Should Borderline Personality Disorder Still Be a Diagnosis?

In a commentary-response article published this past week for the journal Child and Adolescent Mental Health, Peter Tyrer, a personality psychologist, engaged in what some might call heated rhetoric—or perhaps even “fighting words.” Tyrer is a well-known and prolific personality researcher with a focus on tracing the history and evolution of personality disorder categories from antiquity to the present as well as psychometric, longitudinal, and construct validation research.

In his commentary, written in response to a larger debate about whether clinicians should diagnose personality disorders in adolescence, Tyrer argues in favor of retaining personality disorder constructs by advocating for the normalization of personality disorder pathology in general. Tyrer points out that he has his own personality pathology and that some degree of personality pathology can be seen as universal.

These observations are well-taken and supported by empirical evidence on the high rates of positive screening results for numerous PDs within a single respondent on a WHO PD screening questionnaire (IPDE-SQ). Many respondents often screen positive for at least several different personality disorders.

However, in my view, Tyrer takes a turn towards controversy by saying that one PD—borderline personality disorder—"has no right to exist."

The Anti-BPD Perspective

Tyrer provides a list of reasons for this position with some elaboration and clarification. He cites the nature of BPD's diagnostic criteria (being strictly behaviorally observable) as defined by the DSM; its overlap with other personality disorder syndromes (high co-morbidity); a lack of theoretical glue tying the disparate DSM symptoms together in a meaningful way—something which has very clearly been contradicted by the IPDE structured interview for PDs (WHO, 1997) which makes links between symptoms, criterion, and behaviors explicit and rational. Lastly, Tyrer points out, that BPD has its roots in scientifically questionable practices—specifically, psychoanalytic theory.

But I argue that he falls short of addressing the elephant in the room: BPD is one of the most common, severe, scientifically studied, and treatment-ready syndromes in psychiatry that are also highly co-morbid with a variety of other mental disorders. And one major problem with Tyrer's last position, in particular, is that virtually all of the post-DSM-III PDs, including BPD, have their roots in psychoanalytic theory. This is not, in my view, a rationale for removal; it is simply a descriptive and historical fact.

Anger outburst

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Re-Upping Borderline Personality Disorder

History and Background

The diagnosis of borderline personality disorder has a long and controversial past that continues to spark debates in psychology today.

Originally, the term “borderline” was a psychoanalytic construct that referred to a level of functioning or psychopathology that was an intermediary between neurosis (everyday anxiety, phobias, etc) and psychosis (schizophrenia). Hence, the phrase “borderline psychotic” is sometimes seen and refers to this Freudian concept of severe—but not the most severe—form of psychopathology.

After DSM-III, borderline personality disorder was redefined categorically with a content definition and list of criteria. It is this conception of BPD that is, today, the subject of both stigma and science.

Phenomenology and Clinical Presentation

Individuals with BPD often display:

• A relational pattern marked by “intense” and “stormy” relationships with others. These interpersonal relationships are characterized by a high frequency of highs and lows, and a drastically, polar opposite shift in affect and attitude such that the other is either being devalued or idealized. The greater the number of these relationships in the history of the individual with BPD, the more severe this symptom is considered to be.
• Individuals with BPD often report that they don’t know who they are and possess unclear life goals and values. Individuals with BPD often display totally different patterns of behavior and traits with different people. Similar to individuals with histrionic personality disorder, they can display chameleon-like behavior and adopt the personality of the other as they lack a consistent grounded, self.
• Individuals with BPD are unsure about what kind of person they are because they act so differently at different times depending on who they are with: they cannot predict their own behavior which may feel destabilizing, out of control, and anxiety-provoking. Sometimes, an individual with BPD behaves erratically, inconsistently, or in contradictory ways.

  - Individuals with BPD often report that have difficulty deciding about their long-term goals or career choice, resulting in recurrent unstable and constantly changing life endeavors in connection to jobs, long-term planning, or career.

  - Sometimes, people with BPD will report that they have no identifiable goals whatsoever for a career by at least the age of 30. Other times, people with BPD will explicitly deny uncertainty in connection with their career while their behavior suggests the opposite, often in a flagrant fashion.

  - Individuals with BPD lack a consistent coherent set of values and morals (as well as any awareness of this lacking) to live by which creates inconsistent, impulsive behavior. For example, individuals with BPD may drastically change their friend group out of nowhere, all of a sudden preferring a totally different type of person to hang out with. Individuals with BPD may express disturbances in and uncertainty about their sexual orientation, leading to negative affective experiences.

• Individuals with BPD often report persistent and pervasive feelings of subjective loneliness, an unbearable experience often accompanied by maladaptive behavior such as self-harm, suicidality, impulsive sexual activity, and substance abuse. This is consistent with a conceptualization of BPD as a disorder of self-regulation.

• Another key feature of individuals with BPD involves the excessive preoccupation with “fears of being left alone to take care of oneself” (IPDE Interview). These fears also reflect a core underlying feature of individuals with BPD—i.e., a constant, chronic, destabilizing, anxiety-provoking fear of abandonment that leads to frantic and reckless behaviors to prevent real or imagined abandonment.

• Suicidal and self-injurious behaviors, including threatening to commit suicide; actually making a suicide attempt or gesture; or intentional cutting, burning, or other self-injurious behavior (breaking glass with the body; head banging).

• Finally, mood lability or emotional volatility is a key feature of BPD, including outbursts of uncontrollable rage, fits of anger, or violence; as well as, an antagonistic oppositional attitude when criticized.

Summary and Conclusion

Borderline personality disorder (BPD) is associated with severe psychiatric risk; has an identifiable, reliable, and valid symptom profile that is easily recognizable by psychologists and psychiatrists; and is one of the few personality disorders that has benefited from huge levels of research funding and attention. In fact, two widely known evidence-based treatments have been developed specifically for BPD—dialectical behavior therapy (DBT) and transference-focused therapy (TFP).

According to the DSM-V-TR, 10 percent of psychiatric outpatients and 20 percent of psychiatric inpatients have a diagnosis of BPD. It is commonly seen and treated. Entire departments at major academic medical centers across America specifically cater to its care and treatment.

To suggest that this syndrome “does not have the right to exist” is, in my view, absurd and suggests a chasm between clinical practice and academic psychology. Research should be informed by real-world practice. As noted by the historian of psychiatry, G.E. Berrios, while recognizable patterns of behavior have been observed throughout time, their labels change.

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The construct of borderline personality disorder exists, has a right to exist, and is one of the better-understood forms of psychopathology in psychiatry. A debate about the merits and pragmatic clinical implications of relabeling BPD something apparently less stigmatizing would be worthwhile.

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