1/ Question from commenter: "Can psychopathy and Borderline be comorbid? Or NPD and BPD?"
NPD and BPD are definitely comorbid: hence the term "cluster B"
NPD and BPD are definitely comorbid: hence the term "cluster B"
2/ Narcissistic personality disorder, histrionic personality disorder, antisocial personality disorder, and borderline personality disorder, all share a common core of extreme difficulty managing ("regulating") emotional experience and the self.
3/ And they all share a pattern of underdeveloped coping (also called primitive defenses), marked by distortions in reality (and sometimes a departure from it). Psychopathy and Borderline Personality Disorder can also easily overlap.
4/ The reason has to do with what a "borderline organization" means historically (and still does to some extent)--a lack of psychological ("intrapsychic" or inner world) integration.
5/
As recently as 50 years ago, the term "borderline" literally meant "on the border of psychosis and neurosis."
As recently as 50 years ago, the term "borderline" literally meant "on the border of psychosis and neurosis."
6/ These were patients who seemed, one minute, in touch with the real world and lucid, and then the next, under stress, their thinking became disorganized, magical, and deeply flawed (and their behavior just as disturbed). This wasn't supposed to happen.
7/ People were supposed to be either depressed or anxious in normal ways, or hearing and seeing things, but not vacillating between the two.
8/ Our understanding in the field at the time was that their poor coping skills, especially their inability to maintain a sense of self and stable emotional state, made them vulnerable to essentially becoming unglued.
9/ When their sense of self was threatened, they fell back on reality distorting strategies, like denial (the reality I see isn't happening), projection (I'm not angry, you are), splitting (black & white thinking)...
10/ ... and projective identification (in which people don't just, for example, imagine you're angry when they in fact are angry--they work you over until you feel the anger they refuse to recognize in themselves).
11/ Psychopathy, historically, was a character type--specifically someone who organized their sense of self and managed feelings by power over others, or a defense called "omnipotent control." Everything is done to assure themselves of their power and invulnerability.
12/ "I'm am powerful and in charge and you are weak and controllable, at my whim" is their way of viewing the world and people around them. In fact, this simple way of thinking about psychopathy still captures a lot of what psychopaths do and why they do it.
13/ Psychopaths could be more or less in touch with reality, we assumed. They could be psychotic, as many psychopathic serial killers are, or they could be neurotic (think Dexter from the TV show), or they could be borderline, depending on how well put together they are.
14/
Though we've separated out all these disorders and moved "borderline" from a level of psychological organization to a disorder in and of itself, many of us in the field still think this way, and you can see it explains why there's a "cluster B" in the first place.
Though we've separated out all these disorders and moved "borderline" from a level of psychological organization to a disorder in and of itself, many of us in the field still think this way, and you can see it explains why there's a "cluster B" in the first place.
15/
All cluster B disorders in the DSM tend to function at the borderline level of organization. That's not why they're called cluster B, but when I was learning about them, that's how we remembered what cluster B indicated.
All cluster B disorders in the DSM tend to function at the borderline level of organization. That's not why they're called cluster B, but when I was learning about them, that's how we remembered what cluster B indicated.
16/
Essentially, people with ASPD are really just psychopaths at the borderline level of organization.
Essentially, people with ASPD are really just psychopaths at the borderline level of organization.
17/ NPD is narcissistic character with a borderline organization, HPD is histrionic character, borderline organization, and BPD is what used be called, unflatteringly, Infantile character, borderline organization.
18/
The new nomenclature had many benefits but one huge draw back was proceeding as though this cluster of disorders had less overlap than they actually do.
The new nomenclature had many benefits but one huge draw back was proceeding as though this cluster of disorders had less overlap than they actually do.
