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Borderline Personality Disorder (BPD for short) is a condition that is both difficult to diagnose properly and difficult to treat. Adolf Stern coined the term “borderline” in 1938 to describe low-functioning neurotic patients; using the word to refer to the “borderline” between psychoses and neuroses. (Mondimore & Kelly, 2013) The word stuck, and continues to be used in the DSM-V despite some criticism of its accuracy and politeness. “Borderline” is weirdly casual and doesn’t do a very good job describing the actual symptoms or issues that afflicted patients face, and the argument that the term in fact has several relevant meanings (it has been associated with schizophrenia, bipolar disorder, and post-traumatic stress disorder) just makes it more complicated and confusing for patients. Name issues aside, borderline personality disorder is an important diagnosis—and usually a step in the right direction—for people who suffer from some combination of psychotic (delusional or hallucinatory thinking) and neurotic (obsessive thinking, especially with regard to anxious or distressing situations) personalities. Any contention about the name “Borderline” pales in comparison to the criticism the DSM contributors have received since the 3rd edition (and probably earlier) concerning the actual criteria of a BPD diagnosis, and especially concerning the uneven ratio of female/male diagnoses. Since the release of the DSM-III, three women have been diagnosed for every one man in America, despite studies that show the opposite effect in the United Kingdom. (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006.) Although to my knowledge the DSM is mainly distributed in America, this is likely an indication that rather than the criteria simply fitting closer to historically conventional female behavior than male behavior, the diagnostic disparity lies in the preconceived notions of those doing the diagnosing: the psychiatrists. In the DSM-IV-TR, the revised version of the Diagnostic Statistical Manual from 2000, a Borderline Personality Disorder diagnosis can be made if a patient exhibits a “pervasive pattern of excessive emotionality and attention-seeking,” which depends on filling five or more of the following criteria: “is uncomfortable in situations in which he or she is not the center of attention; interaction with others is often characterized by inappropriate sexually seductive or provocative behavior; displays rapidly shifting and shallow expression of emotion; consistently uses physical appearance to draw attention to self; has a style of speech that is excessively impressionistic and lacking in detail; shows self-dramatization, theatricality, and exaggerated expression of emotion; is suggestible, or easily influenced by others or circumstances;” and, “considers relationships to be more intimate than they actually are.” (APA, 2000.) It’s not difficult to understand just from reading through these criteria how some of them target tendencies that would be viewed as socially unacceptable in women but that would be relatively normal in men, like “sexually seductive or provocative behavior.” Clearly, a change was in order. The DSM-5 addresses these issues by splitting criteria into five distinct sections: “Significant impairments in personality functioning” (which contains subsections “impairments in self functioning” & “impairments in interpersonal functioning,” each with two subsubsections), “Pathological personality traits” (which contains subsections “negative affectivity,” “disinhibition,” & “antagonism,” with a total of 8 subsubsections), as well three more qualifications: “The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations,” “The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment,” and “The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).” Basically, it’s a good deal more complicated than the version in any previous DSM, but this is a sign that measures are being taken to ensure more accurate diagnoses. There is a serious stigma surrounding those suffering from BPD that goes beyond gender. It’s well known that Borderline goes hand-in-hand with depression and self-harm (“poor self-image” is mentioned in the criteria as well as risk taking and suicidal thoughts) but whether or not there’s a causal connection between BPD and aggression towards others has been a bit of a grey area in psychology for a very long time. The “psychotic” distinction and the antagonistic nature of people with Borderline have probably contributed to its being stereotyped as a violent disorder. A significant number of people with BPD also have some form of Antisocial Personality Disorder, and the emotional dysregulation of the two when they occur at the same time can be especially severe. One recent study focuses on individuals suffering from a variety of disorders including Borderline, Antisocial, and