Borderline personality disorder: The lability of psychiatric diagnosis
What is borderline personality disorder, if it exists at all? Could it be a mild affective or bipolar disorder, or a label we apply to patients we don’t like? This debate reflects wider issues about psychiatry’s diagnostic system.
Not everyone agrees that borderline personality disorder (BPD) should be a diagnostic category. BPD became “official” with DSM-III in 1980, although the term had been used for 40 years to describe various patient groups. Being listed in DSM-III legitimized BPD, which was thought to represent a specific—though not necessarily distinct—diagnostic category.
The history of the BPD diagnosis and opinions as to its usefulness can be viewed as a microcosm of psychiatric diagnosis in general. Before DSM-III, diagnoses were broadly defined and did not contain specific inclusion or exclusion criteria.1 For the 5 to 10 years prior to DSM-III, however, two assumptions developed:
- distinct diagnostic categories did, in fact, exist
- by rigorously defining and studying those categories we could develop more specific and effective treatments for our patients.2
The specificity and exclusivity that we assumed we could achieve by categorical diagnoses, however, remain a distant wish. Comorbidity appears more common in psychiatry than was originally thought and confounds both treatment and outcome. 3 Also, many patients appear treatment-resistant, despite fitting neatly into diagnostic categories.4
CASE REPORT BREAK-UP WITH BOYFRIEND TRIGGERS VOICES IN HER HEAD
Miss A, age 35, presents to the emergency room with a long history of intermittent depression and self-mutilation. She has never been hospitalized nor on psychotropic medication but has been in and out of psychotherapy for years. She has had intermittent depressive episodes for many years, though the episodes often lasted 2 to 3 weeks and appeared to correct themselves spontaneously.
Agitated and afraid. She is extremely agitated when she arrives at the emergency department. She has hardly slept or eaten but insists she is not hungry. She reports that she cannot concentrate or do her work as an accountant. She says she is hearing voices, knows they are in her head, but nonetheless is terrified that something horrible is about to happen—though she cannot say what it might be.
Voice ‘calling my name.’ When the psychiatric resident inquires further, Miss A says a male voice is calling her name and mumbling some short phrase she cannot understand. She says she has heard the voice the last few days, perhaps for 10 to 15 minutes every few hours, particularly when she ruminates about how she messed up a relationship with her now ex-boyfriend. The breakup occurred 1 week ago.
Feeling detached. She claims she has never heard voices before but describes periods when she has felt detached and unreal. Often these were short-term dissociative episodes that occurred in the wake of what she perceived as a personal failure or a distressful interpersonal encounter (often with a man). Relationships frequently were very difficult for her, and she felt she could easily go from infatuation to detesting someone.
Diagnosis? Talking appears to calm her down. After being in the emergency room for 2 hours, she says she no longer hears the voice. The resident tells the attending psychiatrist he believes the patient is in a major depressive episode, perhaps a psychotic depression, and proposes starting antidepressant treatment. The attending argues that the patient appears to have borderline personality disorder and suggests that she be sent home without medication and given an appointment to the outpatient clinic within the next few days.
As psychiatry considers DSM-V, questions linger as to whether BPD (and personality disorder in general) should remain as a categorical diagnosis or if dimensional measures may be more appropriate. Dimensions imply that no one ever fits into a given box because no specific box exists. Rather, patients are described as being closer to or more distant from a prototypic model of the diagnosis. In personality disorders, the dimensions most often mentioned are cognition, impulsivity, emotional lability, environmental hyperreactivity, and anxiety. The case report (above) illustrates the interplay of these dimensions in a typical patient with presumed BPD.
What’s in a name?
The symptom complex or syndrome that bears the name borderline personality disorder has probably existed for as long as people have thought about patients in psychopathologic terms.5 Before 1980, the term “borderline” applied primarily to two separate but overlapping concepts:
- Patients thought to reside on the “border” with psychosis, such as the patient in our case example. They seemed to have an underlying psychotic disorder, but the psychosis—if it surfaced—appeared briefly, was not exceptionally deep or firmly held, and was not regularly evident or immediately accessible to the clinician.
- Patients who appeared to occupy the space between neurosis and psychosis. This concept evolved into the idea of a character or personality disorder distinguished primarily by unstable interpersonal relationships, a confused or inconsistent sense of identity, and emotional instability.
How DSM is changing. Comparing the disorders listed in DSM-IV (1994)6 versus DSM-II (1968)1 suggests that psychiatry has become enamored of the naming process. For example, DSM-II lists anxiety neurosis (300.0), phobic neurosis (300.2), and obsessive-compulsive neurosis (300.3), whereas DSM-IV lists 11 different categories of anxiety disorders.
But beyond naming, subsequent DSMs have differed even more dramatically from DSM-II. We have seen a shift from describing a diagnostic category with a simple explanatory paragraph to lists of specific inclusion and exclusion criteria. These more-specific lists imply that they define categories closer to some reality or authenticity than did previous definitions.
Before DSM-III, the borderline concept was conceived in broad object relational and psychodynamic terms. In contrast, DSM-III produced a definitive set of criteria and required that a subset be met before the diagnosis could be made.7 An example of this criteria-based model is shown in Box 1, which lists the DSM-IV-TR criteria for BPD.
