The combinatorics of BPD

I was going to write a serious post responding to the issues raised by Polly in her comment on my previous post and in a subsequent post of her own, but as threatened, the language is leaving me - not via disintegrative psychosis as first suggested, but a sad and sorry case of simple schizophrenia, yet another condition I didn't know I had until yesterday. I was going to discuss the diversity inherent in the concept of BPD, and of those diagnosed with BPD, which is something I'd normally do in qualitative terms - and assuming the near certainty of achieving a full remission, I will no doubt get around to doing so soon. But in the meantime, given my 'inability to meet the demands of society', I present the following 'impoverished' observations and analysis.

From DSM-IV, the criteria for Borderline Personality Disorder:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. identity disturbance: markedly and persistently unstable self-image or sense of self

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

7. chronic feelings of emptiness

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. transient, stress-related paranoid ideation or severe dissociative symptoms

Right, if we require five or more of the above criteria to diagnose someone with BPD, then there are


different ways of being borderline. Cool, huh? But let's assume for a minute that BPD wouldn't be diagnosed in the absence of Criterion 5. Strictly speaking, I've got this the wrong way around, as an impressionistic diagnosis of BPD is often made on the basis of someone meeting Criterion 5, without regard to whether they meet enough of the other criteria. But what the hell, I'm going to assume that all people diagnosed as borderline meet Criterion 5. Which now means that there are


ways of being borderline.

Now, let's assume that we have 163 borderlines who, apart from Criterion 5, each embody a unique subset of four or more of the other criteria listed above. They are all in the day room in 'Borderline House' at Mount Misery:

Then I noticed Blair Heiler, watching from the doorway. He took a first kick-step into the jungle of Borderlines, and all hell broke loose. He reached his office door, turned, and said, 'You poor sonsabitches', and closed the door behind him.

....

Heiler entered and stood for a moment inside the door, staring down at us with palpable contempt. A dismayed shake of his head seemed to set his pelvis in motion, and one leg kicked from his hip, and then another...

Suddenly Thorny was in his face, screaming - 'All you are is a life-support system for a dickhead' - and Zoe too, and then all the others. To their rage, his reaction was a cruel smile. By the time he'd shut the door behind him, the ward had once again been transformed into two dozen Borderlines from Hell, the worst patients in the world, proving the Borderline Theory.

I relaxed. When Heiler was with patients, no matter how they really were, they would act towards him like classic Heiler borderlines, lurching into rage, fear, projection... Not only do psychiatrists specialise in their defects. I thought, they evoke them in their patients...

-Samuel Shem, Mount Misery

In the book, the junior psychiatrists attempt to pair up the borderlines as part of a 'Buddy System', so that they may support each other post-discharge, which is sneakily arranged while Heiler is away. There are


ways of choosing two borderlines from among the 163 borderlines currently steaming up the windows. Take the first borderline, set aside, and allow to cool. Take the second borderline... please. Now, having been allowed some time out, assume that the first borderline meets just four (and and no more) of the criteria in addition to Criterion 5. Make a similar, uncharacteristically charitable, assumption about the second borderline. There are just


possible ways for the criteria set for the second borderline to be such that it does not overlap (except for Criterion 5) with that of the first borderline. So the probability of being able to choose two borderlines from the set of 163 borderlines who, apart from Criterion 5, each embody a unique subset of four or more of the other criteria, such that the two borderlines each meet a subset of the criteria that does not overlap with the other, except for Criterion 5, is


Which is almost as low as 1/200. Yeah, so much for diversity, I guess they pretty much are all the same.