Histrionic personality disorders (ones which often occur comorbidly) and the disorders’ “prospective associations” with aggression and violent crime. By examining the behavior of the 150 patients over the course of a year and accounting for the possibility that a patient’s symptoms could result from more than one disorder, researchers could be surer of the legitimacy of their conclusions. The “Methods” section notes that “the most commonly met (above threshold) symptoms of BPD were excessive anger (20%), affective instability (16%), and impulsivity (12%). The most commonly met symptoms of ASPD were consistent irresponsibility (16%) and failure to conform to social norms with respect to lawful behaviors (13%).” (Scott, Lori N., Stepp, Stephanie D., Pilkonis, Paul A., 2014.) The study further concluded that BPD was “uniquely associated with emotional dysregulation” at the 3-month follow up after controlling for ASPD symptoms, and that “in turn, emotion dysregulation predicted both psychological and physical aggression perpetration and victimization in the following 9 months.” Although ASPD had significantly higher numbers for physical assault perpetration in last 3-12 months, patients with BPD were shown to have a higher likelihood of committing a violent act than those without the disorder (and some patients with other similar disorders). So why has it taken until 2014 for this connection to be made? Wouldn’t there have been a number of studies already done on BPD and aggression, especially considering Borderline’s long and contentious history? In fact, there have. One review (which was aggravatingly undated but appears to have begun in 2012 and concluded at some point in 2013) looked at “affective instability” (a.k.a. AI, which is associated with aggression) and its prevalence in certain disorders by examining results from over 11,000 abstracts and studies on the MEDLINE, EMBASE, PsycINFO, PsychArticles and Web of Science databases. (S. Marwaha et al, 2013.) The review emphasized the difficulty of correlating Borderline Personality Disorder with AI in a manner that would yield accurate, usable results; due both to its (BPD’s) high rate of comorbidity with disorders like Attention Deficit Hyperactivity Disorder & APD, and to the lack of a universally accepted definition for “affective instability” in the medical world. The review also noted the apparent bias of researchers and the general populous regarding affective instability and psychotic disorders (especially Borderline); treating it as an erroneous connection, but it didn’t actually disprove the link between aggression and BPD. Instead, the review points towards the extremely high occurrence of AI in patients with ADHD and the simultaneous occurrence of both ADHD and BPD, the implication being that a connection between Borderline and AI could be caused by comorbidity with a disorder for which AI is a symptom. Indeed, a 2010 study found in one sample that 38.1% of BPD patients also had ADHD. (M. Ferrer et al, 2010.) The conclusion of the review doesn’t actually mention any connection or lack thereof between BPD and aggression/AI, but helpfully notes that “a clearer definition of AI is required.” It seems the “prospective association” study from 2014 found a smarter way to organize their results. In “The Plight of Personality Disorders in the DSM-5,” one large section sheds light on the reasoning behind some of the changes made between the DSM-IV & 5, and discusses an even deeper historical perspective of the disorder. The multiaxial diagnostic system was introduced in the DSM-III to distinguish especially volatile disorders (those that require immediate attention on an individual basis, Axis-I) from “modifiers;” disorders that influence level of functioning & the features of Axis 1 disorders. (Limandri, 2012.) Axis-II disorders were originally “maladaptive traits.” The group morphed over the years into the “personality disorder” category we use today, its contents organized by three clusters: Cluster A (odd and eccentric), Cluster B (dramatic and erratic), and Cluster C (anxious and fearful). Limandri predicted in her paper that the DSM-5 would completely drop the cluster system due to its incongruence, but that was not the case. The symptomatic similarities between Borderline Personality Disorder and Bipolar Disorder have gotten BPD more individual criticism than any of the other personality disorders. The “Plight” paper asks: “is impulsivity a stable characteristic (i.e., state) of borderline personality disorder but a trait in bipolar disorder?” Borderline shares a good number of symptoms with many other disorders (not just Cluster B), notably Post-Traumatic Stress Disorder, which suggests that some BPD diagnoses might be erroneous interpretations of environmental effects. Despite all the confusion about shared symptoms, psychologists and psychiatrists have found the diagnosis useful for