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.
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.
- 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.)
DSM-IV’s definition of BPD retains four of Gunderson and Singer‘s criteria among the nine it lists (five being necessary for a diagnosis of BPD). Missing are:
- social adaptiveness—though DSM-IV does say that social adaptiveness may be superficial (as in the “as if” personality) and may hide a disturbed identity6
- and the criterion relating to psychological test performance (this omission reflects a movement since 1980 away from listing “psychological” or psychodynamic criteria in the DSM).
DSM-III. BPD was included in DSM-III7 following an important study that tried to determine whether the term “borderline” refers to patients at the border of psychosis or to a stable group with mood instability and affective lability as part of a personality disorder. Spitzer et al23 asked 808 clinicians to describe patients they would label as borderline and to use 22 items gleaned from the literature to score two of their own patients:
- one patient who the clinician felt truly had borderline personality, borderline personality organization, or borderline schizophrenia
- and a control patient who was not diagnosed as psychotic and did not fall into any borderline category.
- The concept of abandonment, introduced in DSM-III-R, replaced the concept of aloneness in DSM-III.
- In DSM-III and DSM-III-R, a patient needed to meet 5 of 8 criteria for a diagnosis of BPD.
- DSM-IV introduced the ninth criterion, “transient, stress-related paranoid ideation or severe dissociative symptoms.” Since then, a patient has needed to meet 5 of 9 criteria for a diagnosis of BPD.
Their responses showed that BPD and schizotypal personality disorder (SPD) were separate, independent (though not mutually exclusive) disorders. Spitzer et al preserved the “schizotypal” label in DSM-III to describe the personality disorder that closely matched the border-to-psychosis subset. The other criteria set, which they labeled the “unstable personality item set,” was renamed “borderline” in DSM-III to describe the personality disorder that closely matched the emotional lability subset.
From one DSM edition to another, the concept of brief transient psychotic episodes has been included in and excluded from the diagnosis of borderline personality disorder (BPD).
In DSM-III. Because of work by Spitzer et al, these “experiences” were placed within schizotypal personality disorder (SPD) in DSM-III in 1980, though historically they had always been within the borderline concept and were one of Gunderson and Singer’s six criteria for diagnosing BPD (Box 2).22
Out of DSM-III-R. Research in the late 1980s suggested that when patients with BPD were depressed, they had a greater tendency to have psychotic–like episodes.24 Evidence indicated that attributing these psychotic and dissociative phenomena to SPD, rather than—perhaps more appropriately—to BPD, was one of the main reasons for the overlap between the definitions of BPD and SPD.25 Therefore, in DSM-III-R, the transient psychotic/dissociative criterion was removed from the SPD criteria set.
Back in DSM-IV. The criterion “transient stress-related paranoid ideation or severe dissociative symptoms” was placed into the BPD criteria set in DSM-IV. In DSM-IV, these symptoms were further characterized as usually not of “sufficient severity or duration to warrant an additional diagnosis.”
What is “sufficient” duration? The psychotic episodes of BPD last for minutes to hours and often appear when the patient imagines being (or actually is) abandoned by others. Not all agree that the criteria for BPD are met if these episodes last longer (e.g.,a day or two). In that case, they may exceed the transient time frame. More research is needed to better understand the quality and duration of these psychotic-like phenomena.
