Every now and then, one of my patients asks me, “Am I a ?” or “Am I a borderline?” In a way, answering could be very easy. Like most psychiatrists, I own a DSM — the — which contains lists of traits for . You don’t even need a DSM to look this up — google or and the lists are at your fingertips. In fact, you can bet these patients looked this up before asking. Do they have the 5 out of 7 or 6 out of 9 traits that buy them a diagnosis? Maybe. But is knowing that helpful?

To answer that, let’s first think about the term “ disorder.” The DSM says that it’s an “enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition.” OK, it sounds pretty useful to know about problematic patterns, particularly if your goal is to improve them. After all, being aware of your patterns is the first step in trying to change. Whether you are trying to improve your tennis serve or your handwriting, you have to know what you are doing before you try to do something new. And categorizing human patterns has been a psychological Holy Grail for thousands of years, with the likes of Hippocrates and weighing in with potential solutions.

As a therapist, I need to understand my patients’ patterns. These patterns involve the way they think about themselves, have relationships with others, adapt to , think, work, and play. I learn about their patterns by hearing about their lives, listening to how they operate in the world, and experiencing their interactions with me. Recognizing common patterns helps me think about what treatment might be most helpful, predict behavior, and help people have happier and more gratifying lives. Some of their patterns feel good to them, while others cause pain. It’s the latter that generally bring people to . “How can I feel better about myself?” they want to know. “How can I stop hurting people I love?”

But should we conceptualize maladaptive patterns as personality disorders? The dictionary defines a medical disorder as “a disruption of normal or mental functions: a disease or abnormal condition.” Is the tendency to avoid abandonment at all costs a disease? Are desperate measures to maintain abnormal? Saying that people who do these things have disorders often leads to stigma, , and self-blame. How is that helpful?

Source: Deborah Cabaniss

Here’s another way to look at it: little children develop patterns to help them survive, but sometimes those patterns give them trouble later in life. Survival means more than staying fed - it means trying to develop a sense that you matter and are loved. What a task, particularly for tiny, dependent human beings who can barely walk or talk. It’s hard enough if things are going well, but try doing it in the face of neglect, abuse, , or loss. Like seeds sprouting in concrete jungles, children do whatever is necessary to feel good about themselves and believe that their caregivers love them. They dissociate during beatings, indiscriminately assume blame, deny their own needs, and attach to anyone who shows interest. These patterns are vital in , but can wreak havoc when they persist into adulthood, slaying self-esteem and ruining relationships.

When people with these problems come to therapy, should we say, "You did what you needed to do to survive your childhood - and what it got you was a personality disorder"? I don't think so. They have suffered enough, both as children and as adults. It’s terrific that they have come for help. Instead, they need to be told that they are strong, that they did what they needed to do. In her landmark book, Trauma and Recovery, Judith Herman recast borderline personality as “Complex ” in order to emphasize the role of trauma in the development of maladaptive patterns. Marsha Linehan, the creator of , tells patients, “You are doing the best you can, and you can do better.” These trauma-oriented therapists understand the need to emphasize the central role of early childhood in the development of maladaptive patterns, and to focus on strength over disease.

So to the patient who asks if they have a personality disorder, I say, “Personality disorder? Hardly. You did what you needed to survive. Now we need to help you find other ways to feel good about yourself and believe you are loved.” The very problems that cause them distress and shame are actually evidence of strength and . To me, that’s a better place to start.