|What is Borderline Personality Disorder (BPD)?
Description of the Disorder
The essential features or criteria fall under
four main headings with instability being the consistent feature:*
History of the Term
1. Instability of interpersonal relationship
Inability to be alone, sense of panic when alone
Fear of abandonment, seperation, or rejection
Manipulation of others
Devaluation of self or others
2. Self-image is unstable
3. Affect is labile (reactivity of mood)
Odd thinking about self
Rapid change in self-image or sense of self
4. Behavior is impulsive and unstable
Feelings of emptiness, loneliness, worthlessness
Express or experience feelings of anger, anxiety, or guilt
These features are a guideline when conceptualizing the Borderline
Personality, the principal thing to be cognizant of is that these features
occur rapidly, without warning, and are pervasive. The person with
BPD can change right in front of your eyes.
Suicidal gestures and/or self-mutilation
Acting irresponsibly in general (e.g. driving fast, spending
When Adolf Stern first coined the term "border
line" in 1938 he used it to describe outpatients that did not fall into
the standard classification system used in the psychiatric profession (Stern,
1986). The practice during this time was to label behavior as normal,
neurotic, or psychotic (Linehan, 1993; Stone, 1993). Neurotic patients
were considered to have a less severe illness and responded well to classical
psychoanalysis (Freud). The “border line” patient, although, not
as severe as the psychotic, did not respond well to psychoanalysis and
their behavior did not met classification standards for a neurotic or psychotic
diagnosis (Stone, 1986). This term became the catchall term within
the psychoanalytic community to describe patients that did not meet established
diagnostic criteria (Linehan, 1993). Many contributors helped develop
the current label and view of the borderline patient. Stern labeled
and a conceptualized this type of patient using10 descriptors the patients
behavior. In 1942, Helene Deutsch describes an “as-if” group of patients
that also failed to fit into established categories; her theory about these
patients led to the “pathology of internalized object-relations.
Melitta Schmideberg, 1947, described a group of borderlines that were more
schizoid or narcissistic as being “stable in their instability” which is
the nature of the disorder. Kernberg’s definition relied on reality-testing
and identity diffusion: “borderline personality organization is that characteristic
level of functioning where the sense of identity is weak… yet the capacity
to test reality is preserved…”(Stone, 1993, p. 219). This definition
lead to Gunderson and Singer’s development of a six-item criterion set
that was observable and could be better delineated from other disorders
(Stone, 1986). The use of the term “borderline” grew with the psychoanalytic
movement, evolving to describe both a disturbance or severity in personality
functioning and the structure of personality organization. It wasn’t until
1980 when the DSM-III was published that the concept of BPD became an official
diagnostic disorder with it’s own set of criteria (Linehan, 1993).
The definition used in the DSM-III/R and DSM-IV is roughly founded on Gunderson’s
idea of using a set of criterion to define the borderline. (see Stone,
1986 or Linehan, 1993 for complete history).
Features of BPD
A. Paris (1999) gives a brief clinical description
of a borderline patient:
Case 3: Maxine, a 20-year-old woman,
was admitted to the hospital after slashing her wrists and overdosing on
aspirin. Although a brilliant student and an accomplished musician,
she had never been able to achieve any meaningful relationships.
Since childhood she had felt deeply alone in life. Her parents were
well-meaning but insensitive, and had never been able to understand her
emotional needs. Most recently, Maxine had been abandoned by a boyfriend
after a brief and unsuccessful love affair. Over the next few years,
she attempted to obtain treatment from a variety of competent clinicians.
Each time, she left therapy feeling angry and disappointed. She attended
school and was able to obtain a good position after graduation, but continued
to slash her wrists and take overdosed after disappointments in relationships.
B. Personal experience with a borderline patient:
Before coming to graduate school I worked with a young
lady that was too young for the diagnosis but presented with most if not
all of the DSM-IV criteria. She required One-on-One supervision due
to her self-mutilative behaviors. Within an hours time she would change
her identity or her job goals at least 20 times. When she feared
being left alone or abandoned she would find a way to hurt herself or threaten
suicide. For fear of abandonment or rejection, she would place the
staff and/or herself in an ”all good” category or an “all bad” category.
This behavior is referred to as Splitting. The diagnosis for this
young lady is bleak, it is thought by staff and clinical professionals
that she will spend the rest of her life in and out of the mental health
system and may eventually become a perminent resident at a mental health
Splitting is very characteristic of the borderline personality.
Splitting can be thought of as very black or white thinking, there are
no gray areas. The person with BPD will one minute idolize a person
and then in the next minute hate a person. There is no visible "reason"
for the split or the mixed feelings displayed by the borderline.
The person these feelings are directed towards may become confused and
eventually frustrated with the borderline personality due to their erratic
behavior, making interpersonal relationships difficult if not impossible.
