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.