Certainty serves action; diagnostic categories are dynamic

When we're hurting, we seek certainty, because certainty serves action. Both clients and clinicians prefer to be sure of what they're dealing with and how to take care of it. Unfortunately the reality is that human beings are complex enough that a single category scheme doesn't work for all illness.

We can and do construct multiple schemes that overlap because they are based on different initially tenable assumptions. Progress is achieved by trying to detect where our initial assumptions turn out to produce conclusions inconsistent with things we observe.

PTSD terminology and theory works within a trauma-based theory of etiology (what causes illness). It focuses heavily on dealing with the severe and persistent effects of psychological trauma on the human brain. It provides relatively unambiguously useful diagnostic and treatment criteria for things like rape and the effects of war or earthquakes.

Personality disorders like BPD take a little different perspective, since they often assume some degree of heritable predisposition, and some developmental process leading to symptoms, not neccessarily linked to specific trauma.

The difference in theoretical approach leads to slightly different treatment approaches, and more importantly, different kinds of perceived stigma. We tend to push back at seeing ourselves as "flawed" and the personality disorder cluster has that sort of odor to it. Seeing our problems as caused primarily by events from the outside can alleviate some of this discomfort.

I think there is an important empirical distinction to make here in theory, since I'm not aware of any good evidence for heritable predispositon to PTSD in general. So they are meaningfully different diagnoses referring to different processes of producing symptoms. Judith is either right or not in the end, regarding the existence and predominance of BPD, it isn't (just) a matter of waffling over names.

However, the difference to the client here and now is not so much reliant on the theoretical distinction as on the way the label causes them to see themselves, how it causes other people to see them, and how it causes them to act on their circumstances. In my opinion.

kind regards,

Todd

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