The Myth of the Borderline

I have not been comfortable with the diagnosis of Borderline Personality Disorder since it emerged in the 1980’s. Although it has been clearly described in the Diagnostic and Statistical Manual of Mental Disorders since the Third Edition (we’re now using the Fifth Edition) the diagnosis has been misused and become, in my humble opinion, irrelevant.

Back in the 80’s as people diagnosed as Borderline began to appear in the community clinics in which I worked, I was struck by two things: these people were all female and they all had significant histories of abuse as young children. As you can see from the behaviors and symptoms that describe the diagnosis, a person considered Borderline can be difficult to work with. “Borderline” quickly became a designation for any patient who was difficult to deal with and became a negative label. In meetings of clinicians that involved case presentations it was not uncommon for someone to announce: “Oh, they’re Borderline” as a way to dismiss any efforts to help this person. Many colleagues refuse to treat people with this diagnosis as they want to avoid the negative interactions.

It wasn’t until a few years ago when clinicians like Bessel Van Der Kolk reframed this diagnosis as more descriptive of a trauma survivor that some of us began to feel validated as clinicians. In his best selling book “The Body Keeps the Score”, Van Der Kolk illustrates that the mood fluctuations, behavioral outbursts and resistance to treatment are logical responses to trauma. Instead of “bad behavior” it can now be understood as defensive actions to maintain a precarious sense of safety.

Thanks to research like the ACE’s study (Adverse Childhood Experiences) we now know that long-term trauma in childhood may result in changes in brain functioning. Some of these typical changes are: hypersensitivity to stimuli & quicker to “sound the alarm”; less ability to remember experiences to use in interpreting danger or safety; slows functions, including cognition and attention.

We also know treatment such as Dialectical Behavioral Therapy (DBT), Trauma Informed Care and treatment based on the Seeking Safety format can be much more effective for people who have been diagnosed as “Borderline”. Unfortunately, many of my colleagues are not familiar with these models and fewer are trained to provide this type of care.

I continue to see too many people who have been mistreated in the healthcare system because they are perceived only as “Borderline”. As therapists we need to look beyond the behavior and seek to understand its purpose.