The term borderline was first used by Adolf Stern in 1938. He used the expression to describe a group of patients who were not able to benefit from classical psychoanalysis and who did not appear to fit into the standard neurotic or psychotic classifications. These patients, although initially appearing to be good psychotherapeutic cases, would develop a fairly specific pattern of acting out which manifested into severe transference problems that became difficult to treat within the scope of psychoanalysis. At that time psychopathology was viewed as a continuum which ran from normal to neurotic to psychotic. The patient who did not fit clearly into these criteria was considered to be suffering from a borderline group of neuroses.
During the 1950s, the term borderline had evolved into a broad expression with which to describe a group of patients who were lacking the capacity for introspection or insight, showing severe mood swings, and perceiving others as either all good or all bad. However, at that stage the classification still lacked diagnostic precision and so was of little value for research. During the 1970s long term psychoanalytic psychotherapy was considered the most effective treatment for borderline patients. However, this view began to receive increasing attention when Borderline Personality Disorder (BPD) obtained official diagnosis with the publication of the DSM-III in 1980. With the advent of specific criteria with which to diagnose, research now began to develop around how best to treat BPD. Work with BPD patients during the 1980s is reported as rarely being successful and long-term unstructured hospitalisation and long term therapy came under scrutiny and became viewed as questionable or even potentially harmful. During the same decade medical trials began in an effort to treat BPD and although the results were ambiguous, medication became the standard treatment for Borderline patients. However, during the 1990s a new behavioural therapy called Dialectical Behaviour Therapy (DBT) emerged. DBT proved to be especially helpful to people suffering from BPD and is still widely used today. With the advent of successful treatment outcomes, other treatment approaches also developed which proved effective with borderline patients. Some of these approaches that are also used today are supportive, psychoanalytical therapy (with an emphasis on the here-and-now as opposed to the early childhood focus of classical psychoanalysis) and cognitive-behavioural therapy.
Despite the official diagnosis appearing in the DSM-III however, BPD is still a controversial disorder. Prior to the DSM-III publication, it was suggested that BPD was really a spectrum that ranges from neurotic through to psychotic. Kernberg also argued that the borderline concept is actually a personality organisation as opposed to a diagnosable disorder. This concept is still widely held today in the psychodynamic profession.
Presenting Symptom Patterns
Borderline Personality Disorder is described by the DSM-IV as;
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:
1. frantic efforts to avoid real or imagined abandonment Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. identity disturbance: markedly and persistently unstable self-image or sense of self.
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. chronic feelings of emptiness
8. inappropriate intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. transient, stress-related paranoid ideation or severe dissociative symptoms.
Theories of Etiology
BPD appears in different cultures throughout the world and is perhaps one of the most common personality disorders to appear in clinical settings. Theories have changed in recent years regarding the origins of BPD. Early research was based on the clinical observation of a few select patients and the theories that evolved from these emphasised the psychosocial basis of the disorder and the significance of traumatic experiences in sufferer. BPD is one of the most researched of all the personality disorders in regard to the prevalence of early life trauma and numerous studies have found that physical and sexual abuses are common factors associated with people who are diagnosed as suffering BPD. In fact, some studies have noted that abuse or major traumas are almost universal in the early lives of borderline patients. Due to the high correlation of early trauma with BPD there have been hypotheses put forward that perhaps BPD is a form of Post Traumatic Stress Disorder. However, recent research has argued that although there is a strong association between these disorders, the findings are not substantial or distinct enough to define BPD as a variant of PTSD. There have been a number of studies that have attempted to define a biological basis for BPD, but there has been little success in defining a biological source. Twin and family studies have indicated the potential for a heritable basis in some aspects of behaviour such as impulse aggression. Other studies although not absolute in their findings, do indicate that genetic factors play a part in somebody being predisposed to BPD. However, despite research continuing to look for a single variable that might explain how BPD evolves, recent studies have begun to recognise that there are multiple biological and psychosocial variables indicating the complex relationship between genes and environment.