treatment purposes, since treatment often focuses on symptom management anyway. Borderline patients are infamous for their difficulty accepting treatment. It’s kind of expected for patients with a disorder characterized by unstable emotions, outbursts, and difficult interpersonal relationships to be somewhat uncooperative in therapeutic settings where their every word and action is analyzed. Medication can be used to treat urgent symptoms (for example, if a patient might attempt suicide or acts especially aggressively) and comorbid conditions like ADHD, but for BPD itself the best long-term treatment is therapy. Dialectical Behavior Therapy, which was developed in order to treat suicidal patients, has been shown to be remarkably effective at decreasing self-injuring and substance abuse behaviors in patients with BPD. Addressing the problem of a possibly erroneous diagnosis based on symptoms shared with another disorder; DBT is equally effective at treating similar disorders like PTSD. In one case study, a psychologist notes while selecting treatment targets prior to therapy that “if most of [the patient’s] problems are related to trauma symptoms, then choosing a treatment for PTSD may be the best option).” (Landes, 2013.) This particular kind of therapy is practically perfect for treating Borderline patients because of its level of individual personalization based on each patient’s symptoms. Both those in favor of removing Borderline Personality Disorder from the DSM completely and those who feel the diagnosis has an important purpose have research to back up their viewpoints, and in a way neither side is wrong. In the context of the Cluster system, the Axes system, and even the DSM as a whole, the criteria for BPD place it in a strange grey area that makes a sure diagnosis next to impossible. Its ambiguity and the recognized gender bias contribute to bewilderment for the patient and difficulty choosing a correct course of treatment for the psychiatrist and/or therapist. Even the name of the disorder can be a cause of confusion and irrational judgment. On the other hand, would striking Borderline off the list of personality disorders leave patients and psychologists in a better position than they were before? The diagnosis can be unwieldy, but without it a huge number of patients would be pushed into categories they don’t belong with diagnoses like Bipolar II and PTSD. Patients with severe depression and emotional dysregulation might be given some kind of manic label, and treatment would probably downplay the patients’ difficult relationships and manage the depression on an episodic basis, which would probably prove ineffectual. Like it or not, more Borderline-specific treatments like Dialectical Behavior Therapy have the best outcomes even in patients with comorbidity or even slight misdiagnoses based on shared symptoms. The diagnosis is flawed, its precision and history contentious, but its usefulness has been proven time and time again. Until we have a better alternative, BPD will continue to (usually) serve its purpose as a tool designed to make sick people better. Bibliography: Mondimore, Francis Mark, and Patrick Kelly. Borderline Personality Disorder: New Reasons for Hope. Baltimore: Johns Hopkins University Press, 2013. Ebook. Coid, J., Yang, M., Tyrer, P., Roberts, A., & Ullrich, S. “Prevalence and correlates of personality disorder in Great Britain.” The British Journal of Psychiatry, 188, 423–431. (2006) Pdf. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). American Psychiatric Publishing. Washington, DC. Web. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing. Arlington, VA. Web. Scott, L. N., Stepp, S. D., & Pilkonis, P. A. “Personality Disorders: Theory, Research, and Treatment (Prospective Associations Between Features of Borderline Personality Disorder, Emotion Dysregulation, and Aggression)” US Educational Publishing Foundation.(2014) Web. Limandri, Barbara J. “The Plight of Personality Disorders in the DSM-5.” Issues in Mental Health Nursing. 33, 598–604. Informa Healthcare USA, Inc. (2012) Web. Marwaha, S., He, Z., Broome, M., Singh, S. P., Scott, J., Eyeden, J., and Wolke, D. "How Is Affective Instability Defined and Measured? A Systematic Review." Rev. of 11,433 various abstracts & 37 studies. Mental Health Research Network. Web. Ferrer, M., Andion, O., Matali, J., Valero, S., Navarro, J. A., Ramos-Quiroga, J. A., Torrubia, R., Casas, M. “Comorbid attention-deficit/hyperactivity disorder in borderline patients defines an impulsive subtype of borderline personality disorder.” US National Library of Medicine. 2010. Web. Hansell, James, and Damour, Lisa. Abnormal Psychology. 2nd ed. Hobeken, NJ: Wiley, 2007. Print. Landes, Sara. “The Case: Treating Jared through Dialectical Behavior Therapy.” Journal of Clinical Psychology, Vol 69, pp. 488-489. 2013. Web. Motion Fountain

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