Almost 30 years ago, when I started my master's degree program, if we discussed borderline, that meant we were discussing psychosis. A "borderline" was a person on the "border" of psychosis.
In those days we were taught that psychopathology either manifested as
(1) a neurotic disorder, people were depressed or they worried endlessly over problems stemming from unresolved childhood guilt; we called them the Woody Allens;
(2) a psychotic disorder, accompanied with hallucinations and/or delusions; the patient being out of touch "times three," meaning he didn't know his name (person), where he lived (place) or the day of the week (time) ;
(3) a borderline disorder, essentially No-Man's Land, neither neurotic or psychotic, but definitely leaning towards the latter.
Borderline meant having such poor boundaries that the patient felt blended with others psychologically, did not see where his or her perception of others' thoughts or intentions could be wrong. The condition would manifest as severe abandonment anxiety, anger or depression, and certainly suicidality, ala that movie, Girl Interrupted. Perhaps the behavior was manipulative, but who knew for sure?
Disturbed, that we recognized. Depression didn't have to enter the equation (but it usually did).
Merging was thought the natural consequence of not having separated properly from parents, not having individuated or developed into an independent person, secure all on one's own. And to individuate well, one needed psychologically healthy parents who encouraged that differentiation and confidence.
You see why I push it, some thirty years later.
The first Diagnostic Statistical Manual (DSM, 1952), the Big Book of psychiatric diagnosis, included an etiological component that subsequent versions for the most part phased out in favor of statistics. Empirically-based medicine had evolved.
But ideas of merging and family dysfunction had a place in the first manual, as did other etiological explanations of pathology, such as the stress of combat contributing to substance abuse in the military. Not surprisingly, the American Psychiatric Association (APA) released the first DSM to meet the needs of the military— soldiers had returned from war alcoholic and traumatized.
This was also about the time that psychiatrists recognized the association between self-medicating with alcohol, and the manic component of bi-polar disorder.
The need to mesh psychiatric diagnosis with numeric coding consistent with the International Statistical Classification of Diseases and Related Health Problems [(ICD), the World Health Organization] followed soon thereafter. Then the mission of the DSM officially shifted from the explanation of psychiatric disorders to descriptions.
And as clusters of features and symptoms emerged for each new edition, psychological disorders became medical disorders, handily recognizable sets of features and symptomatology.
Our latest edition, the DSM IV-TR has refined the process, adding cultural diversity to the mix and some general psycho-social history that is associated with certain disorders. There is also an occasional reference to how genetics steer the course for others.
But to diagnose, we focus upon what we see and hear in our offices.
And borderline no longer necessarily implies having "poor boundaries." The disorder is now neatly cataloged as an Axis II personality disorder with easy to recognize socially dysfunctional features (see below). But those of us who remember what it means to people to feel less than whole, to have a need to own or merge with someone else's ego, body, or personality, are more likely to empathize with that particular pain, even though it isn't on the list.
Lucky for us, the DSM modifies, adds, and removes diagnoses with each edition.* So I look forward to seeing what the next one (2012) will do with borderline.
As it stands, anyone with or without a college vocabulary can take a stab at reading and understanding the DSM IV-TR to diagnose family and friends. Anyone can look up a diagnosis like "Borderline Personality Disorder," find the features, and label others. I started this post because a patient wanted me to list the features so that she could do that. You, too, might become rather good at psychiatric diagnosis with a working knowledge of the DSM IV-TR, assuming memory and retention serve.
It is a free country. Go buy a copy. (But pop for the full edition if you do, not the condensed spiral). It will teach you little about how a person develops a disorder or what to do about it, but at least you won't be caught using terms like "split personality" or "multiple personality disorder" anymore.
We'll get to the Dissociative Disorders another day.
But you wanted to know about Borderline Personality Disorder. So here you go. Here's what it says in the book:
Diagnostic criteria for 301.83 Borderline Personality DisorderWell, on the re-read, perhaps one might need a dictionary, if not a graduate school education, to really get this.
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 or devaluation
(3) identity disturbance: markedly and persistently unstable self-image or sense of self
(4) impulsivity in at least 2 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
You can see why it's considered a VERY painful condition. Painful to have, painful to treat, painful to live with, all around painful. The disorder always calls me to task, forces my patience, and ultimately brings out my compassion. It's difficult, emotional work and I've heard time and again from peers that working with too many patients suffering from borderline personality disorder contributes significantly to burn-out.
But there are those who burn-out working with people who suffer from depression, too.
Notice my use of language. SUFFER FROM. You'll read on the Web that people think of themselves as borderlines, or bi-polars, obsessive-compulsives, depressives, or schizophrenics.
The better way to refer to someone with a disorder is:
a person who suffers from schizophrenia
or a person suffering from borderline personality disorder.
And so on. We don't say, "She's schizophrenic." Or, "He's bi-polar."
That minimizes a person. The process does that already. We don't need to add to it.
Copyright 2007, therapydoc
*Homosexuality, for example, is no longer considered a disorder, and it is likely that in the fifth edition of the DSM we will see Adult Asperger's and Adult Attention Deficit Disorder, currently two disorders of childhood.