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Comment by zamalek | Hacker News Reader

There's a good chance my brother suffers from borderline personality disorder. My therapist has explained the biggest issue about PDs: the disorders make a person extremely unlikely to seek out help, as (to put it poorly) they believe the problem exists with the people around them and not themselves. This means that very little is understood, medically, about the disorders and how to treat them effectively.

The author of this piece is an extreme anomaly, not for having a PD (it is surprisingly common), but for having received effective treatment.

If you suspect that someone in your life suffers from a PD, I strongly recommend "Out of the FOG[1]." It focuses on what you can do to protect yourself and potentially have the semblance of a healthy relationship.

[1]: https://outofthefog.website/toolbox-intro/

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There is also a healthy debate over the degree to which personality disorders represent a true disorder, or just an extreme personality on the edges of normal distribution. If you consider it in those terms, then “treatment” amounts to having someone voluntarily attempt to change their personality at a fundamental level. Even if they wanted to, how likely is that to succeed?

All too often treatment for personality disorders, especially in Cluster B just train people how to better fake “normalcy” and to speak the language of therapy.

> There is also a healthy debate over the degree to which personality disorders represent a true disorder, or just an extreme personality on the edges of normal distribution.

I'm not sure that's a meaningful distinction. That is to say, a "disorder" should be something that interferes with your ability to function and flourish in a normal environment. I'm not sure it's meaningful to draw a distinction between people who absolutely cannot function and people who merely effectively cannot function. Just because your ankle is sprained and not broken doesn't mean you don't need medical care or that you should be walking.

Well, if functioning and fluorishing is defined by conformity, this doesn’t seem very meaningful. Some personality disorders allow a high functioning career and social life.

To be clear I am trying to illustrate the idea that a disorder seems inherently devilish to define.

Years ago I dated a woman with a “high functioning” career and from outside apparently normal social life who in retrospect was clearly BPD.

She was very good at hiding her feelings during most casual interactions, and was clever and generous and fun to talk to when calm, but had almost a second personality which would come out when she became even slightly stressed which was bitter and entirely self-centered and extremely manipulative. She was at that stage of her life completely incapable of maintaining a close personal relationship, and she was frequently (on a daily basis) under extreme stress about perceived grievous slights from everyone around her that were to an outside observer inconsequential mistakes or misunderstandings, and she was harboring numerous long-term grudges.

It seemed like she knew she had a problem, and during times where she wasn’t stressed out would regret her outbursts and seemed to wish she generally had better emotional control. She seemed generally pretty miserable about it, but maybe I was projecting based on the way her problems made me feel.

I dated a high-functioning borderline as well. It was a horrible experience, but in retrospect I'm (kind of) grateful to have learned about personality disorders as a result. I guess I learned a lot about myself too.

I feel absolutely awful for people who date high-functioning borderlines and never learn about it. At least with the ones who are low-functioning, you absolutely know something is deeply wrong with them at all points in the relationship. With a high-functioning one, you second-guess yourself constantly.

I really do think there needs to be more general awareness about Cluster B personality disorders. The occurrence rate among the population is low, but the nature of the disorder means a high-functioning borderline establishes relationships with (and potentially harms) a large number of people. It's hard for victims to seek help when they don't even know the name or nature of what they're dealing with.

People generally don't write glowing reviews of their exes, so forgive my skepticism of your and parent's anecdotes.

The event that ended the relationship was: I was talking to her nice (edit: male) roommate about politics or something at about midnight while she went to bed apparently in a good mood. Turns out that was unacceptable, and she came back out of her room 20 minutes later, started berating me for it while I was confused, escalated to shouting at me for an hour while I remained calm, and finally threatened to call the cops on me. I walked a couple miles home at 2 AM through a snowstorm, while she sent me 10 desperate text messages. I never talked to her again, though I spent months agonizing about it (to the point of panic attacks), because I felt guilty that she desperately needed help and I thought I might be able to help her through continuing to patiently and reliably engage with her (it didn’t seem like anyone else was around to help her), and I liked and respected her as a person, but decided I couldn’t take it for my own mental health.

We only dated for a relatively short time, but it took me a move across the country and a year to sort out my feelings and start dating again.

