Why It May Be Time to Eliminate the Diagnosis of Borderline Personality

For the past decade, mental health professionals have debated whether personality disorders fall into categories or dimensions. Rather than being an obscure academic controversy, this debate has practical ramifications for the mental health of millions of people around the world.

On the one hand, having a diagnosis on the books can benefit patients who need documentation for insurance purposes. The contrary view is that categorical diagnoses artificially place mental health conditions into bins based on what are, in reality, variations along dimensional scales.

In this ongoing dialogue, no personality disorder has received more attention than borderline personality disorder (BPD). The term “borderline” is often used in a pejorative sense to refer to people who may seem overly clingy and unstable, lacking boundaries between themselves and others.

You may know someone whom you or others refer to in this fashion, generally in a negative light. The question is whether it’s justified to draw a circle around an individual’s entire personality, provide a label, and leave it at that.

A Global View of Borderline Personality Disorder

The Diagnostic and Statistical Manual-5 (DSM-5), used in the U.S. and Canada, retained what researchers maintained was an inaccurate and antiquated system of personality disorder classification based on categories.

Prior to the publication of the DSM-5 in 2013, there was a widespread belief in the mental health community that categories would be scrapped in favor of a new, dimensional classification system. This didn’t happen, but a compromise of sorts was reached in that the DSM-5 contains what’s known as an alternative DSM-5 model that contains personality dimensional ratings along with severity estimates.

The researchers and clinicians involved in revising the International Classification of Diseases (ICD)-10 into its newest version, the ICD-11, decided to avoid this dual approach and instead adopted a system almost exactly like the alternative DSM-5 model. However, the key here is “almost.” Unable to leave the borderline personality disorder category in the rearview mirror, the ICD-11 authors created a “borderline personality specifier” based on the DSM-5 diagnosis.

According to Fernando Gutiérrez of the Institute of Neuroscience, Hospital Clinic (Barcelona), and colleagues (2022), this last-minute addition to the dimensional system could very well be misguided. Clinicians in favor of retaining the category maintain that there was a need for continuity with previous knowledge and treatment.

Those opposed argue, in contrast, that

The borderline construct is based on unsystematic observation and clinical tradition, and it does not emerge in the empirical literature which maps the organization of personality pathology, including that leading to the renewal of ICD-11 (p. 2).

Potentially a “passport to heterogeneity” (quoting from a previous study), the question is whether it holds up under close empirical scrutiny.

What Is This Thing Called Borderline Personality Disorder?

If there is such an entity deserving of the BPD diagnosis, the Spanish researchers believed they could discover it by administering a set of instruments based on the categorical diagnostic system as well as others using dimensional ratings.

A major strength of this research was the fact that the sample (1,799 adults) ranged from 16 to 76 years old (average age: 40) and included a clinical sample of 324 outpatients with a variety of DSM-5 disorders. None of the clinical patients received a categorical personality disorder diagnosis.

All participants completed a set of instruments based both on dimensions and categorical BPD systems. The dimensional measures tapped the five domains of the ICD-11 system. An additional measure asked participants to rate themselves on items measuring the severity or possible undesired consequences of each dimension, namely: negativity affectivity (losing one’s temper, worrying, and feeling helpless), detachment (lacking friends, avoiding people), dissociality (distrusting others and being callous), impulsiveness, and anankastia or being overly organized. Another scale specifically measured the ICD-11’s borderline pattern specifier (the Borderline Pattern Scale; BPS).

The empirical question became determining whether the BPS would stand on its own as a separate entity from the dimensional scale measures. If so, this would justify retaining the specifier in the ICD-11. The findings showed that although the BPS retained its own inner consistency, as the authors concluded, “it adds nothing to the prediction of severity when the other domains are considered” (p. 5). Thus, the original five domains seem to do a reasonably good job on their own as indicators of an individual’s position along a personality disorder continuum.

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Most importantly, however, scores on the BPS overlapped almost entirely with the items tapping into negative affectivity. Indeed, after making the necessary statistical adjustments, the correlation between this severity index and BPS scores was a remarkable .87 out of a maximum of 1.00. Even so, the authors note that there was a place for specification of BPD, but only as a “particularly intense expression of negative affectivity” (p. 5).

Despite this proviso, the authors were highly critical of the ICD-11, based on their data, for including the BPS specifier: “At worst, it will complicate diagnosis, produce ambiguous research, and lead to a misunderstanding of what borderline disorder is” (p. 5).

How to Help Rethink Your Understanding of BPD

In common speech and the media, the term “borderline” will undoubtedly retain its popularity. There will invariably continue to be jokes about BPD as well as fictional characterizations of main figures in literature and drama. Given its widespread usage, you’ll perhaps find yourself slipping into the labeling of people who seem to intrude on your own boundaries or act in puzzling, impulsive ways.

The Gutiérrez et al. findings throw considerable doubt onto the existence of this unique condition as distinct from its components of, particularly, intense negative affectivity. When you think about what makes a person “borderline,” indeed, it may be this quality to which you respond. Reading down the list of ICD-11 domains, the ones next highest in line in relationship to BPS were disinhibition and detachment. This finding would suggest that it’s not even a simple domain that captures all the complexity of BPD.

To sum up, once someone invents a category label, it can be difficult to think of people’s psychological disorders in any way other than through the lens of an all-or-nothing entity. This more nuanced approach to understanding people based on their underlying qualities rather than by their outward name can have implications that stretch beyond diagnosis and into fulfillment in daily life.

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