Falling Through the Cracks: When the DSM Can’t Find You

This week in my DBT group, we were talking about what Borderline Personality Disorder is and how it’s diagnosed (DBT was originally formulated for BPD). Essentially, there are nine traits that are used to diagnose BPD. If your diagnosing therapist sees five or more of them in you, then you are diagnosed with BPD. If you have less than five, but still have some, you are diagnosed with what’s called BPD Traits. I had never heard of BPD Traits before, and I don’t think most people have. Insurance is far less likely to cover something that sounds subclinical like that, and it’s far less likely to be understood by the general public. It simply sounds less severe, right?


Unfortunately, this system has a few major flaws, and it seems to me that these flaws are indicative of many of the problems with the DSM as a diagnostic manual. The main problem with this system of diagnosis is that many of the traits of BPD are things that everyone has to some extent or another (things like anger issue, or efforts to keep people from leaving you), and so they only become diagnosable when they seem to be excessive or problematic. This leaves a great deal up to the discretion of the diagnosing therapist. It also means that that therapist has to draw a hard line about what counts as problematic and what doesn’t, when in reality these traits exist on a spectrum. So you could be just over the line and counted as having the trait, or you could be so far over the line you can barely function on a day to day basis, and in the eyes of the diagnosis, you have the same trait.


This also means that the difference between BPD and BPD traits isn’t as clear cut as it might seem in the first place. For example, someone with BPD might be just over the line on five traits, but someone with BPD traits might be way, way over the line in four. Who’s to say which is more severe, or that one should receive a full diagnosis that allows them access to treatment, while the other receives a diagnosis that gets them almost nothing?


Overall, this illustrates something that is definitely wrong with the DSM: mental illness and mental traits all exist on spectrums. There is no on or off switch to depression, anxiety, paranoia, or any other problem that may be diagnosed as a mental illness (with the possible exception of hallucinations). However in order to diagnose someone (and particularly for that individual to gain coverage of treatment), symptoms are treated as present or not present. Occasionally we use modifiers like “severe” or “mild”, but more often than not it’s either there or it’s not.


This seems to be a recipe for disaster for people whose symptoms either don’t present as traditionally understood, who are barely subclinical, or who have an odd constellation of symptoms. I find that I often have this problem: I have lots of issues (oh LOTS and lots). I have bits of OCD, OCPD, ADD, BPD, depression, anxiety, bulimia, anorexia, and really probably a whole host of other things. But because many of them are subclinical, or I don’t have the right pairings to fit into a particular diagnosis, I have been left without any sort of personality disorder diagnosis, or larger diagnosis to fit it all together. Despite how severe my eating disorder was, I was lumped in the EDNOS category, which is far less often covered, and is often treated with less respect and as less severe than other eating disorders.


This is a serious problem if we want to provide proper services for those people suffering from mental health issues. We shouldn’t have to wait until a symptom is truly interfering with someone’s basic functions before we give them help. There are many problems with the DSM, and trying to posit a replacement for it is extremely difficult, but one element that really could use replacement is this all or nothing thinking. There is no “partially depressed” or “sort of ADD”. You either have it or you don’t. One improvement could be seeing mental health on a spectrum. We all have different traits, and many of those traits are spectrum style traits. Understanding that moving towards the extremes is always a problem is one great way to view mental health in a more understanding and helpful way, because it allows us to try to help everyone move towards a more balanced place, and could allow us to provide treatment for those who have not yet reached the critical zone.


Another issue with this system is the amount of discretion that it allows for the diagnosing clinician. Let’s look at a particular example. One of the criteria for diagnosing BPD is “inappropriate, intense anger or difficulty controlling anger”. This is fairly vague. What counts as inappropriate anger? How might things like race and gender fit into this (hint: black women will always be viewed as having inappropriate anger)? Shouldn’t there be specific examples of things that might constitute inappropriate anger, or the consequences in someone’s life for “difficulty controlling anger” or the number on an emotional scale of what constitutes “intense” anger? How often does one need to be intensely angry to get this trait? All of these things are left up to the discretion of the diagnosing clinician, and unfortunately this allows for a lot of bias.


There is a difficult balance here, because having that kind of specificity means that you could be very close to a diagnosis, but not quite reach the correct number of episodes, or the right “level” of anger to reach diagnosis. It seems to me that having these specific levels combined with a spectrum view of disorder would allow clinicians to have less individual discretion that can lead to variability in diagnosis, but would also allow more people to get the treatment that they need. It is widely recognized that we need some changes in the DSM, but these particular issues are ones that I have seen in action in myself and in people around me, and that seem as if they could be fixed without great difficulty. Get on that DSM.

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