YMMV.

Had a pretty similar relationship. I was the one that wanted to get back together though. But this one time he didn't apologize and did the most incredible 180 on me. Never felt so hated, almost killed myself [0]. I tried to engage once in a while, sometimes he would too. But would never act/talk "normal" again. He found a new bf and talked about how much he loved him just to make me sad [1]. And one day just minutes after insulting me all of a sudden he starts talking like the old him again. Wanted to meet up. Was so happy. He wanted to just hook up tho, not into that, but still I wouldn't outright say know, was very happy to meet him anyways. I tried saying something like "lets go eat something and we'll see what happens", but he snapped and started berating me again. And that was the final end of us, never messaged him again and neither did he.

[0] which what made me start reading about BPD [1] he'd either talk about this or berate me, wouldn't mention anything else, work or anything. We were always super chatty about literally everything so yea

FYI you're responding to a borderline on a throwaway. Don't waste your time.

Don't you think calling out somebody as having BPD based on a couple comments discredits your BPD anecdote somewhat?

For those taking notes, your girlfriend may respond negatively to going to bed alone while you have one-on-one time with her friend or roommate (or any other woman) late at night, especially if the other is being "nice."

Yes, it’s reasonable and entirely within the realm of normal human feelings to not want to go to bed alone while your boyfriend continues a conversation with your male roommate. It is reasonable and normal to feel upset that this desire wasn’t implicitly obvious to your boyfriend.

But the typical response to a minor misunderstanding like that is to make the communication more explicit with a simple request that the boyfriend come to bed and share that you felt upset about it, trusting that your caring boyfriend will feel sorry, make a note and try to do better next time. Not to lead with accusations of ill intent and quickly escalate to a full range of emotional manipulation and threats of physical violence.

Maybe you just need to know better people.

> I feel absolutely awful for people who date high-functioning borderlines and never learn about it. ... I really do think there needs to be more general awareness about Cluster B personality disorders.

But people are increasingly aware of it. The "creepy abuser" (male) and the "crazy chick" (female) are stereotypes for a reason, and both of these seem to closely match Cluster B. More specifically, people are also becoming aware of Cluster B's associated dysfunctional thought patterns, and how to mitigate those, or at least how to effectively counter e.g. the gaslighting, unprovoked outbursts/tantrums, fanciful accusations, etc. that result from such thought patterns.

Right, everyone knows the stereotypes, but not everyone knows that there's an identifiable condition behind it, with signs and patterns that are identifiable and uniform, as well as support for victims.

>More specifically, people are also becoming aware of Cluster B's associated dysfunctional thought patterns, and how to mitigate those, or at least how to effectively counter e.g. the gaslighting, unprovoked outbursts/tantrums, fanciful accusations, etc. that result from such thought patterns.

I also like to think that this is true, but I still don't think awareness is spreading as fast as it should be. We'll get there, though, right?

> Some personality disorders allow a high functioning career and social life.

No, they don't, because built into the definition of disorder is the impact it has one someone's life.

Which is a bit of an issue isn’t it. Is Shkreli in Cluster B? Probably, and now he has the impact on his life to prove it. So before that, when he was just incredibly successful, had no criminal record, and seemed able to function at a high level did he have the same disorder? If outcomes represent a diagnostic criteria then it reveals a weakness in understanding or even defining the disorder in question.

It’s important to distinguish between diagnostic criteria, and the disorder itself, if they are actually disorders.

Ok... so most mental “disorders” with high functioning people aren’t actually disorders? The definition seems useless without meaning simply “nonconforming”.

Homosexuality was considered a disorder until fairly recently

Yes, so was gender identity disorder (i.e., transgender) which was often classified with pedophillia or body integrity disorder.

There is no frame of reference for psychology to use except society and general assessments of normality and expected behavior. That mean the only method to determine whether or not something is a disorder at all is a) determine the impact of the condition on the individual's ability to function, and b) determine whether or not the condition results in harm to the individual or others. These are both very subjective measures. The fact that we think we're more right today than we were yesterday is really pretty immaterial.

>> especially in Cluster B just train people how to better fake “normalcy” and to speak the language of therapy.

