Depression was studied in 1621, OCD in the 1830s, Schizophrenia in the late 19th century, and trauma after the First World War. And yet the infamous Personality Disorder is a mere infant in terms of diagnosis. This is especially true of the ‘Borderline’ type. First identified in 1980, the condition has actually been lurking around for quite some time.
But what is Borderline Personality Disorder? Briefly put BPD, is a severe mental illness marked by emotional, behavioural and cognitive instability, relationship chaos, and chronic self-harm. The statistics are shocking: 10% of those with the condition commit suicide, 70% have attempted it. Despite the fact the BPD sufferers account for half of all psychiatric admissions and collectively cost billions , no one is talking about it — nor how the label shapes the outcome.
What’s in a name? Take a tour of the dusty vestibules of psychiatry, from the analyst’s couch to the hospital corridor, and you’ll see how the diagnosis was created and what it says about our deepest held beliefs.
Brain Damage and Birth Defects
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 […] they shed tears without cause, give expression to thoughts of suicide, and bring forward hypochondriac complaints […] In consequence of their irritability and their changing mood, their conduct of life is subject to the most multifarious incidents.
The youthful musings of a psychological undergraduate? Rather the work of pioneer psychiatrist Emil Kraepelin who in 1921 created the excitable personality, a diagnosis soon consigned to the dustbin of history on account of its poor outcome. The good German doctor considered those with the condition brain-damaged from birth.
Nevertheless, as psychiatry dragged its heels into the 20th century, biology was replaced by psychology, Victorian Doctors, by modern Freudians. By the 1930s, psychoanalysts were fighting-back, and new ideas of personality were now emerging.
On the Border of Insanity
In 1937, a Hungarian-American psychoanalyst Adolph Stern stood before the New York Psychoanalytic Society musing on a strange group of patients who’d been frequenting his clinic. Hypersensitive, paranoid, depressed, anxious, and altogether unstable, they seemed to exist on the ‘border line’ of insanity.
Stern admittedly found them ‘difficult’ and the fact they’d fly off the handle or collapse into a heap at any moment made them impossible to treat. These are our BPD ancestors; mad, bad and dangerous to know, they often languished in old-fashioned asylums unable to get help.
While Stern was wrong about prognosis his symptom checklist was pretty accurate. He was also pretty much right about the cause. Such patients were sick, not due to brain damage, but because of ‘not being, or having not been sufficiently loved in childhood.’ After Stern’s groundbreaking essay, a spate of new research soon followed.
Chaos all around
In 1942, Freud’s disciple Dr Helene Deutsch called Borderline patients As if Personalities, strange individuals, who lived amongst ordinary folk acting as if they were normal, but in fact were not. As If personalities survived by insidiously copying others; nevertheless this chameleon-like ability to blend in eventually betrayed itself. According to Deutsch, those with the condition were such good copycats because they were themselves dead inside.
A few years later in 1947, Dr Melitta Schmideberg, complained Borderline patients lived lives of absolute chaos; in her words ‘something is always happening.’ One psychiatrist called it Extractive Disorder, because sufferers extract life from others, another called it Hysteroid Disorder, because patients were hysterical. In 1949 Paul Hoch and Phillip Polatin, concluded BPD was actually ‘a pseudoneurotic form of schizophrenia.’ Beneath superficial surface-level calm was psychosis.
Finally, 1952 Robert Knight following on directly from Stern said these subset of patients had no sense of self, and so in times of stress succumbed to ‘borderline states’ of madness. This last idea was one that stuck.
Perusing the early literature, it soon becomes clear, clinicians have never understood this illness now called BPD. Like Victorian taxonomists they did well in listing characteristics, but their assumptions about the condition were wrong. While they bandied about labels, the Borderline individual suffered not only account of the illness, but also lack of help. Borderline became a synonym for insanity for the simple reason it didn’t conform to traditional interpretations. Brain-damaged from birth, or psychologically warped, through the prurient puritanical eye of Freudianism, patients were forevermore untreatable.
