). Erikson and Marcia both describe identity diffusion as being most commonly manifested in lack of commitments to career, religion, or values. Our data indicate that while this factor is a central component of identity disturbance and is somewhat elevated in patients with borderline personality disorder, it does not distinguish borderline personality disorder from other types of psychopathology. Lack of commitment may thus be a less specific index of identity disturbance that is related to multiple forms of psychopathology and not specifically to borderline personality disorder. To what degree this reflects peculiarities of our patient group, in which occupational instability did not distinguish patients with borderline personality disorder, is unclear, and hence requires replication.

             

Hmmmm. This one I’m a little dubious about personally. I know many Borderlines that tell me they have a hard time with commitment and keeping a job, so I’m sure there is some validity to this. But at the same time I wonder how much of this is culturally imposed on us as a necessary thing. Many people go through life not knowing what they want to be when they grow up, bouncing from one job to another without a formal career. Or explore different religions or spiritualties, pulling from one or another to form their own eclectic mantra. As we grow often our values change. We learn new things, who we are, who we think we are, were, changes. I know I have. I’m glad for it. Life is an evolution of change over time after all so I’m not really sure about all of this as a matter of psychosis. Just because some doctor says I should have my entire future figured out by the time I’m 30 does it mean he’s really right and that I’m crazy for not having a solid idea of what I want by then? Hell, my idea of what I want for my future is always changing, and why not? I have the luxury of it because I have a solid well-paying job and no children. I’ll do what I want thanks.

Sexual Abuse, Borderline Personality Disorder, and Identity Disturbance

One of the goals of this research was to disentangle the role of sexual abuse history in borderline identity disturbance. In the present study, half of the borderline patients had a history of sexual abuse (in comparison with 11.5% of the subjects without borderline personality disorder), which allowed us to examine the relation between identity disturbance and borderline personality disorder while holding sexual abuse constant. The data suggest that sexual abuse contributes to only one aspect of borderline identity disturbance and does not account for all of the variance on even that aspect.

Interesting. Very, very interesting. A history of sexual abuse really only affects one main area of identity disturbance? And doesn’t even account for all of the variance in that aspect. The extrapolation being BPD symptoms would exist even without a history of sexual abuse, though potentially not as severely or in the same way.

Many researchers have found a strong relationship between a history of sexual abuse and dissociative symptoms. Sexual abuse history was highly correlated primarily with the painful incoherence factor, and the item content of this factor suggests that sexual abuse history may play a role in the more dissociative aspects of identity disturbance.

This makes a lot of sense to me. I don’t recall dissociative symptoms before my history of sexual abuse but it sure explains it afterwards. I very vividly recall the emptiness, the hollowness and a lot of the other painful feelings I felt before it though. So some of the painful incoherence factor was definitely already there, and not only from that history, but it certainly may have exacerbated it. And I wouldn’t be surprised if my dissociative disorder was a product of my history of abuse.

Although the painful incoherence factor was strongly associated with a sexual abuse history, the model that best predicted subjects’ scores on this factor included both abuse history and borderline diagnosis. The patient’s painful concern about identity incoherence is not only the result of trauma; it appears to be integral to the nature of borderline personality disorder, whether or not the patient has an abuse history. Sexual abuse was largely uncorrelated with the other three identity factors, all of which are associated with borderline personality disorder.

           

It’s interesting to me. I can be incredibly ambivalent about my identity at times. Sometimes I know. I’m sure. Other times I don’t care. No. I think it just doesn’t matter. Who are any of us anyways but specs of atoms pulled together for a short period of time until the Universe blows us away. Then other times, I just can’t wrap my mind around all the aspect that hold me together and make me a solid composition.

I’m everything and I’m nothing and none of it really matters in the end.  

            ….. and with that I’m drained. We’ll wrap this up tomorrow! 

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 3

We’re getting there. So let’s move along! 

Identity Disturbance in Borderline Personality Disorder: An Empirical Investigation – Part 3

Tess Wilkinson-Ryan, A.B.; Drew Westen, Ph.D.