Differential Diagnosis Considerations
BPD is often diagnosed alongside a mood disorder and when this occurs, both should be listed under the diagnosis. Symptoms of BPD often appear to overlap some mood disorders which can make a differential diagnosis complicated. Bipolar disorder features affective instability that may initially appear similar to BPD. However, in BPD the mood swings will often be triggered by interpersonal stressors such as perceived rejection. Depressive features might be indicative of a major depressive disorder or they can be symptoms of the BPD. Depressive symptoms which appear to be associated BPD can include emptiness, self condemnation, abandonment fears and self destructive thoughts. Dysthymic disorder can be difficult to distinguish from BPD because chronic dysthymic feelings are common among borderline patients. A common comorbid condition existing with BPD is PTSD. Historical trauma is common in BPD however, and does not necessarily indicate that PTSD will be present. A PTSD diagnosis should only be given when all of the DSM-IV criteria are met. Dissociative Identity Disorder is another comorbid condition that may be present with BPD, however DID is indicated by the existence of two or more personality states that appear distinct from each other and display differing patterns of behaviour. Histrionic Personality Disorder similarly features rapidly changing emotions and attention seeking, manipulative behaviour, but lacks the self-destructiveness and angry disruptions that can be seen in BPD. Schizotypal Personality Disorder features paranoid delusions that might appear similar to BPD however, in BPD these symptoms are more interpersonally triggered and more transient. Paranoid Personality Disorder and Narcissistic Personality Disorder both feature angry reactions to relatively minor stimuli but retain a relatively stable self image and lack the self-destructiveness of BPD. Antisocial Personality Disorder features manipulative behaviours similarly associated with BPD but differs in that individuals with APD manipulate for material gain whereas BPD manipulation is usually aimed at gaining some form of caring from others. Dependent Personality Disorder is characterised by a fear of abandonment similar to that of BPD. The dependent personality responds to abandonment with pacification and submissiveness though, whereas the borderline personality becomes angry and demanding at the threat of being abandoned. Finally, BPD must be distinguished from a general medical condition and also from the symptoms that can develop from substance abuse.
Current Treatment Recommendations
As previously discussed, the treatment for BPD has evolved over time as a clinical understanding of the disorder has developed. Treatment has evolved from a traditional psychoanalytic approach on to a medication based model, with current treatment approaches now including both medication and specialised therapies. Although there are no well-designed studies available that offer a sufficient comparison of these differing treatments, clinical experience does indicate that most patients with BPD will need some form of extended psychotherapy in order to improve interpersonal problems and maintain improvements in overall functioning.
Personality disorders do not have specific drugs for treatment, unlike some mood disorders such as major depression or panic disorder. However, there are a range of drugs available that are able to help reduce dysfunctional traits associated with the disorder. Medication is usually aimed at reducing the co-morbid symptoms such as the depression or anxiety. Treatments include anti-psychotics, mood stabilisers, and anti-depressants. Despite the availability of symptom reducing drugs however, evidence based research in this area is currently sparse and more specialised research is needed.
According to the American Psychiatric Association there are two approaches to psychotherapy that have been shown effective in randomised, controlled trials. These are psychoanalytic/psychodynamic therapy and Dialectical Behavioural Therapy (DBT). It is important to note that the trials in which both these approaches proved helpful utilised these approaches to therapy as part of a structured program. Both programs included weekly individual therapy sessions, one or more weekly group therapy sessions, and meetings between the treating therapists for consultation and supervision. The APA also states that the length of treatment is an important aspect for success with a period of one year being recognised as a minimum.
DBT is a specialised adaptation of cognitive therapy that was originally developed as an intervention for patients with extreme suicidal behaviour. DBT includes techniques which target behaviour, cognition and support for the borderline patient. The treatment teaches patients skills to help them cope with emotional regulation and also interpersonal effectiveness.
The style of psychoanalytic or psychodynamic therapy which has proven effective with BPD maintains the core principles of traditional psychotherapy such as making unconscious motives conscious and working with transference. However, the focus is primarily on the here-and-now relationship between client and therapist as opposed to past relationships and childhood.
Mentalization is another therapeutic approach developed for use with BPD. Mentalization is defined as “the mental process by which an individual implicitly and explicitly interprets the actions of himself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs, and reasons”. In other words, one’s ability to understand the thoughts and intentions of oneself and others based on observable behaviour.
Group therapy aims at helping with impulse management and can be helpful in providing additional social support for patients. The group environment can also help to diffuse the intense transferential responses that are common with this disorder due to the interaction and shared experience with other group members.
Possible Cultural Factors
As discussed under differential diagnosis, BPD can often be confusing when attempting a definitive diagnosis. When diagnosing this disorder it is also important to be considerate of cultural variations such as sexual behaviour and expressions of emotion. Most research and treatment studies for BPD have been conducted on women and it is reported that men are often misdiagnosed as suffering from antisocial or narcissistic personality disorders. An American study suggested that Borderline Personality Disorder is prevalent in 2% in the general population and 20% among psychiatry in-patients. A Norwegian study found a slightly lower prevalence of 1.2%. Whilst the former study found that BPD is more commonly diagnosed in women with an estimated gender ratio of 3:1, the Norwegian study concluded equal occurrences in men and women. In a study concerning sexual practices and BPD it was found homosexuality was ten times more common in men with BPD and six times more common in women with BPD than in a control group of depressed patients or in the general population.