Borderline Personality Disorder is Real - Part I. Diagnostic Validity

The most savage controversies are those about matters as to which there is no good evidence either way.

- Bertrand Russell, British author, mathematician, & philosopher (1872 - 1970)

Is BPD a bona fide psychological disorder? Over at least the last three decades, this question has plagued both BPD experts and BPD-afflicted individuals. In my clinical and research roles there have been many occasions where I have heard the BPD diagnosis disparaged by colleagues as a “garbage bin” diagnosis, or, a “really” a version of another disorder.

But what is the current state of the science on this issue? This is the first post to begin to summarize the literature on this topic. I refer readers with more interest to consult three excellent summaries in the peer reviewed scientific literature that address this issue in greater detail (New, Triebwasser, & Charney, 2008; Paris, 2005, 2007)

Is the BPD diagnosis less valid than other psychological/psychiatric diagnoses?

The 5 criteria for a valid mental health diagnoses have been enumerated in an influential paper by Robins and Guze in the American Journal of Psychiatry (1970):

1) An observable and distinct symptom profile (e.g., prolonged and consistently depressed mood and significant loss of appetite are two symptoms that are distinctive of Major Depressive Disorder);

2) Laboratory studies that can document the pathogenenesis, or, cause of the disorder (e.g., a protozoa parasite causes Malaria);

3) Differentiation from other disorders (e.g., schizophrenia can be distinguished from an alcohol abuse disorder based on the differing symptom profiles);

4) Follow-up studies documenting a characteristic course and outcome (e.g., schizophrenia emerges most clearly in young adulthood and commonly has a course of progressive decline in functioning with age);

5) Family prevalence studies to document familial clustering (e.g., one is more likely to see schizophrenia in relatives of those with the disorder than in relatives of those who do not have the disorder).

BPD does have a distinct clinical profile (criterion 1). Two studies (Clifton & Pilkonis, 2007; Fossati et al., 1999) explored single and multiple category explanatory models of BPD symptoms. Sophisticated statistical techniques were used to evaluate whether the symptoms of BPD grouped together coherently and distinguished themselves from other mental disorders. Both studies concluded that the BPD criteria describe a single, coherent disorder rather than multiple, distinguishable conditions.

BPD does not respond well to treatments developed for other disorders such as bipolar and/or unipolar depression (criterion 4), and BPD has a characteristic outcome and course that distinguishes it from other affective disorders and personality disorders (criterion 4).

Further, there is some evidence of familial clustering (criterion 5). For instance, first-degree relatives of individuals with BPD patients are 10 fold more likely to have the BPD diagnosis than relatives of those who do not have BPD.

Finally, there are no psychological or psychiatric disorders that meet all these criteria for a valid diagnosis. As BPD researcher Joel Paris notes, “Even the most intensely studied categories, such as schizophrenia and bipolar disorder, have serious problems with overlap, lack laboratory tests to identify them, and do not consistently conform to an expected family pattern.”

I hope these science-based rebuttals will be used to challenge those who continue to question this diagnosis, and put to rest some of the “savage controversy” that Bertrand Russel speaks about. The troubling and dangerous myth that BPD is not a “real” disorder hampers research (Why research something that doesn’t exist?) and treatment (e.g., Health insurance companies do not pay for BPD treatment because they argue that is not a “real” disorder.).

In future posts I will address other questions about BPD, such as whether it is better explained as a variant of another disorder such as Bipolar or a “complex” Post Traumatic Stress Disorder (PTSD). This is criterion 3 above, overlap with other disorders.

The bottom line is, if someone states that BPD is not a “real” diagnosis, tell him or her that the scientific literature indicates it is just as real a diagnosis as other established psychiatric disorders such as schizophrenia and bipolar disorder.

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References

Clifton, A., & Pilkonis, P. A. (2007). Evidence for a single latent class of Diagnostic and Statistical Manual of Mental Disorders borderline personality pathology. Comprehensive Psychiatry, 48(1), 70-78. Epub 2006 Sep 2006.
Fossati, A., Maffei, C., Bagnato, M., Donati, D., Namia, C., & Novella, L. (1999). Latent structure analysis of DSM-IV borderline personality disorder criteria. Comprehensive Psychiatry, 40(1), 72-79.
New, A. S., Triebwasser, J., & Charney, D. S. (2008). The Case for Shifting Borderline Personality Disorder to Axis I. Biological Psychiatry, 64(8), 653-659.
Paris, J. (2005). The diagnosis of borderline personality disorder: problematic but better than the alternatives. Annals of Clinical Psychiatry, 17(1), 41-46.
Paris, J. (2007). The nature of borderline personality disorder: Multiple dimensions, multiple symptoms, but one category. Journal of Personality Disorders, 21(5), 457-473.