Borderline personality disorder: diagnosis

birdonwireJust as I was formulating a few thoughts on borderline personality disorder (BPD), I see the NY Times beat me to it. Jane E. Brody’s 6/15/09 “Personal Health” column, “An Emotional Hair Trigger, Often Misread,” provides an evocative description of this vexing disorder. Brody’s column seems informed largely by her consultant, Dr. Marsha M. Linehan, who devised the best known and best studied treatment for BPD, a combined individual and group therapy called Dialectical Behavior Therapy, or DBT. (Here are some links describing DBT: 1, 2, 3). Dr. Linehan also invited readers’ questions about BPD on a related NY Times blog, garnering over 200 comments. She began to answer some of those questions here.

In this post I’ll offer some of my own views on diagnosing borderline personality disorder, and in the next I’ll share some more reflections and thoughts on BPD.

The term “borderline” came from the impression of early clinicians that the disorder originates at the border of neurosis and psychosis: too severe to be the former, not severe enough to be the latter. Over the decades psychiatry has refined its understanding of this syndrome , yet much remains unclear. The May 2009 issue of the American Journal of Psychiatry was devoted in part to BPD. One article by psychiatric diagnostician John Gunderson MD reviews the history of the diagnosis and is well worth reading.

BPD is not as easily diagnosed as people, including many clinicians, think it is. Not all dramatic, irritable, self-destructive, and/or manipulative people have BPD. I currently see two patients in my practice who were referred to me by other well-trained psychiatrists as clearly having BPD. They don’t. One is a woman who suffered repeated childhood sexual abuse, leaving her full of mistrust, anxiety, and anger. She hardly discussed her traumatic past with her former psychiatrist of many years, who saw her weekly and maintained her on several antidepressant, tranquilizing, and sedating medications. I confess that I, too, thought she had BPD when we first met: She was overwhelmed by affect and seemed unable to sustain relationships. This has all changed with therapy. Now, about two and a half years later, she takes no psychiatric medications, has several important relationships, and usually can tolerate her own strong emotions. Either I cured her BPD (I don’t think so), or she never had it in the first place. My other patient has dramatic affective storms, identity diffusion, frequent limit-testing, “manipulative” suicidal threats, and so forth. But psychotherapy has revealed emotional conflicts, not borderline pathology, at the root of her distress. She too is improving.

I have no doubt that Dr. Linehan’s DBT helps a great many patients suffering from BPD. But I can’t help but worry about all those who do not really have BPD, and who could be helped in more fundamental ways by a nuanced understanding of their emotional dynamics. It is worth remembering that Dr. Linehan herself does not claim that improvement from DBT is diagnostic of any particular disorder. Who would not benefit by increased mindfulness, improved interpersonal effectiveness, and better emotion regulation and distress tolerance? (These are the four “modules” of DBT.) Perhaps some variant of these modules should be taught to all schoolchildren as a public health measure!

So there are people who “look” like they have BPD, but really have neurotic conflicts. Conversely, I have seen a number of patients who carry a diagnosis of bipolar disorder, usually qualified with terms like “atypical” or “rapid cycling,” who really have BPD. The world of psychiatry is divided into those who believe bipolar disorder is under-diagnosed, and those who believe it is over-diagnosed. (The same is true of ADHD and other popular [trendy?] diagnoses.) I happen to believe it is over-diagnosed. Rapid-cycling bipolar is defined as four or more extreme mood states per year. These would be moods that last at least a week or two, usually considerably longer. Dramatic mood swings that occur hour to hour, or day to day, are most likely something else: a personality disorder, an organic brain condition, a drug or alcohol addiction. It’s a waste and a risk to take unneeded bipolar medication for years and years, surely worse than undergoing DBT for a mistaken BPD diagnosis. Worst of all, I suppose, is to be given both diagnoses, bipolar and BPD, when neither is correct. I am very wary when patients tell me they have both disorders. While not impossible, it far more likely points to sloppy diagnosis than to a particularly unlucky patient.