Really effective, non-superficial therapy is very hard. You may have to dig deep. Really deep. And when you do reach the roots there's still the issue of how to deal with what you find. It's not like surgery where you take out an infected appendix and say "you're cured".

>> If you consider it in those terms, then “treatment” amounts to having someone voluntarily attempt to change their personality at a fundamental level. Even if they wanted to, how likely is that to succeed?

That's exactly why it's hard. The fundamental drivers are often hidden and can be scattered (my term). You don't really change until you change the core. Most therapy seems to try to work from the outside in - probably because it's easier to do but less effective.

There's a more nuanced debate about the degree to which many personality disorders (particularly Cluster B disorders) don't qualify as a mental illness for another reason. You are considered mentally ill if you have cognitive and behavioral patterns that harm yourself. If your cognitive and behavioral patterns harm other people but leave you relatively unscathed, that's arguably not mental illness.

Where are you getting that definition from please, because it's not one I recognise.

While I can't find a source, it's a relatively common standard that I've seen used in multiple places, including in the psychology classes that I took (or sometimes dropped in on) in college.

The distinction is most useful because many mental illnesses aren't necessarily qualitatively different than "normal" or "healthy" human behavior and cognition; they're just more extreme versions. For example, normal people regularly engage in compulsive rituals, and engaging in these rituals is sometimes beneficial to them--consider a baseball player's ritual at stepping up to the plate, or a basketball player's ritual when stepping up to the free throw line. But if you start engaging in rituals that are a little too compulsive and too disruptive to "living a normal life", that's when it crosses the line into obsessive-compulsive disorder.

However, even if you can life a "normal" and successful life, that doesn't mean you aren't harming the people around you, unless you harm them enough that the long-term social consequences end up hurting you. Most cluster B personality disorders end up with the disordered person alienating people and suffering the consequences of their antisocial behavior. But if you're a high-functioning narcissist or whatever and you get away with everything...?

Here's a rather snarky example of this standard being applied to a certain alleged narcissist (whose name I'll redact in my quote, below, since this person's identity is a bit of a distraction from the more general point): https://www.nytimes.com/2017/02/14/opinion/an-eminent-psychi...

> Most amateur diagnosticians have mislabeled <<a prominent individual>> with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and <<this person>> doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder. <<this person>> causes severe distress rather than experiencing it and has been richly rewarded, rather than punished, for his grandiosity, self-absorption and lack of empathy.

Have we just defined conscience as a mental disorder?

that wouldn't be profitable to the current industries so I guess not. There was talk of "An Ancient Virus May Be Responsible for Human Consciousness" not long ago so that at least is some acknowledgement in that direction: https://www.livescience.com/61627-ancient-virus-brain.html

Excessive conscience probably constitutes an anxiety disorder.

in general i'm skeptical that the medicalization of these kinds of idiosyncrasies is helpful. implicit to that process is normalization (defining the normal and the abnormal), and that by itself causes psychological and social pain for the so-called abnormal. we each have our crosses to bear (in all kinds of abilities, including mental and physical) and medicalization can give a false sense of understanding, treatability, and absolution of personal responsibility.

tangentially, on a population level evolution happens on the margins and medicalization can only dampen that process (not that this is important on a personal level).

There is not. Anyone takes care of a person with a PD would tell you that.

And the high functioning people with PDs would explain to you the all the very specific deficits they have to overcome in order to function.

And the clinical researchers would explain to you as much as we know regarding regarding the developmental and environmental causes of specific PDs.

There is not. Anyone takes care of a person with a PD would tell you that. And the high functioning people with PDs would explain to you the all the very specific deficits they have to overcome in order to function.

Interviewing people in Cluster B is often an exercise in being lied to. It also requires them to have insight which is generally lacking as a clinical feature. Their caretakers are in a tough position, since they’re often the target of many manipulations gauges to engender sympathy and continued care. All in all it reveals a weakness in diagnosis and formulation of disorders by anecdote.

And the clinical researchers would explain to you as much as we know regarding regarding the developmental and environmental causes of specific PDs.

When they can accurately predict such outcomes from first principles even as well as they do for something like major depressive episode, schizophrenia, etc, I’ll take those claims seriously.

