Borderline Personality Disorder – Useful Diagnosis or Stigmatizing Label?
By JP Sutherland
Deidre sat with her knees pulled up in a seat in the corner of the ER waiting room. The misery of her last few days was now laced with anger, and while it was the misery that had led her to buy the bottle of pills for an overdose, it was the anger that finally led her to unscrew the lid and take a handful.
Deidre had been my patient on the acute psychiatry unit twice in the last week, and each time she had discharged herself against medical advice. I had been reluctant to readmit her, doubtful of what value a second quick admission could have when so many previous hospitalizations had failed to alter the trajectory of her tumultuous adult life, and I had deliberately avoided using the Mental Health Act to detain her against her will. After the second self-discharge I had set my mind against continuing this pattern any longer, but I was unaware that she was already back in the ER, within a couple of hours of storming off our ward.
As she felt the pills beginning to make her drowsy, Deidre looked around at her fellow patients in the waiting room, and realized that none of them seemed to have noticed her. She reached into her pocket and drew out the bottle again, and noisily took another handful. Finally, as she began to feel the first hints of an impending slide into unconsciousness, she reached into her bag and took out a pen and paper. Having written her message, she then removed a shoelace and used it to tie the paper round her neck like a bib. The last thing she saw before finally going under was the commotion amongst her neighbors, who were now staring at the sign which proclaimed in capital letters ‘I AM TAKING AN OVERDOSE’.
“That diagnosis.” I repeated. “You mean borderline personality disorder?”
“Yes,” she scowled, “that’s just a label for people you don’t like and can’t help.”
The Diagnostic and Statistical Manual (DSM) is the psychiatrist’s handbook for how to diagnose mental illness. Now in its 5th edition (DSM-5) it lists diagnostic criteria for all psychiatric disorders. Having used it for so long I take it for granted, as a heavy tome that lies on my desk for occasional reference when a patient brings me a diagnosis that I only rarely see. But as a trainee I was awed by its size, and resented its existence as one of the many volumes that I would be required to memorize for my final exams. To the public I expect it appears as unintelligible lists of criteria, as well as an appalling catalogue of all the different ways in which someone’s mind may let them down. It is an imperfect document, to phrase it politely, and each new edition generates a further round of heated debate about what should and shouldn’t be ‘in the DSM’. But of all the contentious and problematic chapters, it is the one describing personality disorders that is the worst, most flawed, and the one that makes people angriest.
Deidre needed an admission to a medical ward in order to treat her overdose and protect her liver from the delayed, but potentially fatal, effects of the medication she had taken. Once she was through the danger period, then I was consulted to see her to determine further plans, which is when I first heard about her overdose in the ER.
“Of course, I didn’t want to die”, she told me angrily, “do you think I would have written a sign telling everyone, if that’s what I had in mind?”
“So, what was it then, Deidre, if not a suicide attempt?”
“I wanted the pain to stop.” She said, touching her head to remind me that this was psychic pain, rather than anything that could actually be helped by the analgesics she had used to overdose. “And I was mad at you too, for making that diagnosis.”
She sat up in her bed, eyes averted now, as if fearing my response. I had grown used to dealing with the instability in her mood which would see her in tears one moment, before nonchalantly recovering and setting out to challenge me on some new subject. But now I saw a subdued young woman, uncertain of her future, and worried about what she might have done.
“That diagnosis.” I repeated. “You mean borderline personality disorder?”
“Yes,” she scowled, “that’s just a label for people you don’t like and can’t help.”
“Deidre, that isn’t true.”
“It’s what people say.”
“Yes, I know they do. But we do have very specific treatments to offer.”
“I don’t care, because that’s not my diagnosis. I’m depressed.”
Personality disorders differ from almost all other mental illnesses in that they reflect problems arising from an individual’s basic make-up (their personality) rather than an illness that arrives at some point in time, and is a departure from who the person was before. In someone suffering from depression or schizophrenia we recognize a pre-morbid period, before they became ill. Whereas someone with a personality disorder has always been that way, since the end of adolescence (when we arbitrarily declare the personality established), and often through childhood as well. Declaring that someone’s personality is in itself ‘a disorder’ is a major step for anyone to take, and is often received badly. So, what grounds do psychiatrists have to make such pronouncements?
One approach to deciding what personalities are disordered would be statistical, and to arrange them on a spectrum. Consider obsessional organization as an example. Some people are more precise and obsessional, such as doctors in general and myself in particular, whereas others are more happy-go-lucky. While acknowledging a natural variation across a range of individuals, one could draw a line and say that those people beyond a certain degree of obsessionality have a disorder (which DSM-5 would call obsessive compulsive personality disorder). Such an approach might make sense scientifically and statistically, but isn’t so much use clinically. Instead, the DSM defines a personality disorder as something that causes significant distress, or impairment in functioning. Hence my obsessionality is a personality trait, but doesn’t cross the threshold to a disorder, because I’m not distressed by it. I would also argue that it not only fails to impair me, but makes me more functional, by reliably getting things done on time. Usually.