Some psychiatrists objected that BPD was solely a psychoanalytic construct and too theoretical for inclusion in DSM-III. Others argued that if BPD were not defined, it would be difficult to study the clinical usefulness of that definition or any other. Nonetheless, many have argued that BPD does not exist, though to what category BPD patients should belong has changed over the years:
- Is BPD nothing more than a milder or unusual presentation of an affective disorder8 or actually bipolar II disorder? 9
- Is it a presentation of posttraumatic stress disorder (PTSD) called “complex PTSD,”10-11 or an adult presentation of attention-deficit/ hyperactivity or other brain disorder?12
- Is it a stigmatizing diagnosis that we apply to patients whom we do not like?13
In truth, the diagnosis of BPD reflects a particular clinical presentation no more or less accurately than many of the well-accepted axis I disorders. Despite recent advances in the neurosciences, the dilemma we face as psychiatrists is that we make a diagnosis based upon what we see in the clinical setting (i.e., a phenotype). Yet in labeling what we believe is a specific psychiatric disorder, we make assumptions—for better or for worse, consciously or unconsciously—about pathophysiology and indirectly about genotype.
DSM-IV CRITERIA FOR DIAGNOSIS OF BORDERLINE PERSONALITY DISORDER
A pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Frantic efforts to avoid real or imagined abandonment
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Identity disturbance: markedly and persistent unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, binge eating, reckless driving)
- Recurrent suicidal behavior, gestures, or threats; self-mutilating behavior
- Affective instability due to a marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Defining the borderline personality
Stern first used the term “borderline” in 1938 to describe patients who appeared to occupy the border between neurosis and psychosis.14 In 1942, Deutsch described the “as if” personality in patients who seemed chameleon-like. They could adapt or play the role demanded of them in specific situations, yet elsewhere—as in the analyst’s office—they had little sense of themselves and were thought to be internally disorganized and probably psychotic.15
Border to psychosis. The idea that borderline-type patients were psychotic continued in Hoch and Polatin’s description of the “pseudoneurotic schizophrenic,”16 a patient who appeared severely neurotic but was thought to employ many defenses and interpersonal styles to ward off a fundamental inner psychosis. Knight used the label “borderline states”17 to describe severely ill patients who were not frankly psychotic but fell within the realm of psychosis without qualifying for a diagnosis of schizophrenia. Knight was the first person to use the term “borderline” as a diagnostic entity, though simultaneously he argued against its use as a label because the term lacked precision.
Psychotic character. About the same time, Schmideberg characterized a group of patients whose emotional lability or affective reactivity seemed to be a consistent aspect of their clinical presentation. She believed this appearance of “stable instability”18 represented the patient’s characterologic adaptation to the world.
Frosch coined the term “psychotic character”19 that aptly captured both the characterologic and the border-to-psychosis aspects of these patients’ clinical picture. According to Frosch, these patients appeared to regress readily into psychotic thinking, yet they did not lose their ability to test reality.
Affective and emotional instability. Thus until the 1960s, the term borderline was applied primarily to patients who appeared to occupy the border between neurosis and psychosis but were thought to be closer to psychotic than neurotic. And this sitting close to the edge of psychosis appeared to be a stable condition.
Most of the attention up until this point had been paid to how these patients thought—with little attention to their affective lability or emotional instability, save for Schmideberg’s comments. In the 1960s, however, the term borderline was applied somewhat differently—not completely divorced from previous concepts but with greater emphasis on borderline as a stable but psychopathologic functioning of the personality that included affective and emotional instability and an impaired sense of self.
GUNDERSON AND SINGER’S SIX CRITERIA FOR DEFINING BORDERLINE PATIENTS22
- Intense affect, usually depressive or hostile
- History of impulsive, often self-destructive behavior
- Social adaptiveness that may mask a disturbed identity
- Brief psychotic episodes, often paranoid and evident in unstructured situations
- “Loose thinking” or primitive answers on unstructured psychological tests
- Relationships vacillate between transient superficiality and intense dependency
Impaired personality organization. In 1967, Kernberg published a seminal article in the history of BPD diagnosis. Although he did not discuss the diagnosis of BPD, Kernberg did develop a concept concerning a specific organization of the personality based upon impaired object relations. This impaired organization could apply across several personality disorders. The construct, named borderline personality organization (BPO),20 was defined by:
- an impaired sense of identity and lack of integration of one’s own identity
- use of primitive defenses, including splitting, rage, and regression
- ability to test reality.
Kernberg’s theory is too complex to summarize here, but he—along with Roy Grinker—is responsible for placing BPD on the diagnostic map. He was the first to describe BPO (and by extension BPD) in terms of a personality disorder.
Grinker’s ‘core’ group. Almost simultaneously (in 1968), Grinker published a careful study of 50 hospitalized patients. His work on the “borderline syndrome”21 revealed four subgroups to which the label of borderline had been applied:
- those occupying the border with psychosis
- those occupying the border with neurosis
- those similar to Deutsch’s “as if” group
- the “core” borderline group.
The core group—with its symptoms of anger and loneliness, a nonintegrated sense of self, and labile and oscillating interpersonal relationships— defined patients closest to our current definition.
Six criteria for BPD. In 1975, Gunderson and Singer published an article that greatly influenced our definition of BPD. They reviewed major descriptive accounts of BPD or BPD-like syndromes22 and proposed six diagnostic criteria (Box 2), though they did not identify a specific number or subset of the criteria as needing to be met for the diagnosis. (It is important to note that the term BPD did not become official for 5 more years.)