Evidence-Based Reviews

Borderline personality disorder: The lability of psychiatric diagnosis

Current Psychiatry. 2002 November;1(11):24-33

References

1. Diagnostic and statistical manual of mental disorders (2nd ed). Washington, DC: American Psychiatric Association, 1968.

2. Feighner JP, Robins E, Guze SB, et al. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 1972;26:57-63.

3. Merikangas KR, Angst J, Eaton W, et al. Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force. Br J Psychiatry 1996;30(suppl):58-67.

4. Nierenberg AA. DeCecco LM.Definitions of antidepressant treatment response, remission, nonresponse, partial response, and other relevant outcomes: a focus on treatment-resistant depression. J Clin Psychiatry 2001;62(suppl 16):5-9.

5. Stone MH (ed). Essential papers on borderline disorders: one hundred years at the border. New York: New York University Press, 1986.

6. Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: American Psychiatric Association, 1994.

7. Diagnostic and statistical manual of mental disorders (3rd ed). Washington, DC: American Psychiatric Association, 1980.

8. Akiskal HS. Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders in the “borderline” realm. Psychiatric Clin N Am 1981;4:25-46.

9. Henry C, Mitropoulou V, New AS, et al. Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences. J Psychiatric Res 2001;35:307-12.

10. Herman JL, van der Kolk BA. Traumatic antecedents of borderline personality disorder. In: van der Kolk, BA. Psychological trauma. Washington, DC: American Psychiatric Press, 1987;111-26.

11. Silk KR, Lee S, Hill EM, Lohr NE. Borderline symptoms and severity of sexual abuse. Am J Psychiatry 1995;152:1059-64.

12. Streeter CC, Van Reekum R, Shorr RI, Bachman DL. Prior head injury in male veterans with borderline personality disorder. J Nerv Ment Dis 1995;183:577-81.

13. Maltsberger JT. Countertransference in borderline conditions: some further notes. Int J Psychoanal Psychother 1982-83;9:125-34.

14. Stern A. Psychoanalytic investigation and therapy in the borderline group of neuroses. Psychoanal Q 1938;7:467-89.

15. Deutsch H. Some forms of emotional disturbance and their relationship to schizophrenia. Psychoanal Q 1942;11:301-21.

16. Hoch P, Polatin P. Pseudoneurotic forms of schizophrenia. Psychiatric Q 1949;23:248-76.

17. Knight R. Borderline states. Bull Menn Clin 1953;17:1-12.

18. Schmideberg M. The treatment of psychopaths and borderline patients. Am J Psychotherapy 1947;1:45-70.

19. Frosch J. The psychotic character: clinical psychiatric considerations. Psychiatric Q 1964;38:81-96.

20. Kernberg O. Borderline personality organization. J Am Psychoanal Assoc 1967;15:641-85.

21. Grinker RR, Werble B, Drye R. The borderline syndrome: a behavioral study of ego functions. New York: Basic Books, 1968.

22. Gunderson JG, Singer MT. Defining borderline patients: an overview. Am J Psychiatry 1975;132:1-10.

23. Spitzer RL, Endicott J, Gibbon M. Crossing the border into borderline personality and borderline schizophrenia: the development of criteria. Arch Gen Psychiatry 1979;36:17-24.

24. Silk KR, Lohr NE, Westen D, Goodrich S. Psychosis in borderline patients with depression. J Personality Disord 1989;3:92-100.

25. Silk KR, Westen D, Lohr NE, et al. DSM-III and DSM-III-R schizotypal symptoms in borderline personality disorder. Comprehen Psychiatry 1990;31:103-10.

26. Livesley WJ, Jang KL, Vernon PA. Phenotypic and genetic structure of traits delineating personality disorder. Arch Gen Psychiatry 1998;55:941-8.

27. McCrae RR, Yang J, Costa PT, Jr, et al. Personality profiles and the prediction of categorical personality disorders. J Personality 2001;69:155-74.

28. Siever LJ, Davis KL. A psychobiological perspective on the personality disorders. Am J Psychiatry 1991;148:1647-58.

29. New AS, Gelernter J, Goodman M, et al. Suicide, impulsive aggression, and HTR1B genotype. Biolog Psychiatry 2001;50:62-5.

30. Oldham JM, Skodol AE. Charting the future of axis II. J Personality Disord 2000;14:17-29.

Not everyone agrees with renaming the unstable set “borderline” because the word:

has always been ambiguous
does not connote or denote any specific criteria or characteristic of patients who bear the label
brands the patient as untreatable, defiant, or just “bad.”

Post-DSM-III: Where are we now?

From DSM-III evolved the hope that psychiatry could describe valid, well-defined diagnostic categories. Lost in the DSM-III enthusiasm was the fact that the categories were based upon theoretic constructs—theories no more or less valid than other theories that had preceded them. Because some of these categories were based upon empiric data— such as the Spitzer et al study—these diagnoses were perceived as more valid and more related to pathophysiology and perhaps genotype than prior constructs and definitions.

In the 1980s and early 1990s, a proliferation of studies attempted to examine the validity and reliability of DSM-III definitions, and BPD became the most studied of the personality disorders. The BPD concept took hold, even though several studies did not support it and despite refinements in subsequent DSM editions (Box 3).

One refinement in the BPD construct applied to transient psychotic or psychotic-like experiences, including dissociative phenomena. Yet questions remain about the duration of these transient episodes (Box 4).

Categorical versus dimensional

The categorical concept of BPD is facing new scrutiny,^26,27 as recent studies have implied that biological disturbances may be spread across a number of personality disorders.²⁸ If biological findings are found to be more closely allied with genotypic variations (alleles),²⁹ then perhaps a dimensional classification system is needed for BPD and personality disorders in general.

On the other hand, categories provide a well-defined population that we can study and try to delineate from other populations, whereas dimensions—while perhaps closer to the reality of clinical presentation—may allow too much variability for research to proceed without confounding restraints.

BPD will continue to evolve, as will all psychiatric diagnostic categories, but the need to modify its definition does not negate its usefulness and clinical applicability. Most of our patients do not read the DSM before coming to us. They present with symptom complexes and problems that demand that we listen to what they say and understand who they are while we also try to fit them—as best we can—into categories or dimensions³⁰ that help us choose the most appropriate interventions.

Related resources

BPD Sanctuary (borderline personality disorder education, communities, support, books, and resources) http://www.mhsanctuary.com/borderline/ Borderline Central (resources for people who care about someone with borderline personality disorder) http://www.bpdcentral.com/
Gunderson JG. Borderline personality disorder: a clinical guide. Washington, DC: American Psychiatric Publishing, Inc., 200l.
Paris J (ed). Borderline personality disorder. Psych Clin N Am 2000;23:1 (entire volume devoted to BPD).
Silk KR (ed). Biological and neurobehavioral studies of borderline personality disorder. Washington, DC: American Psychiatric Press, 1994.