I'm in recovery for BPD. I did a shit load of emotional damage to my family because of it.

My BPD stems from childhood abandonment (absent father) and persistent emotional abuse from my likely NPD mother. I learned to doubt things I feel/thought and often reality sometimes. Real love and emotion connection were terrifying to me on a subconscious level. I never could trust anyone, not even myself (the only one to trust was my abuser). I developed so many coping mechanisms to protect myself from my mother that involve projection, distortion of reality and emotional manipulation. My brain learned all these horrible ways of protect myself from my abuser and I applied those behaviors to everyone around me.

It has taken years of unpacking my childhood trauma to get to like 90% remission of symptoms. Before that it was years of denial about my behaviors before I even started to entertain the fact I had BPD.

I'm sorry to hear BPD is effecting both you and your brother. There is hope but he has to be on board and it's a long road.

> he has to be on board

I'll always love my brother but, for this reason, I'd need to see proof that he's doing what you are. My brother has taught me that forgiveness does not imply a return to the previous status quo: we have our own, our spouses' and our childrens' mental health to protect.

I wish the best for you and patching up things with your family; I'm sure that they all still love you and want nothing more than a healthy relationship with you.

It's a hard decision to cut family off but sometimes it's necessary. I gave my mother an ultimatum a few years back, either hear what I'm saying and deal with your shit or I can't talk to you anymore. She chose the later. Going through the same process now with my dad. Yet to see where that's going. But you must defend yourself first. If others are causing tons of harm and totally unwilling to hear you and work on things, there's no shame in disconnecting. You don't owe anyone anything because they are blood.

>> The author of this piece is an extreme anomaly, not for having a PD (it is surprisingly common), but for having received effective treatment.

Last I checked, the only accepted treatment for any PD is DBT, and then only for borderline PD. I think real change is quite possible but it's LOT of internal mental work. Work you can only begin once you can see the problems. Half the stuff therapists do is really superficial and possibly harmful. The other half can be useful to varying degrees. And I'm gonna guess the line that divides these two varies a bit depending on both the person and the therapist.

...oh brother. That types overviews describes, like, half my disorder arsenal.

Probably not a good idea, to self-diagnose online.

> My therapist has explained the biggest issue about PDs: the disorders make a person extremely unlikely to seek out help

Sounds like a completely shit therapist, because the vast majority of people with BPD know full well they have a problem and are desperately seeking help for it.

What do you base this statement on? Are you confusing BPD (borderline personality disorder) with bipolar disorder? BPD and NPD, based on several psychology books I've read, including the very good book Schema Therapy, are very unlikely to seek treatment.

Most cluster B personality disorders inflict the bulk of the suffering and anxiety, not on the person with the disorder, but on those around them. Most of the suffering experienced by someone with this disorder comes as an indirect consequence as they alienate themselves from others. Making matters worse, cluster B disorders tend to cognitively predispose people to avoid any kind of self-blame or self-criticism.

These are sweeping claims to dismiss the suffering of a group of people who kill themselves at a rate ~50x higher than normal. I have no idea what the rate is for those around them, but it's hard to imagine it's any higher. It's true that they rarely seek treatment for a personality disorder but anecdotally, the person I knew was always in treatment for something. BPD is highly comorbid with other disorders:

> 96% of patients with BPD have a mood disorder during their life, and lifetime depression is reported at 71% to 83%. Anxiety disorders are also extremely common: 88% of patients have an anxiety disorder, 34% to 48% have panic disorder, and 47% to 56% have PTSD. Alcohol and substance abuse or dependence are reported by 50% to 65%; eating disorders affect 7% to 26% over a lifetime

http://www.psychiatrictimes.com/borderline-personality/comor...

I was talking about cluster B disorders in general, and not BPD in particular. A lot of the literature I've read seems to indicate that BPD in particular can be an unhealthy coping mechanism for extended childhood trauma, which also explains a lot of the comorbidity. But a high-functioning narcissist or antisocial or even borderline who doesn't have any other untreated disorders might be completely toxic to everyone else in their lives without ever suffering any consequences themselves, as long as they can cycle through victims and enablers fast enough.

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