The American Journal of Psychiatry, VOL. 157, No. 4

RESULTS

The patients described by the clinician respondents ranged in age from 18 to 66 years. We initially intended simply to compare patients with borderline personality disorder (N=34) to patients without the disorder. However, when we examined the data, we found that the nonborderline group (N=61) included 20 patients diagnosed by their clinicians with personality disorders other than borderline personality disorder, which allowed us to test hypotheses more conservatively. Although the reliability of the "other personality disorders" category is unknown, we were able to assess whether these patients differed in their general social adjustment and level of psychopathology from the subjects with no personality disorder. In any event, diagnostic unreliability and smaller group sizes would foster type II, rather than type I, errors; thus, any findings that emerged with this three-group comparison would be very conservative. Given the preliminary nature of this study, which constitutes the first (to our knowledge) systematic effort to explore the precise nature of identity disturbance in patients with borderline personality disorder, this conservatism seemed warranted. As a secondary analysis, we ran analyses with just two groups (borderline personality disorder versus no borderline personality disorder). The results were the same or stronger in all cases, so here we report the more conservative findings.

In short, they took the safe approach to get the most accurate comparison between Borderline and Non-Borderline groups.

As expected, gender ratios differed somewhat among the groups. In the borderline personality disorder group, 82.4% of subjects (N=28) were female, which resembles the gender ratio for this disorder in the population (approximately 75%, according to DSM-IV). Half of the subjects with other personality disorders were female; the corresponding percentage in the no personality disorder group was 65.9% (N=27). Thus, we used sex as a covariate in subsequent analyses.

Diagnostic Validity

To distinguish patients with borderline personality disorder from other patients, we first asked clinicians to fill in an axis II diagnosis. As a validity check, we then asked them to 1) indicate whether each of the nine DSM-IV criteria for borderline personality disorder was present or absent, 2) rate the extent to which the patient showed symptoms of borderline personality disorder as well as symptoms of each of the other axis II personality disorders, and 3) report on level of functioning (Global Assessment of Functioning scores, employment history, and number and quality of peer relationships).

Data relevant to diagnostic reliability for the 95 subjects are presented in t2. To be diagnosed with borderline personality disorder, a patient must manifest at least five of the nine DSM-IV criteria. In this study, patients diagnosed with borderline personality disorder fulfilled an average of 7.4 criteria. Patients with other personality disorders or no personality disorder averaged fewer than five. Differences among these means were statistically significant. Similar findings emerged when we compared the severity ratings of each borderline personality disorder criterion.

            Standard DSM you have BPD, stand you don’t have BPD.

To compare personality pathology, we averaged all the personality disorder symptom ratings for the three groups for each of the 10 personality disorders, which produced a composite index of the extent to which patients in each group had personality disorder symptoms of any kind. As expected, the borderline personality disorder group had the highest mean ratings, followed by the subjects with other personality disorders and then those with no personality disorder. The differences among these means were significant. As a specific validity check on the diagnosis of "other personality disorders," we then recomputed these means excluding borderline personality disorder symptom ratings. Post hoc comparisons revealed significant differences but only between the no personality disorder group on the one hand and both personality disorder groups on the other. Thus, both personality disorder groups appeared to score higher on personality disorder characteristics than the no personality disorder group, and the borderline personality disorder group was specifically higher than both other groups on borderline characteristics.

This is all about comparing averages if you’re interested in averages. BPD “wins” on having more disordered traits, yay us, compared to people without BPD and people with “other personality disorders”.

Level of functioning variables also provided support for diagnostic reliability. Mean scores on the Global Assessment of Functioning were significantly different for the three groups as were the quality of peer relationships and the number of close relationships; employment stability, however, did not differ.           

One peculiarity of the data did emerge: 19.7% of the patients without borderline personality disorder (N=12, split roughly evenly between the subjects with other personality disorders and those with no personality disorder) fulfilled five borderline criteria. We suspect this reflects both the high comorbidity of borderline personality disorder with nearly all other personality disorders and the tendency of clinicians to prioritize axis II diagnoses, giving such diagnoses as "narcissistic personality disorder with borderline features". We addressed this in two ways. First, in line with our strategy of minimizing type I errors and maximizing conservatism of the findings, we kept patients in the diagnostic categories to which clinicians assigned them. If some subjects with no personality disorder really met borderline personality disorder criteria, that would reduce mean differences between the two groups, not overestimate them. Second, as planned, we supplemented categorical analyses with continuous analyses, with number of borderline criteria as the dependent variable, and used multiple regression to predict the number of borderline personality disorder criteria from identity factor scores. Thus, our findings are applicable not only to categorical but to dimensional analyses of borderline personality disorder symptoms.