The term “borderline” has seeped into public consciousness just enough to make it a powerful putdown, or pseudo-explanation to account for a socially difficult or antagonistic person. Moreover, the DSM-IV does a poor job with personality disorders, perhaps because it aims to be atheoretical, whereas personality assessment relies inherently on a theory of mind. I believe a psychodynamic framework is required to understand BPD, even if effective interventions need not themselves be psychodynamic.

More reflections to follow in the next post.

10 comments to Borderline personality disorder: diagnosis

  • terry

    Just read your article and found it interesting. I have a 24 year old son who is on heroin for the past 6 months (he says) and has been in 3 rehabs in different parts of the country. He was released on Tuesday and used again with hours. He is angry with me because this time I did not want him home, because the other times he immediately used. Well, it happened again. He has been to mental health pros for the past 6 years. He has went to psychiatrists who said he was normal, another said BPD, more recently in rehab he was diagnosed as bipolar mixed, next rehab said ADHD, now most current rehab doctor said cluster 3 traits of bpd. After doing research I do agree with bpd. Is there any way I can convince him of his condition and urge him to seek therapy. I just went to a support group for myself. I am out of my mind with worry. He bashes me to no end and threatens suicide to punish me. I am walking of eggshells. He does not do this to my husband, only me. Any help you can give me would be greatly appreciated. I contacted the Mental Health Association in my area and that is how I got to a support group. The woman in charge does do the dbt. Her name is Edie Mannion. We live in Philadelphia. Thank you for anything you can provide me


    • Terry,

      While your experience is not rare, it’s a unique nightmare for every family when it happens. People with drug addictions, BPD, and some types of bipolar disorder can all look alike; psychiatric diagnosis remains an art as well as a science. “Cluster B” (not 3) points toward BPD without making a firm diagnosis.

      Many mental health professionals, including me, say the place to start is the substance abuse. It may not be the whole story, but it’s impossible to tell while the person is still using. Sometimes suspected personality or bipolar disorders evaporate when the person is finally clean and sober, although you imply these problems preceded your son’s drug use.

      I know of no secret to convince your son he needs help. 12-step groups like AA and NA (Narcotics Anonymous) say a user has to “hit bottom” — face consequences unacceptable to them — before submitting to treatment. This is painful for a parent to watch, to put it mildly. The situation is essentially the same with non-drug problems like BPD. The person has to seek help because his life is dissatisfying to him. You might point to your son’s suicidal feelings as something he could address in a treatment like DBT.

      Meanwhile, it’s good you are in a support group yourself. Maintaining you own standards, e.g., no drug use in your house, is hard but essential. Hang in there.

      • terry

        Hi Dr. Reidboard
        I wrote to you back in July and you did answer, however, I just read it while surfinjg the web again for some answers and input. You sound like a great doctor, however, you are in California and I live in Philadelphia. Is there anyone within a 100 mile radius that you could recommend to me for my son. Again, he has been diagnosed with ADHD, BPD, Bipolar. He is willing now to seek help to find out what is wrong with him. Any info you can give me would be greatly appreciated.


        [email address deleted]

        • Terry,
          Sorry, I don’t know anyone to recommend in your area. This is what I tell people who ask for a referral in or near a major city (when I don’t have anyone specific to recommend): Call the closest university medical center’s department of psychiatry, and ask for a referral to someone on their teaching faculty. It may be hard to get an appointment, but such doctors are very likely to be knowledgeable and have good professional reputations. Good luck.