A Divided Self a Broken Heart
By the mid 20th century, new pioneers arose. Latter-day psychoanalysts began to extend the limits of treatability, Otto Kernberg, a Jewish-American psychoanalytic psychiatrist led the charge. A wise old owl of the New York Presbyterian Hospital, he was convinced BPD patients weren’t just experiencing borderline states of madness, their internal world was structured by them.
In 1967 he published his article Borderline Personality Organisation and ushered in a new diagnosis. In his view BPD is predicated on the primitive defence mechanism of splitting. Individuals with the condition have been unable to overcome the good-mother bad-mother dichotomy first experienced in infancy, and as a result split themselves and world in half. As result, BPD patients see all relationships in extremes: Hero and villain, saviour and persecutor, victim and torturer. The result of this is relationship chaos, as well as cognitive, emotional and behavioural instability.
Despite providing little evidence for his theory Kernberg has continued to bang the drum for psychoanalysis. His ideas remain compelling and influential. However, an establishment-figure from the start, Kernberg’s assumptions leave a lot to be desired. It’s no wonder most individuals in that era diagnosed happened to be women — this was gendered condition tied in to the myth of female hysteria. It would take a heroic female outsider, to challenge the Freudian fraternity, but in 1991 one woman did exactly that.
The Biosocial Theory of BPD
At the age of 17, a young suicidal girl by the name of Marsha Linehan was locked in the seclusion room of a mental hospital in Connecticut. Diagnosed as schizophrenic, and cited one of the most disturbed patients on the ward, she went on to become a world-renowned psychologist and in the creator of what was until recently the only evidence-based treatment for Borderline Personality Disorder, Dialectical Behaviour Therapy.
Linehan’s groundbreaking work was born of personal experience. The fact that her true illness was not Schizophrenia but rather BPD — a fact she announced 50 years later at the same mental hospital she was once incarcerated in — was beside the point. Her chronic suicidality was due the iatrogenic harm caused by clinicians who reinforced the idea of illness; an idea she later weaved into her therapy. She claimed when a biologically vulnerable individual is placed an invalidating environment BPD is the result. Validation on the other hand leads to recovery. Linehan eventually escaped the hospital, but made a vow to one day go back and rescue others.
Bursting onto the scenes in 1991, Linehan experienced a lot of push-back. How dare this woman from the backwoods of Tulsa, challenge the time-worn traditions of psychoanalysis? At the time, behaviourism was on the rise. Old assumptions about the Id, Ego, and Superego, where being dismantled; Linehan who spent her early career researching suicide, as sociological phenomena, used data to chastise Kernberg and his friends for positing theories without evidence. She then came up with something better; a therapy which now has one of the highest rates of recovery, draws on cognitive-behavioural tools, mindfulness but ultimately the power of validation — what you feel is valid, however there’s still a better way.
Mentalising for Mental Health
Around the same time Linehan was locked-up in Connecticut, across pond in Great Britain, a Hungarian refugee was being treated for suicidal thoughts at a mental health clinic in Hampstead, London. The year was 1967, and while Peter Fonagy, was lying on the analyst’s couch gushing about his old Ford Anglia, the therapist broke script, remarking ‘that is a wonderful car Peter.’ It was the impetus for the young boy’s recovery.
Fonagy still resides at that same clinic, now renamed the Anna Freud Centre, not as a patient but chief executive and leading psychologist. Over the last fifty years has dedicated his life to understanding BPD which he believes is the result of poor mentalisation; A word used to describe our ability to infer and imagine mental states experienced in ourselves and other people, personality-disordered individuals just don’t have it. It was never taught. The result of this is deficits in understanding and burgeoning instability.
In the early 2000s Fonagy created Mentalisation-Based Treatment (MBT) a new line of treatment for personality disorder which aims to help clients recover mentalisation skills via collobrative reflection. While it’s not without critics — many argue mentalisation is a syonomn of empathy, and therefore stigmatises BPD individuals further — it’s evidence-based approach, and high success rate, makes it a serious competitor of Linehan’s DBT.