There is no way you’re going to be classified as having BPD in this study if you don’t actually have it. Really? It’s true. They’re being super stringent.

The prevalence and confirmation of abuse history for the patients are reported in t1. Of the 24 clinicians who marked "Yes" on the sexual abuse question, all reported confirmation from at least one outside source. Four clinicians who completed this section marked the sexual abuse history as "Unsure." None of these four patients entered treatment with clear, conscious memories or documenting evidence of abuse. The data thus suggest that clinicians were using sensible (although of course not infallible) algorithms in determining degree of likelihood of sexual abuse history.

Hmmm. I wonder if they were correcting for sexual abuse in childhood, adolescence, or adulthood. I have a history of sexual abuse, but not in childhood. My BPD symptoms were already full blown by the time that happened. Either way, I’m sure it has a significant effect. I know it affected me.

To ascertain the extent to which our measure of identity disturbance was really capturing the construct it was designed to assess, we used clinicians’ ratings of whether the identity disturbance criterion from DSM-IV was present or absent, which divided patients into two groups. We then compared the mean ratings for each identity disturbance item for these two groups in an effort to assess the extent to which our items were capturing the same construct clinicians classify as identity disturbance. Twenty-eight of the 35 items significantly discriminated between patients with and without identity disturbance at the 0.05 level (conservatively using two-tailed tests, even though predictions were directional), which indicates that our items did in fact address identity disturbance as clinicians conceptualize it.

            Yay the tests work!

The items that did not predict identity disturbance tended to describe unusual phenomena with low base rates, such as "patient ‘displays’ identity in ways that appear unusual or deviant (e.g., multiple tattoos, piercings, highly peculiar hair style or coloring)," on which most subjects received a rating of "1." Although deviant appearance may be an indicator of identity disturbance in the general (or psychiatric) population, our study group size may not have been large enough to detect this.

I like this quite a bit actually. Tattoos, piercings, crazy hair, and things like that did NOT indicate identity disturbance! That’s absolutely fabulous. Well, not really anyways.

           

Distinguishing Identity Disturbance in Borderline Personality Disorder: Item, Factor, and Construct Analyses

To examine the nature of identity disturbance in borderline personality disorder, as a first step we compared means for each item for patients with borderline personality disorder with means for each of the other two diagnostic groupings (t3). To be conservative, we only considered those items that distinguished borderline personality disorder from both of the other groups as clear markers of borderline identity disturbance, again by using two-tailed tests despite directional hypotheses. Thirty-two of the 35 items distinguished subjects with borderline personality disorder from those with no personality disorders; of these, 17 items also distinguished subjects with borderline personality disorder from those with other personality disorders. Thus, the data suggest that robust differences do exist between patients with borderline personality disorder and other patients, whether or not they have a personality disorder. It is important to note that the data did not support potential concerns about clinician response bias. Respondents did not simply give high ratings to all 35 indicators of identity disturbance if they had diagnosed the patient with borderline personality disorder and give low ratings otherwise; over half the items that discriminated patients with borderline personality disorder from those with no personality disorder did not discriminate patients with borderline personality disorder from those with other personality disorders, who clinicians clearly identified as nonborderline.

To discern whether identity disturbance was a unitary or multidimensional construct they went on to determine a variety of factors.

1. The first factor was role absorption, in which patients appeared to absorb themselves in, or define themselves in terms of, a specific role, cause, or unusual group.

2. The second factor, painful incoherence, reflected patients’ subjective experience and concern about a lack of coherence.

3. The third factor, inconsistency, was characterized less by subjective than objective incoherence (i.e., did not imply distress).

