Dr. Shahal Rozenblatt, Clinical Neuropsychologist, New York

Scientific American-Diagnosis of Borderline Personality Disorder Is Often Flawed

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Diagnosis of Borderline Personality Disorder Is Often Flawed

True sufferers are often troubled—and yet time and treatment can often improve their lives

By Scott O. Lilienfeld and Hal Arkowitz | Wednesday, January 4, 2012 | 7

Image: Stuart Bradford

This past June renowned clinical psychologist Marsha M. Linehan of the University of Washington made a striking admission. Known for her pioneering work on borderline personality disorder (BPD), a severe and intractable psychiatric condition, 68-year-old Linehan announced that as an adolescent, she had been hospitalized for BPD. Suicidal and self-destructive, the teenage Linehan had slashed her limbs repeatedly with knives and other sharp objects and banged her head violently against the hospital walls. The hospital’s discharge summary in 1963 described her as “one of the most disturbed patients in the hospital.” Yet despite a second hospitalization, Linehan eventually improved and earned a Ph.D. from Chicago’s Loyola University in 1971.

Many psychologists and psychiatrists were taken aback by Linehan’s courageous admission, which received high-profile coverage in the New York Times. Part of their surprise almost surely stemmed from an uncomfortable truth: people with BPD are often regarded as hopeless individuals, destined to a life of emotional misery. They are also frequently viewed as so disturbed that they cannot possibly achieve success in everyday life. As a consequence, highly accomplished individuals such as Linehan do not fit the stereotypical mold of a former BPD sufferer. But as Linehan’s case suggests, much of the intense pessimism and stigma surrounding this disorder are unjustified. Indeed, few psychological disorders are more mischaracterized or misunderstood.

Fuzzy Borders
New York psychoanalyst Adolf Stern coined the term “borderline” in 1938, believing this condition to lie on the murky “border” between neurosis and psychosis. The term was a misnomer because BPD bears little relation to most psychotic disorders. The name may have perpetuated a widespread misimpression that the disorder applies to people on the edge of psychosis, who have at best a tenuous grasp of reality. Not surprisingly, the popular conception of BPD, shaped by such films as the 1987 movie Fatal Attraction (featuring actress Glenn Close as a woman with the condition), is that of individuals who often act in bizarre and violent ways.

An error committed by some clinicians is presuming that patients who do not respond well to treatment or who are resistant to therapists’ suggestions are frequently “borderlines.” Some mental health workers even seem to habitually attach the label “borderline” to virtually any client who is extremely difficult to deal with. As Harvard University psychiatrist George Valliant observed in a 1992 article, the BPD diagnosis often reflects clinicians’ frustrated responses to challenging patients.

In reality, BPD is meant to apply to a specific subgroup of individuals who are emotionally and interpersonally unstable. Indeed, Linehan has argued that a better name for the condition is “emotion dysregulation disorder.” Much of the everyday life of individuals with BPD is an emotional roller coaster. Their moods often careen wildly from normal to sad or hostile at the slightest provocation. As Linehan pointed out in a 2009 interview with Time magazine, “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin.” Their perceptions of other people are inconsistent, and they often vacillate between worshipping their romantic partners one day and detesting them the next. Their identity is similarly unstable; patients may lack a clear sense of who they are. And their impulse control is poor; they are prone to explosive displays of anger toward others—and themselves. [For more on the symptoms, causes and treatment of BPD, see “When Passion Is the Enemy,” by Molly Knight Raskin; Scientific American Mind, July/August 2010.]

Further fueling the stigma attached to BPD is the assumption that nearly all individuals who engage in self-cutting, such as wrist slashing, are so-called borderlines. In fact, in a 2006 study of 89 hospitalized adolescents who engaged in cutting and related forms of nonsuicidal self-injury, Harvard psychologist Matthew Nock and his colleagues found that 48 percent did not meet criteria for BPD. The lion’s share of these individuals exhibited other personality disorders, such as avoidant personality disorder, which is associated with a pronounced fear of rejection.

Once Borderline Always Borderline?
Two allied myths about BPD are that patients virtually never improve over time and are essentially untreatable. Yet a number of recent studies indicate that many patients with BPD shed their diagnoses after several years. In a 2006 investigation, for example, psychologists C. Emily Durbin and Daniel N. Klein, both then at Stony Brook University, found that although 16 percent of 142 psychiatrically disturbed adults initially met criteria for BPD, only 7 percent did after a decade. Moreover, the average levels of BPD symptoms in the sample declined significantly over time. Work by psychologist Timothy J. Trull and his colleagues at the University of Missouri–Columbia similarly suggests that many young adults who display some features of BPD do not exhibit these features after only a two-year period, indicating that early signs of BPD often abate.

BPD is not easy to treat. Yet Linehan has shown that an intervention she calls “dialectical behavior therapy” (DBT) is modestly helpful to many sufferers of the condition. DBT encourages clients to accept their painful emotions while acknowledging that they are unhealthy and need help. It teaches patients specific coping skills, such as mindfulness (observing their own thoughts and feelings nonjudgmentally), tolerating distress and mastering negative emotions. Controlled studies, reviewed by Duke University psychologist Thomas R. Lynch and his colleagues in 2007, indicate that DBT somewhat reduces the suicidal and self-destructive behaviors of patients. Lynch and his collaborators also found that DBT may lessen feelings of hopelessness and other symptoms of depression. Still, DBT is not a panacea, and no clear evidence exists that DBT can stabilize patients’ identity or relationships. Preliminary but promising data suggest that certain medications, including such mood stabilizers as Valproate, can alleviate the interpersonal and emotional volatility that characterize BPD, according to a 2010 review by psychiatrist Klaus Lieb of University Medical Center in Mainz, Germany, and his colleagues.

A Continuing Challenge
Not all BPD patients improve on their own or with treatment, and even those who do typically continue to battle the demons of emotional and interpersonal volatility. Nevertheless, the extreme negative views of this condition are undeserved, as is the mislabeling of a wide swath of the psychiatric population as borderline. It is also undeniable that many clinicians must become more judicious in their use of the BPD label and avoid attaching it to virtually any patient who is oppositional or unresponsive to treatment.

Fortunately, there is room for cautious optimism. As psychiatrist Len Sperry of Barry University noted in a 2003 review, BPD is the most researched of all personality disorders, a fact that remains true today. The fruits of that work promise to yield an improved understanding of BPD, which may reduce the stigma surrounding this widely misunderstood diagnosis. If so, perhaps the day will soon come when successful people who once struggled with BPD, such as Marsha Linehan, are no longer perceived as exceptions that prove the rule.