Borderline personality disorder: a motley diagnosis in need of reform

The Development of the ICD-11 Classification of Personality Disorders: An Amalgam of Science, Pragmatism, and Politics

The nomenclature of personality disorders in the 11th revision of the International Classification of Diseases and Related Health Problems represents the most radical change in the classification history of personality disorders. A dimensional structure now replaces categorical description. It was argued by the Working Group that only a dimensional system was consistent with the empirical evidence and, in the spirit of clinical utility, the new system is based on two steps. The first step is to assign one of five levels of severity, and the second step is to assign up to five prominent domain traits. There was resistance to this structure from those who feel that categorical diagnosis, particularly of borderline personality disorder, should be retained. After lengthy discussion, described in detail here, there is now an option for a borderline pattern descriptor to be selected as a diagnostic option after severity has been determined.

Borderline Personality Disorder: Barriers to Borderline Personality Disorder Treatment and Opportunities for Advocacy

Patients experience difficulty in accessing the evidence-based treatments that exist for borderline personality disorder. This article identifies barriers to treatment within the US structural, economic, and political landscape and how families have created an advocacy movement to address this problem. It explores how the United States has addressed such barriers, in comparison to other countries. Finally, it offers recommendations for future advocacy to increase access to treatment for borderline personality disorder.

Trait-based assessment of borderline personality disorder using the NEO Five-Factor Inventory: Phenotypic and genetic support

[Correction Notice: An Erratum for this article was reported in Vol 28(1) of Psychological Assessment (see record 2015-54029-001). The FFI-BPD values for Sample 3 in Table 2 should read 1.42 (0.44), 0.83.] The aim of the current study was to examine the reliability and validity of a trait-based assessment of borderline personality disorder (BPD) using the NEO Five-Factor Inventory. Correlations between the Five-Factor Inventory-BPD composite (FFI-BPD) and explicit measures of BPD were examined across 6 samples, including undergraduate, community, and clinical samples. The median correlation was .60, which was nearly identical to the correlation between measures of BPD and a BPD composite generated from the full Revised NEO Personality Inventory (i.e., NEO-BPD; r = .61). Correlations between FFI-BPD and relevant measures of psychiatric symptomatology and etiology (e.g., childhood abuse, drug use, depression, and personality disorders) were also examined and compared to those generated using explicit measures of BPD and NEO-BPD. As expected, the FFI-BPD composite correlated most strongly with measures associated with high levels of Neuroticism, such as depression, anxiety, and emotion dysregulation, and the pattern of correlations generated using the FFI-BPD was highly similar to those generated using explicit measures of BPD and NEO-BPD. Finally, genetic analyses estimated that FFI-BPD is 44% heritable, which is comparable to meta-analytic research examining genetics associated with BPD, and revealed that 71% of the genetic influences are shared between FFI-BPD and a self-report measure assessing BPD (Personality Assessment Inventory-Borderline subscale; Morey, 1991). Generally, these results support the use of FFI-BPD as a reasonable proxy for BPD, which has considerable implications, particularly for potential gene-finding efforts in large, epidemiological datasets that include the NEO FFI.

A (re)-evaluation of the symptom structure of borderline personality disorder

OBJECTIVE

Despite evidence of significant symptom heterogeneity and excessive diagnostic comorbidity, many contend that borderline personality disorder (BPD) is unidimensional, an assumption that rests primarily on results from factor analytic investigations of BPD symptom criteria. We note several limitations in the literature and argue that the symptom structure of BPD can be best clarified by using both factor analytic techniques and examining the BPD symptom dimensions in relation to external criteria (that is, personality traits). Our goals were to: examine if the symptoms of BPD are best conceptualized as unidimensional or multidimensional, and determine the extent to which personality traits account for any symptom dimensions that underlie BPD.

METHOD

All published structural models of the BPD symptom criteria were identified and tested for statistical fit using confirmatory factor analysis in a sample of 373 patients who had completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-Axis II Personality Questionnaire BPD scale. Dimensions from the best fitting model were examined in relation to traits from the Five-Factor Model (FFM) and the Personality Psychopathology Five (PSY-5) using correlational and regression analyses.

RESULTS

Sanislow's 3-factor model, containing affect dysregulation, behavioural dysregulation, and disturbed relations symptom dimensions, provided the best fit; the unidimensional model produced the worst. The symptom dimensions of the 3-factor model were differentiable from one another and had unique associations with the FFM and PSY-5 personality traits.