4. The fourth factor was lack of commitment (i.e., to jobs or values).

The factors all showed high internal consistency, with the following reliabilities (coefficient alpha): factor 1=0.85, factor 2=0.90, factor 3=0.88, factor 4=0.82. t4 describes the items that loaded above 0.50 on each factor.

Basically the closer to 1 = closer to 100%. This is all mostly about data analysis if you’re interested.

To see whether patients diagnosed with borderline personality disorder would differ from other patients on these four dimensions of identity disturbance, we compared the means of the three groups by using a one-way analysis of variance (ANOVA) for an omnibus F, and then tested specific hypotheses by using contrast analysis. The ANOVA showed a significant difference between the three groups on the first (F=3.87, df=2, 92, p=0.02), second (F=16.14, df=2, 92, p<0.001), and third (F=4.82, df=2, 92, p=0.01) factors and approached significance on the fourth (F=2.65, df=2, 92, p=0.08).

The more important analysis is the contrast analysis, which asks more focused questions than the omnibus F. We tested three competing hypotheses for each factor, specified in advance. Borderline patients would score higher than the other two groups, who would not differ from each other (contrast weights: 2, –1, –1). 2) Scores for the three groups would be linearly related, such that borderline personality disorder patients would have the highest scores, followed by patients with other personality disorders and then those with no personality disorder (contrast weights: 1, 0, –1). 3) Mean scores would follow the same order as in the previous contrast but with a larger mean difference between patients with borderline personality disorder and those with other personality disorders than between patients with other personality disorders and those with no personality disorders (contrast weights: 4, –1, –3). The second, linear model, tended to be the most robust, revealing predicted differences among all three groups. These differences are all the more striking given the limited diagnostic reliability data for the group with other personality disorders. The results of these analyses are detailed in t5. (For simplicity, we only report the first two contrasts in each case, because contrasts two and three were largely redundant.)

Analyzing the data a second way, we used multiple regression to predict borderline pathology, measured dimensionally by the number of DSM-IV borderline symptoms, from patients’ scores on the four identity factors. The four factors together (R=0.71) accounted for 50.2% of the variance, with the first three factors contributing significantly to the variance (p<0.05) and the fourth showing a trend (p=0.10).

Basically no matter which way they analyzed the data people with BPD had much higher degrees of identity disturbance than people with “other personality disorders” and as much as four times the degree of identity disturbance as those with no personality disorder.

Disentangling Borderline Personality Disorder and Sexual Abuse

The data thus far indicate that patients with borderline personality disorder do indeed differ from both subjects with other personality disorders and those with no personality disorder in multiple dimensions of identity disturbance. What is not indicated is whether, or to what extent, those findings reflect the greater incidence of sexual abuse in patients with borderline personality disorder (or gender differences, given the higher prevalence of borderline personality disorder among women).

We thus wanted to examine the extent to which a diagnosis of borderline personality disorder contributed to factor scores independent of a patient’s gender and sexual abuse history. To accomplish this, we used multiple regression to assess the predictive value of gender (dummy coded 0=male, 1=female), sexual abuse history (coded 0=no, 1=unsure, 2=yes), and diagnosis (borderline personality disorder=1, no borderline personality disorder=0) for each factor, entering gender and sexual abuse history in the first step and diagnosis in the second.

Sexual abuse history was correlated to varying degrees with each factor; however, in all cases, the model that included borderline personality disorder diagnosis was significantly more predictive than the model that included only patient gender and sexual abuse history (t6). For the first factor, role absorption, gender and sexual abuse contributed substantially less than the borderline diagnosis to the predictive power of the model. The second factor, characterized by painful feelings of identity incoherence, was highly correlated with sexual abuse history, although inclusion of borderline personality disorder diagnosis significantly improved the model’s predictive power. For the other two factors, patient gender and sexual abuse history did not account for enough variance to reach significance. The fourth factor was best predicted by the model that included borderline personality disorder diagnosis, but this model did not account for a significant amount of the variance.