Another feature worth mentioning separately is self-mutilation/self-injurious
behavior. This type of behavior is very distinctive to the borderline
and BPD is the only diagnosis that has this feature as part of its diagnostic
criteria set (APA, 2000). This act is not always a suicidal gesture.
Often a borderline patient will describe the need to “feel something” or
will cut themselves as a cry for help. Other borderlines have described
the use of self-mutilation as a way to test reality. What ever the
reason there is always a risk that the self-injury will result in accidental
death. It is discussed in much of the literature that even though
a borderline person is at risk of attempting suicide most of this behavior
is attention-seeking or manipulative.
The clinical description of BPD does not capture the
multiplicity of characteristics and features with which the disorder manifests
itself within the individual. The DSM-IV-TR requires at least five
of the nine diagnostic criteria be met for a diagnosis but this doesn’t
make the BPD group a homogenous one (Linehan, 1993; Paris, 1999).
The heterogeneous nature of the BPD group makes developing a universal
treatment strategy difficult. Hurt et al. (1990), tried to
determine if these patients could be put into clusters or categories (cited
in Hurt, et al., 1992 and Stone, 1993). Using the DSM-III and four
separate studies of BPD inpatients, three distinctive personality clusters
emerged: an identity cluster, an affective cluster, and an impulse
cluster. The identity cluster is characterized as “identity disturbances,
intolerance of being alone, and boredom/ emptiness”, the affective cluster
features are “anger, affect instability, and unstable relationships”, and
an impulse cluster “is characterized by impulsivity and self-damaging acts”
(cited in Stone, 1993, p. 225). By identifying the BPD features into
these clusters Hurt el al. (1992), believed that treatment strategies and
appropriate accommodations could be developed to provide the best therapeutic
The outcome for the BPD patient has no dependency on
the initial diagnosis; it is however contingent upon the person.
Stone (1993) did a follow up study of his borderline patients and observed
that successful outcomes were related to certain personality characteristics.
The strength of the patient’s character: likeability; patient affect: level
of anger or hostility; and the ability of the patient to maintain their
impulsivity: self-discipline vs. chaotic, are just a few examples of the
predictive traits that will help to determine the “treatability” of the
When the borderline patient was first introduced in the
literature, it was originally believed that these patients were showing
different forms of schizophrenia or psychosis (Stone, 1986). This
notion is no longer debated but identifying the borderline patient is still
questioned and made difficult due to the variability in how it manifests
itself. When comorbidity is present the clinician is faced with trying
to determine which disorder is pervasive, are the symptoms of one disorder
a subset or subtype of the other, and if the presentation of both are actually
a single disorder. In most of the literature, the question of diagnosis
becomes difficult when borderline personality is comorbid with depression
or dysthymia, PTSD, and coexists with other Axis II disorders (Stone, 1993;
Zanarini, et al., 1998; Paris, 1999). The borderline patient presents
with a number of symptoms and characteristics of these disorders.
Many of them are depressed because they are lonely, may appear to have
PTSD as a result of their childhood traumas, and the nature of the instability
in their identity make it a challenge when trying to rule out one or the
other. Although trying to tease out the appropriate diagnosis is
problematic, in clinical practice when BPD is recognized in a client no
other personality disorder is considered (Stone, 1993; Paris, 1999).
Adolescents and BPD
When diagnosing any personality disorder before the age
of 18 it is important to be critical of the reliability of the diagnosis.***
A recent study was done with a small inpatient sample (n=21; age 15-19,
m=17) diagnosed using the Personality Disorder Examination and then matched
to the criteria in the DSM-III-R (Garnet, 1994). The study looked
at the ability to identify diagnostic criteria specific to BPD and determined
if these symptoms are stable over-time when dealing with developing adolescents.
The results found that only seven of the 21 met the BPD criteria showing
that diagnosis in adolescents is uncertain if not harmful to the patient.
The Difficult Client
Whether a therapist is working with an adult carrying
this diagnosis or an adolescent that is showing signs of presentation it
is important to always monitor personal feelings or frustrations that may
be manifested by the client. ALL the literature testifies to the
difficult nature of dealing with the BPD. These clients/patients
are described as being difficult, frustrating, and down right irritating.
The BPD client will test boundaries, push limits, and demand a lot of attention-in
or out of the therapeutic setting. Therapists need to keep their
own feelings and thoughts out of the therapeutic environment but when dealing
with a borderline personality this is often difficult.
*This list was adapted using the Diagnostic Interview for Borderlines,
Revised (DIB-R) and the DSM-IV ( APA, 2001; llama
**The example given was chosen for its brevity and so it should be
mentioned that unlike Maxine, not every story has a successful conclusion
(Paris, 1999). When self-mutilation is involved often times the result
is death (Stone, 1993).
***Antisocial Personality Disorder is the acception to this rule, it
can only be diagnosed after the age of 18