CONCLUSION

BPD is a multidimensional construct.

Personality disorders and mood disorders: perspectives on diagnosis and classification from studies of longitudinal course and familial associations

The results of three rigorous studies of the naturalistic course of personality disorders indicate the following: (1) personality psychopathology improves over time at unexpectedly significant rates; (2) particular maladaptive personality traits are more stable than personality disorder diagnoses; (3) although personality psychopathology improves, residual effects are usually seen in the form of persistent functional impairment and ongoing Axis I psychopathology; and (4) improvement in personality psychopathology may eventually be associated with reduction in ongoing personal and social burden. A comparison of the longitudinal stability of personality disorders and mood disorders does not support a clear distinction between them based on differential stability of either psychopathology (at least based on remission rates) or functional impairment. Differences may yet emerge with respect to relapse rates over the longer term. Both types of disorders may share some common underlying vulnerabilities best conceptualized in term of personality traits. A group of promising, though methodologically flawed, family studies suggest familiality of at least BPD among the personality disorders and the coaggregation of BPD and depressive disorders (but not bipolar disorders) that may contribute to their frequent co-occurrence. Again, underlying personality traits may prove to be more heritable than either type of disorder.

The borderlines of bipolar affective disorder

This paper provides an overview of the major studies of bipolar affective disorder (BAD) and borderline personality disorder (BPD), and assesses whether the disorders might be better understood as variants of the same basic disorder. There is a shortage of research that delineates the features of both disorders within their representative samples. As a consequence the symptomatic overlap of the disorders, detected by categorical assessment instruments, is often misconstrued as an indication of the disorders' high rates of comorbidity (up to 81%). In paying particular attention to features of both disorders, eg. affective instability and impulsivity, the paper provides evidence that BPD attenuates bipolar disorder along the spectrum of affective disorders, from non-classical bipolar presentation through to severe BAD with borderline features. The paper cites clinical, research and pharmacologic support of the contention that BPD, rather than representing a distinct disorder, is merely an attenuation of Axis I disorders, most especially bipolar affective disorder. Borderline personality is evident across the bipolar spectrum and exacerbates symptomatology and leads to poorer recovery prognosis.

Brokering authenticity: Borderline personality disorder and the ethics of care in an American eating disorder clinic

This paper examines the moral work of a controversial psychiatric diagnosis--Borderline Personality Disorder--in an American eating disorder treatment center in the era of managed mental health care. Based on fieldwork at this clinic spanning more than 6 years, I consider how clinicians invoke aspects of Borderline Personality Disorder in everyday conversation, in a practice I call "borderline talk." I argue that borderline talk emerges in response to being caught between contradictory models of the subject entailed in managed care and psychodynamic discourses. Specifically, borderline talk enables clinicians to endorse a formulation of the subject that, although considered pathological, provides them with a clear path of ethical action in otherwise ethically ambiguous situations. These kinds of everyday ethical negotiations percolate throughout the American health care system and are key mechanisms through which notions of economic expediency become entangled with concepts of the healthy subject. As clinicians struggle out a course of action between competing ethical imperatives, they also struggle out the workability--and failures--of various articulations of the subject within contemporary American cultural ideologies of health and pathology.

Borderline Personality Disorder: What do We Know? Diagnosis, Course, Co-Morbidity, and Aetiology

Evidence regarding the diagnostic dilemmas, course, co-morbidity, and aetiology of Borderline Personality Disorder (BPD) is reviewed. After considering problems that the clinician and researcher face in using BPD as a diagnostic category, I argue that current evidence indicates that there is reason to be more optimistic about the course of BPD. Emerging dilemmas in considering co-morbidity in the BPD patient are considered. Aetiological factors are presented in support of a ‘multiple pathways’ model of aetiology where characterological and temperamental characteristics interact in complex idiosyncratic ways.

Personality diatheses: a superior explanation than disorder

Diatheses confer vulnerability to disorder but are not necessarily manifest overtly or consistently. It is suggested that the main empirical findings of studies with abnormal personality support the notion that they are diatheses rather than disorders. This includes their onset early in life, their variability of expression dependent on setting, their greater association with more severe disorders and their acceptance as intrinsic components of functioning by most suffering from these conditions. It is argued that a separate axis of classification for personality diatheses rather than disorders is justified.