  • Intresting i have been diagnosed with BPD 3 times including a main stream hospital what i wounder with what is siad do i actualy have BPD or is it a miss diagnosis could it maybe be something else or not. but if its not BPD what is it then

  • Leslie

    Dr. Reidbord,
    I am curious about your take on the “quiet” borderline type (vs. the “classic” type). I’ve gathered that this is not something that is official, in the DSM-5, yet from what I’ve read about it (from patient/layperson perspectives), it sounds like an important distinction and like it is a real problem that such presentations of the disorder easily fall through the cracks. I’m a bit baffled how little/no(?) information is out there on this from professional sources. For a bit of background on where I’m coming from, I was “offered” the diagnosis of BPD by a psychiatrist, but didn’t quite meet criteria, based on the screening questions I was given. The suggestion of it, though, came as quite a jolt and when I subsequently discussed it with my therapist, she assured me that I definitely did not fit the picture of BPD. I did my own search on it, though, and when I ran into info on the “quiet” type, it really brought back into question – in my mind – “Is that me?” Any thoughts/opinions you have on this topic, I would be interested to know. Thank you!

    • Hi Leslie,
      There are at least 4 ways to be called “borderline.”

      1. Psychiatric diagnosis relies on meeting DSM “diagnostic criteria.” DSM diagnoses are categorical, i.e., you’re either in the category, or you’re not. Since the main idea of DSM is high diagnostic agreement (reliability), it emphasizes overt symptoms that everyone can see. Many mental health experts, including me, think categorical diagnosis doesn’t apply well to personality problems.
      2. Psychologists mostly prefer dimensional ratings over categories. More of this and less of that, as measured on rating scales. A person so rated may have “borderline traits” or a “borderline style.” Whether the quiet type is counted depends on the rating scales used.
      3. Psychoanalysts and psychodynamic therapists don’t use diagnostic criteria or rating scales. Instead, we have a theory of personality development that predicts a range of mood and relational problems due to parenting and childhood trauma. The quiet type is explained psychoanalytically just as well as the classic type: here the term “borderline” refers less to symptoms and more to personality organization, e.g., the way a person sees self and others.
      4. Unfortunately, “borderline” is sometimes used as a catch-all for difficult people who stir up trouble. This would not be the quiet type, of course.

      Since there is no medical treatment specifically for BPD, it’s unclear to me what DSM diagnosis (i.e., #1) offers. Rating scales (#2) may clarify personality assessment but also don’t point toward specific treatment. In my view, dynamic psychotherapy (#3) is especially helpful for quiet type borderline personality disorder, while DBT is the gold standard for the classic type. They can be used together as well. Most important is to avoid using the term “borderline” as a putdown (#4), which helps no one. Thanks for writing.

  • Leslie

    Dr. Reidbord,
    Thank you for your reply – it’s helpful clarification. On first thought, it sounds like – whether one is the true quiet type or a muddle on Axis 1 (e.g., the two patients you referenced) – the path for growth is the same, and is a better investment of one’s energy than remaining hung up on labels. On second thought, I’m still a bit confused… I got the impression that for your two patients, BPD was ruled out because they responded well to therapy. Yet, quiet BPD (i.e. true BPD) is responsive to “dynamic psychotherapy.” How does this all fit together? Maybe your two patients initially appeared as “classic” BPD, and therefore responsiveness to dynamic psychotherapy(?), vs. DBT, ruled out true BPD? I may be overthinking things; just trying to understand as much as possible. 🙂 Thank you!

    • Sorry for the confusion; I could have been more clear.

      The overt signs of classic BPD respond well to DBT, and both the classic and quiet types improve with dynamic/analytic therapy — although it often takes a long time. The two patient examples in my original post were meant to illustrate that BPD can be mimicked by “complex PTSD” (I’m not sure the term was even available when I wrote the post 9 years ago), and by what used to be called “neurosis.” According to psychoanalytic theory, borderline personality organization arises and operates differently than neurotic conflicts, and the treatment in psychotherapy is different as well.

      All the above conditions — BPD, complex PTSD, and neurotic conflicts — respond to psychotherapy. But not exactly the same style of therapy. A competent psychotherapist should differentiate these problems and tailor his/her approach to that specific patient.

  • Leslie

    Thank you for the further clarification. That helps.

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