What Is New and What Isn't in Our Understanding of BPD

Just as in the rest of medicine, much of our understanding of psychiatric illness has changed over the years. And much has stayed the same. Completing the update of the expanded, third edition of my book (I Hate You, Don’t Leave Me: Understanding the Borderline Personality—2021), I was struck with how much of our conceptualization of the syndrome of borderline personality has progressed, and how much remains unchanged since the first two editions of the book in 1989 and 2010. I have been particularly intrigued by what is new and what is not since 1980, when the diagnosis of borderline personality disorder was descriptively defined and generally accepted with the publication of DSM-III.

What Has Changed Little

Diagnosis is one area that has solidified with only minor changes over the past 40 years. Prior to DSM-III, “borderline” was an ambiguous term. First invoked by Stern in 1938, it referred to patients he diagnosed as being on the border between neurosis and psychosis. In 1953, Knight resurrected the concept of “borderline states,” and others began to recognize “borderline” symptoms. Kernberg, in 1967, developed the construct of “borderline personality organization,” based on psychoanalytic understanding of defense mechanisms. Gunderson and Singer published in 1975 the first attempts to define borderline personality disorder with descriptive observations. They cited characteristics of affective instability, impulsivity, self-destructive behavior, identity disturbance, impaired relationships, and brief psychotic experiences that they proposed to define the illness. DSM-III adopted this categorical approach to diagnosis, and in the succeeding years there has been little change.

Alternative models for diagnosis have been proposed. These include a dimensional model along a spectrum of degree of illness, outlined in the supplemental section of DSM-5. The World Health Organization (WHO) publishes the International Classification of Diseases (ICD) which defines an Emotionally Unstable Personality Disorder divided into Impulsive Type and Borderline Type. The National Institute of Mental Health (NIMH) has proposed the Research Domain Criteria (RDoC) as a research tool, invoking biological and genetic information for a definitive diagnosis. It is likely that in the future, diagnostic considerations will change.

The general approach to treatment has also remained the same over the decades. Despite some investigations by pharmaceutical companies, no medicine has ever been approved for the treatment of BPD. (Antidepressants, mood stabilizers, and some other medicines have been utilized for collateral symptoms.) “Practice Guidelines” published by the American Psychiatric Association in 2001 affirmed what had long been accepted, that psychotherapy was the only treatment for BPD. Fortunately, over the past 20 years, several specific psychotherapy approaches have been studied and shown to be effective. These include dialectical behavioral therapy, mentalization-based therapy, transference-focused therapy, good psychiatric management, and others.

Regrettably, stigma and misinformation remain associated with the diagnosis of BPD. Where designations of depression or anxiety are more likely accepted with sympathy by many people, the term “borderline” is still often connected to “the crazy ex-girlfriend.” Many professionals continue to approach the disorder with pessimism or avoid patients with the diagnosis altogether. Fortunately, some entertainers and others in the public eye have acknowledged receiving the diagnosis and coping with the disorder. Increased openness about this illness and other psychiatric maladies may decrease such negativity over time.

What Has Changed a Lot

Recognition of biological components of BPD and research into these areas have continued with remarkable progress. Possible genetic markers are being researched. How situational events may affect genetic structure (termed epigenetic) is adjusting our understanding of genetic influences. Hormonal effects are being studied. Neuronal connections between different parts of the brain have been associated with BPD. In the DSM-III description of BPD, “No information” was noted under the heading Predisposing factors and familial pattern. Forty years later we can now recognize that, indeed, there is much information.

Perhaps the most significant change over the years of how we perceive BPD is in prognosis. DSM-II (1968) referred to personality disorders as “lifelong.” Succeeding DSM editions noted them to be “enduring.” For many years, BPD and many other personality disorders were perceived by professionals to be essentially unchangeable and incurable. Long-term studies continue to show that most individuals with the BPD diagnosis improve considerably. Most patients over time will no longer fulfill the symptom criteria that define the diagnosis, and technically would be considered “cured.”

As a clinician, researcher, and writer, I have had the privilege of examining the evolution of our understanding of BPD—what has changed, and what has not. It will be exciting to continue to monitor the beneficial changes that will progress for those who struggle with BPD.