In our last article, Psychological Profiling: An interactive case study (linked below), Althea presented the case of "Tom" who had reacted very sharply and aggressively to a simple comment she had made that challenged the core of his belief system. As she spent time with and learned more about Tom it became apparent he had a personality disorder. His history of relationships, behaviors, and worldview were presented, and we invited readers to share their thoughts and try their hand at diagnosing Tom from a list of suggested personality disorders. We thank those that did, and invite you to click on the article to read their comments and play along.
In this article we will present our diagnosis of Tom and how we came to that conclusion. Mike will describe the types of calls you are most likely to meet him on, and discuss the best-practice responses for police officers when faced with a "Tom."
Personality disorders and our diagnosis of Tom
A personality disorder is a type of mental disorder marked by very rigid and pervasive patterns of feeling, thinking, and behavior. They are chronic and maladaptive, causing serious personal and social difficulties, and deeply impact an individual throughout the lifespan. The DSM-IV (the diagnostic manual of mental health professionals) lists ten distinct personality disorders that are subdivided into three different clusters based on how the personality disorder manifests. Each disorder in the DSM-IV is presented with a list of common symptoms or behaviors that, if enough are present as elemental components of a patient's normal persona, allow a clinician to make a diagnosis.
We have determined Tom has Borderline Personality Disorder (BPD). To understand how that diagnosis was reached, first look at the nine diagnostic criteria as listed in the DSM-IV:
- Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
- Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself.
- 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).
- Chronic feelings of emptiness, worthlessness.
- Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms
In order to reach a diagnosis five out of nine of the symptoms must be present for a significant period of time, and as pervasive components of the patient's personality.
Using the list of symptoms, and looking back at Tom's case history, we see his frantic efforts to avoid abandonment by his wife (1), ironically while his actions toward her are impulsively abusive as he allows his rage to flow out onto her (4 & 8). Beyond his marriage, he has a long string of relationships marked by similar instability, wherein he saw people in his life as "all good" or "all bad" and frequently fluctuating between the two labels (2). Tom often exhibits wild mood swings that take over his whole being, and is especially prone to extreme irritability (6). He feels so "unloved, defective, and discarded" (7) following his string of broken and unstable relationships, he has lost sight of who he even is (3), if he ever knew. Finally, Tom admits to frequent non-lethal "suicide" attempts used to manipulate people when he sensed relationships were falling apart (5).
Borderline personality disorder is rare - only about 1 to 3% of the overall population is believed to be afflicted with BPD - yet persons with this disorder are very well known to psychiatrists and therapists. Both men and women can be diagnosed with BPD, but the diagnosis is three times more common in women than in men. To mental health professionals, people with BPD are both fascinating and dreaded! The DSM-IV's dry, clinical list of symptoms does not do justice to the experience of working with a BPD patient. There is a lot of well-written information available - we encourage you to study it further - but it does not capture the experience of being face-to-face with a BPD patient. But let me try...
BPD is the angry personification of chaos.
Chaos and anger permeate the internal, and frequently the external, world of the borderline. Someone with this disorder may be outwardly bright, witty, and charming. People may even be drawn to them in many ways. But beneath the outward appearance is a cauldron of chaos. Eventually it touches everything in the person's life - relationships, school, work, and even how they manage their finances - and defines their world. And it is a world of extremes... a simple disagreement is felt as absolute rejection; slight frustration quickly morphs into rage; a loved one going away for a weekend is experienced as terminal abandonment.
BPD and the law enforcement officer
The simple fact is, if you are a cop you are going to come into frequent contact with this disorder. Some of the most common scenarios you may encounter it are:
Domestic disputes - while most domestics do not involve someone with BPD, it is fairly certain that if someone has BPD they will have domestics. The borderline lacks the ability to effectively resolve conflict and instead will escalate until an outside influence intervenes;
Neighborhood Trouble - people with BPD are often highly conflictual with neighbors, just as they are with family and friends;
Suicidal subject - not necessarily the deeply depressed guy who really does want to end it all, but the person "overdosing" on five Advil and scratching their arm with a paper clip for the fourteenth time? Yeah, probably;
Civil disputes - their inability to manage stress can propel simple disputes into world-class conflicts. Again, not everyone having a dispute has BPD, obviously, but someone with BPD will have frequent disputes and may involve the police;
Intoxicated subject - "Self-medicating" with alcohol or drugs is common, usually to extremes, and the antics often "go public." Substance abuse is frequently involved in the previous scenarios, as well;
Dealing with "sex workers" - BPD is prevalent among persons employed in the adult service industries, both legally and illegally, and should be considered a factor in your dealings with them.
So how can you tell if you might be dealing with BPD? Familiarize yourself with this, as well as other, mental disorders so you can at least make an educated guess about what you might be seeing when you come into contact with it. We are often the first responders to mental health crises, so it is in our interest to develop a working knowledge of them.
Also, be in tune with your own emotional reactions to a situation. You will likely feel a strange combination of pity and anger, or the desire to both rescue and punish, all at once. Borderlines are adept at sucking others in, including cops. Althea describes the feeling she gets when with a borderline as "a knot of anger in the pit of my stomach." You will know.
Tips for an effective response
If you know or suspect someone you are dealing with has BPD, I suggest the following strategies for an effective response:
- Understand the chronic, lifelong nature of the disorder and how deeply it touches someone. Know your limitations and work within them.
- Avoid engaging with the borderline at an emotional level. Your buttons WILL be pushed, but it is important you not react to provocation. Be calm and professional, and do not get pulled into the chaos, which is what the borderline wants.
- Avoid arguing or debating irrational words, thoughts, or actions. Instead, focus on setting clear behavioral limits with clear consequences if they are violated. Follow through with consequences when those limits are breached.
- Be firm and decisive, while remaining empathetic, pleasant, and professional.
- Have a solid action plan in place before you get on scene. Have a solid backup plan, since the first one is just going to get messed up.
- FOCUS ON SAFETY ABOVE ALL ELSE! People with BPD can be impulsive, explosive, and physically dangerous.
- Remember this - mental illness does not trump personal responsibility. If someone needs to go to jail, take them to jail.
Borderline personality disorder is one of the most challenging psychiatric disorders mental health professionals face, and can be one of the most challenging for cops, as well. With understanding of the disorder, and a strategy built upon that understanding, we can meet the challenge with an effective response.