In a second set of analyses, we assessed the relationship between sexual abuse and severity of the disorder (total number of symptoms). A history of sexual abuse predicted a higher likelihood of borderline features (r=0.49, df=90, p<0.001). A regression model including patient gender and sexual abuse (R=0.51) accounted for 25.6% of the total variance on number of symptoms present (F=12.75, df=2, 74, p=0.001). In contrast, a model including patient gender, sexual abuse history, and the four identity factors (R=0.73) accounted for 53.1% of the total variance (F=13.20, df=6, 70, p<0.001); this change was highly significant (F=10.24, df=4, 70, p<0.001). Comparable findings emerged when we used gender, sexual abuse, and the four identity factors to predict the presence or absence of the borderline diagnosis. The combined model (R=0.73) explained 53.1% of the variance (F=13.20, df=6, 70, p<0.001). The same was true when we used these variables to predict number of borderline symptoms excluding the identity disturbance criterion. Gender and sexual abuse alone in this analysis explained 25.0% of the variance, whereas adding the identity variables (R=0.67) explained an additional 20.0% (F=15.20, df=4, 75, p<0.001), a highly significant change (F=7.61, df=4, 70, p<0.001).

Basically in this study they compared Sexual Abused to a number of factors like BPD, Gender, Identity, etc; on their own, and combined and compared them to see where sexual abuse had significant impacts. A history of sexual abuse predicted a higher likelihood of borderline features and a higher severity of borderline features. That shouldn’t be a surprise to many of us. It was also found that when they combined gender, sexual abuse history and identity issues over 50% were impacted significantly. Comparable findings also emerged for distinguishing a borderline diagnosis; that is with gender, sexual abuse history, and identity issues. Something to keep an eye on I’d say.

           

Identity Disturbance and Borderline Subtypes

As an exploratory analysis, we followed up on findings of two recent studies that isolated two distinct types of patients currently diagnosed with borderline personality disorder, one with more dysphoric features and the other with more histrionic features. The first type (emotionally dysregulated) includes patients who have intense, painful, and poorly regulated emotions that they attempt to escape by using various maladaptive affect-regulatory strategies. The second (histrionic) type have emotions that are intense and dramatic but not very troubling to them; for these patients, dramatic emotions may even be self-defining.

To examine identity disturbance in patients who approximate the emotionally dysregulated type, we examined the partial correlations between ratings of borderline personality disorder and each identity disturbance factor, holding constant ratings of the extent to which the patient had histrionic features. (To maximize the comparability of dimensional diagnoses of borderline personality disorder and histrionic personality disorder, we used clinicians’ 1–7 ratings of each.) As predicted, this analysis indicated a very strong relationship (r=0.58, df=70, p<0.001) between severity of borderline personality disorder and the second factor, painful incoherence, after controlling for histrionic features. The only other significant partial correlation was with the fourth factor, lack of commitment (r=0.24, df=70, p=0.05).

Conversely, to examine identity disturbance in patients who approximate the histrionic type, we examined the partial correlations between ratings of histrionic personality disorder and each identity factor, holding constant borderline personality disorder ratings. For the first factor, role absorption, the partial correlation with the histrionic rating was significant (r=0.24, df=82, p=0.03). Strikingly, the second factor, which correlated so strongly with borderline personality disorder, showed a slightly negative correlation with histrionic ratings (r=–0.07, df=82, p=0.50). The last two factors correlated slightly positively with the histrionic rating (r=0.19, df=82, p=0.08; and r=0.13, df=82, p=0.28, respectively. Thus, some elements of identity disturbance appear more closely associated with histrionic than with borderline features, particularly role absorption, and, secondarily, inconsistency.

On the one hand I feel I like that they’re exploring more than one expression of BPD but I think they’re sort of missing the point at the same time. Personally I could be both dysphoric and histrionic at times, especially when I was younger. In fact it was either one or the other. I was either in intense pain or incredibly angry and moody… or I was really attention-seeking and involved in my relationships and sexually involved and the life of the party. Being Borderline is rarely so cleanly cut. So it’s not surprising that they they would still have a correlation with the control factor of the dysphoric or histrionic feature for the other group. I will say though that even when I was in my more histrionic phases I did have a very self-loathing streak. I don’t know if that’s present in people with histrionic personality disorder. I was trying to escape my pain which they were definitely spot on for.

I know this post was a lot of Analysis and numbers and data collection and it’s hard to wade through. Next is the Discussion! That’s the good stuff!