Borderline Personality Disorder: What’s in a Name?

Depression was studied in 1621, OCD in the 1830s, Schizophrenia in the late 19th century, and trauma after the World War I, and yet the infamous Personality Disorder is a mere infant in terms of diagnosis. This is especially true of the most famous, or infamous ‘borderline’ type. BPD a much maligned condition was only identified in 1980 in DSM III. And yet its been lurking around for quite some time.

‘The patients display from youth up, extraordinarily great fluctuations in emotional equilibrium […] They fall into outbursts of boundless fury […] the colouring of mood is subject to frequent change […] irritable and ill-humoured, also perhaps sad, spiritless, anxious, they shed tears without cause, give expression to thoughts of suicide, bring forward hypochondriac complaints […] In consequence of their irritability and their changing mood, their conduct of life is subject to the most multifarious incidents.’

Multifarious indeed! An extract from a casual psychiatric lecture at some unnamed modern hospital? No, Emil Kraepelin wrote this down in 1921! The diagnostic criteria for what he called the ‘Excitable Personality’ was established. What we now know to be BPD has a symtom checklist dating back a century and beyond. Back then it was a wastepaper-basket diagnosis but how have things changed, if at all? Today there is controversy and contention surrounding the condition, not least its name — pejorative or accurate — character flaw or mental illness? To understand the label we have to understand it’s history.

After Kraepelin created the ‘excitable personality’ and established its aetiology as a congenital brain defect, early psychoanalysts staged a fightback. As pyschiatry dragged its heels into the 20th century, biology was replaced by psychology, Victorian Doctors, by modern Freudians.

Adolph Stern and Robert Knight two american psychiatrists can be credited with naming the illness, ‘borderline.’ Both believed patients were indeed just that, hovering on he precarious line between neuroses and psychosis. The test to decide which side of the ‘border’ you fell upon depended on whether reality remained intact in times of stress.

By the mid 20th century, a few decades later, pioneers arose. Latter-day psychoanalysts began positing the outrageous suggestion that BPD was not only a psychological illness, but that it could even be treated. Otto Kernberg, a jewish-american psychiatrist led the charge.

In his view BPD is predicated on the defence mechanism of splitting or in layman’s terms ‘black-and-white thinking’. People suffering Borderline Personality Disorder had inevitably experienced stormy and anxious attachments to their caregivers while still in their infancy, the effects of which were devastating: If a parent vacillates from love and affection, to anger and rejection, a child will grow up to have many problems. Unable to transcend this either/or approach, he or she will go into adulthood subject to the whim of chaos, what was now increasingly called ‘borderline.’

Whatever can be said about psychoanalysis, the early practitioners should be championed. They were the first to put the BPD on the map, first to categorise its symptoms, and first to offer treatment when the rest of the believed it hopelessly irremediable. After the work of Otto Kernberg, BPD belatedly appeared in DSM III. Even to this day the classification remains strikingly the same. The 1980's was a time of great innovation and research, and paved the way for the most groundbreaking therapy of all.

at the age of 17, Dr. Marsha Linehan was in the midst of a crisis. Locked in the seclusion room, of a mental institution, in Connecticut, and cited as one of the most disturbed patients on the ward, who would have thought she would not only recover, from the illness, but create the revolutionary therapy to treat it.

Dialectical Behaviour Therapy, or DBT for short, is a radical form of cognitive-behavioural psychotherapy which places a core emphasis on ‘dialectics’. It starts with a belief in opposites, the most important of which is ‘acceptance and commitment.’ A complex mix of Hegelian philosophy and buddhist wisdom asks BPD sufferers to not only see opposites but learn to transcend them. That old defense mechanism of splitting must be respected, but ultimately overcome.

‘Validation’ is another core treatment principle. According to Linehan’s Borderline Personality Disorder, has two causes, one, a genetic vulnerability and two, an ‘invalidating environment’ in childhood. With DBT the emphasis is always on compassion; sufferers are doing the best they can, with the limited skills they have. Whether environmental trauma or biological bad luck patients can learn to regulate the storms within. The results are now confirmed: A disorder once considered untreatable has now become a good prognosis condition.

In the final years of the 20th century, psychiatry experienced a high-tech revolution, and once more the neurological component to mental illness became apparent. Indeed some unexpected news has arrived. Advancements in genetics and neuroscience have shown Borderline Personality Disorder has a hereditary component, and whats more, people with the condition have recognisable brain structure abnormalities. Rather than be a cause for alarm we have every reason to be hopeful!

Study after study has shown people with Borderline Personality Disorder do get better! It may take some time, even decades, but 80% of all sufferers eventually go into remission. Marsha Linehan is the embodiment of such a prognosis but the statistics now prove it. It is not only observed in practise, but in science as well.

Now here we are today, on April 1st 2008, the US House of representatives passed an unanimous vote on resolution 1005 to make May the ‘Borderline Personality Disorder Awareness Month.’ We owe a huge debt to the early pioneers from bringing this castaway diagnosis in from the cold.

However as of 2015, treatment is still lacking and stigma rife. It is not so much the diagnosis itself but the way we use the label, that leads to problems. One day it will be relabelled ‘Developmental Trauma Disorder’ as suggested by Bessel Van Der Kolk until then we have work to do. As we approach the centurion of Kraepelin ‘excitable personality,’ and its multifarious symptoms, lets make sure we won’t wait so long for good treatment for all.