Evidence for a single latent class of Diagnostic and Statistical Manual of Mental Disorders borderline personality pathology

Borderline personality disorder (BPD) has been described as clinically heterogeneous, with numerous subtypes of the disorder posited. The present study investigated this potential heterogeneity by conducting both confirmatory factor analysis and latent class analysis of consensus ratings of Diagnostic and Statistical Manual of Mental Disorders (DSM) Revised Third Edition BPD criteria in a mixed clinical and nonclinical sample (n = 411). Confirmatory factor analysis results suggested that a single factor fit the data most parsimoniously. Latent class analysis results supported 2 latent classes: those with a high likelihood of BPD symptoms (n = 171) and those with a low likelihood (n = 240). The borderline latent class was more inclusive than diagnoses made based on DSM-III-R thresholds and improved prediction of symptom severity and interpersonal dysfunction, suggesting the clinical importance of 3 or more BPD criteria. Future research on subtypes of BPD may benefit by focusing on variables that supplement the DSM criteria.

Synthesizing dimensional and categorical approaches to personality disorders: refining the research agenda for DSM-V Axis II

Personality disorder researchers have long considered the utility of dimensional approaches to diagnosis, signaling the need to consider a dimensional approach for personality disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Nevertheless, a dimensional approach to personality disorders in DSM-V is more likely to succeed if it represents an orderly and logical progression from the categorical system in DSM-IV. With these considerations and opportunities in mind, the authors sought to delineate ways of synthesizing categorical and dimensional approaches to personality disorders that could inform the construction of DSM-V. This discussion resulted in (1) the idea of having a set of core descriptive elements of personality for DSM-V, (2) an approach to rating those elements for specific patients, (3) a way of combining those elements into personality disorder prototypes, and (4) a revised conception of personality disorder as a construct separate from personality traits.

Continuity of axes I and II: toward a unified model of personality, personality disorders, and clinical disorders

In the current standard psychiatric nomenclature, the DSM-IV-TR (APA, 2000), mental disorders are divided into two groups: Clinical Disorders (CDs) and Personality Disorders (PDs), and CD and PD diagnoses are recorded on two separate axes (Axes I and II, respectively). This article considers evidence regarding putative bases for distinguishing between CDs and PDs, and finds that these constructs are more similar than distinct. Links between the domains may be better understood by focusing on how personality connects CDs and PDs. This perspective underlines the need to work toward a more unified model of personality, PDs, and CDs in research and in future editions of the DSM.

The diagnosis of borderline personality disorder: problematic but better than the alternatives

BACKGROUND

The purpose of this review is to examine empirical evidence concerning critiques of the diagnosis of borderline personality disorder (BPD): for uncertain validity, and for overlap with other mental disorders.

METHODS

A review of the literature on the validity and comorbidity of BPD was conducted.

RESULTS

Since BPD is a complex multidimensional construct, its validity is inevitably problematic, but no more so than most other psychiatric diagnoses. The comorbidity of BPD is probably an artefact of the current classification system, and there is no convincing evidence that BPD is a variant of an Axis I disorder.

CONCLUSIONS

Although further research should lead to changes in classification, the diagnosis of BPD retains significant clinical utility.

Never good enough--part 1: Shame or borderline personality disorder?

This paper takes a deconstructive approach to the historical, clinical, and social context of the diagnosis of borderline personality disorder (BPD). This is undertaken by providing an overview of pertinent literature, an examination of the diagnostic criteria, a discussion of the development of the shame affect, a discussion of women's narratives and a reinterpretation of the symptoms of BPD as an overwhelming shame response. An argument is developed that shame is an integral but neglected feature in the experiences of mental distress that are characteristic of BPD. This discussion is supported with evidence of shame in narrative quotes from women with a diagnosis of BPD. There are striking similarities between what is currently pathologized as BPD and an overwhelming shame response. Recognizing the influence of shame may assist mental health nurses to provide mental health nursing care that best meets the needs of women experiencing these symptoms.

Disclosure of a diagnosis of borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is a common psychiatric disorder with a prevalence of 1%-2% in the general population. BPD also has the potential to cause significant distress in the lives of patients with BPD and their families. The diagnosis of BPD, however, is often withheld from patients. The purpose of this article is to explore the history of diagnostic disclosure in medicine and psychiatry and then discuss reasons why clinicians may or may not disclose the diagnosis of BPD.

