Borderline personality disorder (BPD) has come of age.
That's the message in a series of articles in the May American Journal
of Psychiatry examining the history of diagnosis and treatment of BPD and
the achievements and remaining challenges associated with a psychiatric
condition that is among the most troubling—for patients and therapists
Leaders in research, diagnosis, and treatment of borderline personality
disorder agree that what was once a catch-all term originating as a
psychoanalytic category is now a highly refined diagnostic entity for which
there is an abundant and growing body of research and several evidence-based
At the same time, there remain numerous questions to be answered about the
neurobiological basis of the disorder; a number of obstacles to treatment of
BPD—especially as a growing body of evidence indicates that successful
treatment requires expensive, long-term therapies; and a residue of
Leading lights in BPD research and treatment including Robert M ichels,
M.D., Otto Kernberg, M.D., Glen Gabbard, M.D., John Oldham, M.D., and John
Gunderson, M.D., among others, contributed to the series. The series is timed
in honor of Congress's designating May "BPD Awareness Month."
In the article "Borderline Personality Disorder Comes of Age,"
Oldham described the largely pejorative description that attached to
borderline patients 25 years ago.
"A prototypic image of a borderline patient emerged within clinical
settings as an angry, volatile patient prone to reject help, blame others, and
behave self-destructively," Oldham wrote. "Too often, this
behavior was seen as willfully oppositional, and borderline patients were
spoken of as dreaded pariahs. Recommended treatment was generally
psychodynamic psychotherapy or psychoanalysis, often referred to as 'heroic'
and of uncertain or poor prognosis."
In contrast, Oldham described the considerably more informed—and
hopeful—state of understanding about the disorder today: key heritable
risk factors—especially affect ive dysregulation and impulsive
aggression—have been identified, and it is now known that"
[b]orderline pathology is at least partially 'hardwired' involving
brain abnormalities that can be identified by brain imaging
In addition, new findings suggest that inherent hyperactivity of the
amygdala and overreaction to negative facial expressions may correlate with
interpersonal hyperactivity, and that these heritable risk factors interfere
with normal attachment during development.
"For patients with BPD, these combined etiological factors produce
arrested, distorted, or incomplete integration of aspects of self and others,
resulting in early onset and persistence of profound interpersonal
difficulties," Oldham wrote. "Normal early development becomes
derailed, and the crucial developmental milestone of basic trust is not
Gunderson, in the article "The Ontogeny of a Diagnosis,"
offered a detailed outline of the origins of BPD as a "psychoanalytic
colloquialism," a category of patients "bordered" by sicker,
psychotic patients on the one side and healthier neurotic patients on the
other. From there, the conceptualization of the disorder evolved into a"
syndrome," one largely defined by predictable negative phenomena
that occurred within the context of psychotherapeutic treatment.
With the advent of biological psychiatry, research on the disorder began to
grow in earnest along with a better understanding of the features that
distinguished patients with BPD. And in the 1990s a number of creative
psychotherapies—mentalization-based therapy and dialectical behavior
therapy—began to be tested and found useful.
Today, Gunderson said, the stigma associated with the disorder among
professionals continues, even as public awareness of the condition has
grown—as evidenced by an increase in the number of books written about
BPD for the general population (see
Much remains to be learned. "Still unknown are the public health
costs of this disorder, but given the borderline patients' heavy utilization
of psychiatric services; medical complications; involvement in divorce, libel,
and childrearing lawsuits; and their violence and sexual indiscretions, the
costs can be expected to be tremendous," Gunderson wrote. "Also
unknown, despite significant advances, is borderline personality disorder's
core psychopathology and its related neurobiology."
For this reason, the defining clinical features of BPD continue to be
interpersonal ones, he wrote.
So, even as the disorder has evolved from its early amorphous days as a"
psychoanalytic colloquialism," some aspects of a refined
psychoanalytic approach remain highly important in treatment. For instance,
Gabbard presented a case history illustrating the usefulness of transference
interpretation in treatment.
While some patients show a positive response to certain medications, the
effects appear to be short-lived as the core underlying traits of BPD seem to
overcome the usefulness of medication. And the successful
psychotherapies—whether transference based, mentalization based, or
dialectical behavior therapy—require long-term treatment, a major
challenge to successful outcome.
"A major shortcoming of present-day research in the treatment of
borderline personality is the limited time span of randomized, controlled,
clinical trials, contrasting with the widespread clinical impression that
long-term treatments are essential for these patients," wrote Kernberg
and Michels in a lead editorial for the series.
"Borderline patients, 20 or 30 years after completion of treatment,
still show impoverishment of their personality: a lack of effectiveness and
satisfaction in their lives, in their work and professions, and a lack of
stability in intimate love and sexual relationships, in establishing families,
and difficulty overcoming social isolation. The focus on the long-range course
of borderline psychopathology and the effect of interventions on modifying it
constitute a major challenge for future research."
The special series of articles is posted at<ajp.psychiatryonline.org>
under the May issue. ▪