As of Today
Brainscans and Genomes
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 in some unexpected news, scientists have discovered a brain can be Borderline; with fMRI scans revealing significant abnormalities in the cerebrum of sufferers, including an overactive amygdala and a prefrontal cortex that’s half asleep.
Geneticists are also investigating several genes implicated in the onset of BPD, the most promising being the serotonin transporter gene 5HTT, which relates to impulsivity. We may soon find out why the risk of inheriting BPD still hovers around 45%.
At the same time, new and old therapies have suddenly come into fashion. Dr Jeffrey Young’s Schema-Focused Therapy, which looks at the role of cognitive schemas in the emergence and maintenance of personality disorder is vying with Richard Schwartz’s Internal Family Systems Therapy to be the next best treatment. Meanwhile, Francine Shapiro’s Eye Movement Desensitisation and Reprocessing (EMDR) is in vogue, and claims to help sufferers process traumatic memories by rapid eye movements. This itself speaks of perhaps the most profound change to take place in psychiatry: Borderline Personality Disorder has been reconcieved as a form of PTSD.
It’s now well-established trauma is in fact ubiquitous in the histories of those diagnosed with Borderline Personality Disorder. Some psychiatrists are even going so far as to rename it Complex-Post Traumatic Stress Disorder. This is very much in keeping with the times and at the very least it’s now considered incontrovertible BPD is at least caused my trauma. Or is it? Welcome to a new battlefront: Bigwigs at Harvard, Yale and other research universities say PTSD and BPD overlap but are in fact different — others disagree. Some outliers go so far as to call BPD, Dissociative Identity Disorder, a new name for an old diagnosis; that of Multiple Personality Disorder. Are there several selves inside a single personality? Or is it just another name for Knight’s ‘Borderline States’? History might be repeating itself.
The most heartening news to emerge this century is that individuals with Borderline Personality Disorder do get better. A longitudinal study conducted by Dr Mary Zanarini suggest recovery rates of 60%, some put it as high as 90% if measured by symptom remission. While relapse is possible, the rate of recovery grows exponentially with each passing year.
Mental Health Heroes and Villains
The wider movement to de-stigmatise mental health conditions has even extended to an illness once confined to the hinterland of public opinion. Due to lingering stigma, BPD was until recently an illness which daren’t speak its name. However 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.’ Meanwhile celebrities like Brandon Marshall and Pete Davidson have spoken candidly about their struggles with the condition, taking the shame out it, while advocating better treatment. There are now Facebook groups, Instagram pages and YouTube videos spreading awareness.
The dark side of this, is that the proliferation of the diagnosis both in clinical settings and on social media, runs the risk of delegitimising it completely. The cool and trendy topic of films and TV shows, belies the 1000+ A&E admissions each year. It hides the fact that 20% of prisoners are languishing in jail because they couldn’t get help. It negates the terrible statistic, that 10% of those with this condition die by their own hand.
Why is that? The usual line is that healthcare systems are unequipped, but we’ve seen how states mobilise in more pressing crises. The truth is, stigma is built into the diagnosis and its history. Clinicians don’t like BPD patients, and that’s not only on account of their behaviour, but also lingering attitudes which can be traced back over a 100 years. One on hand it’s a catch-all term to throw at every ‘difficult’ patient, on the other its deliberately avoided if the patient is viewed more favourably.
Today’s idea of “Personality Disorder” should also reveal how the diagnosis and progonisis are shaped by context. This is the story of how the world’s worst mental health label came into existence. When we see it we are also looking at an anagram of history; a mirror to culture wars where battles are fought between from university halls to hospital corridors. Finally we see ourselves. From hidden unconscious energies of neuroses and psychoses, to attachment, abuse and everything in between, this is a condition which reflects are own prejudices but also what we want believe about ourselves.
Still unique and ever controversial, behind the label is the individual. By bestowing a name we allow for better treatment; but for the sufferer it’s better to get the treatment and then renounce the name altogether.