METHODS

The authors review medical literature about diagnostic disclosure and other issues that may affect the decision to disclose a diagnosis of BPD.

RESULTS

The authors discuss the historical precedents for diagnostic disclosure and reasons a clinician may not disclose the diagnosis of BPD to a patient: questions regarding the validity of BPD as a diagnosis, worries about the stigma of the diagnosis being harmful to the patient, and transference/countertransference issues common in the treatment of patients with BPD. The authors cite factors promoting disclosure, such as the ideal of patient autonomy, possibilities for psychoeducation and collaboration with the patient toward more specific and effective therapies, and the increasing availability of diagnostic information available to patients from sources other than their clinicians.

CONCLUSIONS

There are compelling reasons to make the diagnosis the subject of open examination and discussion between clinician and patient, and reasons to believe that disclosure would serve to advance the patient in his or her recovery.

Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders

This article addresses the question whether borderline personality disorder (BPD) can be understood as a variant of bipolar disorder. In the past, borderline pathology has been seen as a variant of psychosis, depression, or posttraumatic stress disorder, but there are important differences between all of these conditions and BPD. The proposal that BPD falls within the bipolar spectrum depends on the assumption that affective instability develops through the same mechanism in both diagnostic categories. There are major differences in phenomenology, family history, longitudinal course, and treatment response between BPD and bipolar disorder, and the findings of comorbidity studies are equivocal. Thus, existing evidence is insufficient to support the concept that BPD falls in the bipolar spectrum.

Stability as a distinction between Axis I and Axis II disorders

Temporal stability has served as a conceptual basis for the distinction between the clinical syndromes of Axis I disorders and the Axis II personality disorders, the latter being viewed as lifelong enduring patterns. However, comparisons of the stability of Axis I and II disorders have been limited. The present review examines findings from three naturalistic longitudinal studies that utilize similar methodology: the Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000), the Collaborative Depression Study (CDS; Katz & Klerman, 1979), and the Harvard/Brown Anxiety Research Program (HARP; Keller et al., 1994). Using a definition of remission/recovery as having no or minimal symptoms for 8 consecutive weeks, the courses of personality, depressive, and anxiety disorders were compared. Though remission/recovery rate at the 2-year follow-up was highest for mood disorders, the probability of recurrence was also particularly high. Personality disorders, with remission rates higher than the anxiety disorders, appear to be less stable than conceptualized. The anxiety disorders had remarkably low recovery rates even beyond 5 years of prospective follow-up. Factors that may explain these findings, as well as implications for future conceptualization of DSM, are discussed.

The development of an attachment-based treatment program for borderline personality disorder

The treatment of borderline personality disorder (BPD) remains controversial. The authors have developed an evidence-based treatment program rooted in attachment theory that integrates research on constitutional factors with environmental influences. BPD is conceived of as a disorder in the self-structure brought about through environmentally induced distortion of psychological functioning, which decouples key mental processes necessary for interpersonal and social function. The primary mental function involved is mentalization, which is enfeebled by an absence of contingent and marked mirroring during development. Treatment strategies target mentalization in order to foster the development of stable internal representations, to aid the formation of a coherent sense of self, and to enable to borderline patient to form more secure relationships in which motivations of self and other are better understood. Destabilization of the self leads to emotional volatility, so treatment also needs to focus on identification and appropriate expression of affect. This article describes some of the techniques used to enhance mentalization within the context of group and individual psychotherapy. Targeting of current symptomatology and behavior is insufficient. Therapists need to retain their own ability to mentalize, maintain mental closeness, focus on current mental states, and avoid excessive use of conflict interpretation and metaphor while paying careful attention to the use of transference and countertransference.

Treatment rejecting and treatment seeking personality disorders: Type R and Type S

An important distinguishing feature of one group of personality disorders is the wish of the sufferer to seek treatment. For another group this wish is rarely entertained. Although there is some variation between different types of personality disorder the wish to change is not confined to any one diagnostic category. A useful subclassification of personality disorders is therefore into Type R (treatment rejecting) and Type S (treatment seeking) personality disorders, and these are defined operationally. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others. It is suggested that this typology is useful for those contemplating treatment with those who have personality disorders.

Borderline personality disorder from the perspective of general personality functioning

The authors extended previous work on the hypothesis that borderline personality disorder (BPD) can be understood as a maladaptive variant of personality traits included within the 5-factor model (FFM) of personality. In each of 3 samples, an empirically derived prototypic FFM borderline profile was correlated with individuals' FFM profiles to yield a similarity score, an FFM borderline index. Results across all samples indicated that the FFM borderline index correlated as highly with existing borderline measures as they correlated with one another, and the FFM borderline index correlated as highly with measures of dysfunction, history of childhood abuse, and parental psychopathology as did traditional measures of BPD. Findings support the hypothesis that BPD is a maladaptive variant of FFM personality traits.

Personality disorder and Axis I psychopathology: the problematic boundary of Axis I and Axis II

The confusion of personality disorders with Axis I disorders can be traced in part to inadequacies of assessment instruments and diagnostic criterion sets. However, it also reflects the absence of adequate conceptualization. If Axis I continues to include early onset, chronic impairments that characterize everyday functioning, then there is unlikely to be a clear or meaningful distinction. Inherent and unique to personality disorders is that they concern a person's sense of self and identity. They are disorders of everyday functioning. Personality disorders have an early onset, characterize everyday functioning, and relate closely to personality functioning evident within the general population; Axis I disorders, in contrast, have an onset throughout adult life, are episodic, and are readily distinguishable from normal personality functioning.

Nidotherapy: a new approach to the treatment of personality disorder

OBJECTIVE

To develop a treatment, nidotherapy, or nest therapy, so named because it aims to alter the sufferer's personal environment rather than symptoms or behaviour, in the management of personality disorders.

METHOD

Case studies, in which analysis of the environmental circumstances associated with the problems of personality disorder is followed by planned adjustment to that environment so that it makes a more appropriate fit for the personality.

RESULT

Sustained improvement was found in two individuals with personality disorder after nidotherapy. Those with persistent and predictable personality attributes are easier in principle to treat than those with episodic or variable problems.

CONCLUSION

Nidotherapy deserves further consideration in the management of personality disorders.

Suicidal and self-injurious behavior in personality disorder: controversies and treatment directions

Contrary to common clinical perceptions, individuals with personality disorders attempt and commit suicide at nearly the same rate as individuals with major depression. In particular, those with borderline personality disorder are at high risk for suicidal behavior and nonsuicidal self-injury. Yet there is significant controversy surrounding the diagnosis of borderline personality disorder in terms of its existence, its definition and symptom structure, its Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis location, and its importance as a contributing factor to suicidality and nonsuicidal self-injury. Furthermore, both suicidal and nonsuicidal self-harm is prominent in borderline personality disorder. There is often confusion between suicidal and nonsuicidal self-injury with one sometimes mistaken for the other. Nonsuicidal self-injury is sometimes met with hospitalization, because it is viewed as life threatening. Alternately, the potential lethality of suicidal behavior is underestimated, because it occurs in the context of multiple low lethality self-harm behaviors. It is possible to view these behaviors as distinct yet on a spectrum in borderline personality-disordered patients. With respect to treatment of self-injury in personality disorders, some recent pharmacotherapy trials have been conducted, though efficacy is often unclear. Findings with respect to psychotherapy, particularly dialectical behavior therapy, a form of cognitive behavioral treatment, are promising.

Personality disorder

It is now respectable to read about personality disorder. It was not always so. Despite the impossibility of practising psychiatry without being aware of the term and the subject matter it describes, it was not appropriate in good psychiatric circles to mention the subject unless presaged by a pause and pronounced with a mocking inflexion that indicated that the words were in parentheses: signposts to somewhere undesirable, usually somewhere in the jungle of forensic psychiatry (a subject about which I write very little in this piece, in an attempt ot redres the balance). I think the reason for this was that personality disorder had such a strong flavour of criticism that, even in a discipline in which stigma confronts us on every corner, its words were the ultimate derogatory label that, once attached, became virtually indelible. Or, as my Landcashire grandmother would say about all unsavoury topics, it was “not very nice and no one really wants to know.”. So research and writing on the subject became almost a samizdat topic, written about in code, discussed in quiet corners between professionals when they could not be overheard, or in proxy phrases such as ‘relationship difficulties’ or ‘patients who are difficult to place’ (Coid, 1991).