“Deidre, why don’t I show you the criteria for that diagnosis, and then you can tell me how much they fit you?”
She didn’t answer, but I took her silence as permission to proceed, and opened up the book.
“‘Frantic attempts to avoid real or imagined abandonment’”. I read the first of nine criteria.
“See! They say ‘frantic’. That’s just the kind of negative language I was told to expect from you psychiatrists. You’re biased against us from the start.”
“Hmm. I have to admit that I would prefer something phrased more neutrally. But how about the meaning of the phrase. Do you think you react that strongly to abandonment?”
“You’re thinking about Roger?” She said, referencing a former boyfriend, whose departure had led to a previous overdose and hospitalization. “Maybe.”
“’A pattern of unstable and intense interpersonal relationships…’” I hadn’t even finished reading the next criteria before she answered.
“Oh yeah, that’s fair comment.”
And so we proceeded through the list that sequentially laid out the impulsivity, unstable mood and anger, and wrist cutting that typify someone suffering from this most challenging disorder. Challenging that is for both the person at the heart of it, and their friends and family, and also their healthcare providers. As we got to the end of the page she looked up.
“OK, I guess that’s me. So what?”
“It means a couple of things. First, it means that what you’re going through has a name, and is a recognized disorder, it’s not just you…”
“Not just me fucking things up. OK, I get it. What’s the other thing?”
“There’s a treatment. It’s called dialectical behavior therapy, and I can refer you to our local program.”
“You mean you’re passing me off to someone else? I thought you cared!”
“Deidre, I do. And no, I’ll keep seeing you until the program starts. And then if we meet less often once you’re involved with them, I’ll stay in touch and resume seeing you properly afterwards.”
“How about medication? I’m better with that than sitting around talking.”
“Medication doesn’t do much for this diagnosis I’m afraid. I can continue the antidepressant and occasional benzodiazepine for now, but we’ll be looking to cut them back once you get into therapy properly.”
“There’s no effing way you’re stopping my Ativan. It’s the only thing that calms me. So if you plan on stopping that then you can take your stupid personality diagnosis and stuff it.”
I had been feeling a thaw in our interactions as we worked through the DSM and she saw herself reflected in its descriptions, but now I had lost her again. I tried talking for a while longer, but her hostility shut me out like a wall, and I gently withdrew.
She smiled. “I’ve been pissed off with you before.”
People have been classifying illness for thousands of years, since the days of Hippocrates or earlier. Arranging things in classes is a most human trait, appearing to bring order to an otherwise chaotic world. But the word ‘appearing’ in that last sentence is as important as ‘order’, since many classifications appear impressive, until the passage of time reveals their limitations. For example, melancholia was an ancient label for what we would now call depression, but falsely attributed it to an excess of ‘black bile’, and is no longer used. And the pitfalls of classification were never better debunked than by the Argentinian author Jorge Luis Borges, who created a fictitious classification of animals including ‘those that belong to the emperor’, and ‘those that look like flies from a distance’.
Nonetheless, science needs a classification of some sort as it addresses an area of knowledge, and being science it can work with a theory for a while before dropping it in favor of a better supported idea. The DSM has been doing exactly this with mental illness, and it remains a work in progress.
The most positive effect of the DSM has been to make clinicians reliable in their diagnoses. Reliability in scientific terms means consistency, and whether different psychiatrists seeing the same patient will make the same diagnosis. It’s a very basic requirement, and is contrasted with validity, which describes whether the label is accurate or not. The DSM has made us reliable, but the validity of our diagnoses remains uncertain, and will need advances in the understanding of mood disorders and psychoses before we can progress further.
Reliability may seem like an obvious requirement, but prior to the release of DSM III in 1980, psychiatric diagnosis was highly unreliable. DSM II had described what a typical diagnostic presentation would look like, but without specifying what was necessary. The most dramatic example of how this caused problems was shown in a research study by Robert Kendall and colleagues in 1971 that compared the diagnoses of American and British psychiatrists. Doctors on opposite sides of the Atlantic were shown videos of patient interviews, and asked to make a diagnosis. The results showed that American physicians diagnosed schizophrenia almost twice as often as their old-world counterparts, demonstrating the hopeless unreliability of diagnosis before DSM III. It also led to the joke that the best way to treat schizophrenia in the USA at that time was to get on a plane to Europe, and find on disembarkation that the diagnosis no longer applied.
DSM III answered this problem by specifying exactly what was required for each diagnosis, usually in the form of needing X number of symptoms from a list of Y possibilities for a time period of Z. It’s a basic formula, but it achieved the desired effect that meant all clinicians were now speaking the same language. Whether what we have to say accurately depicts what is going on in the brain is another story, but in most areas of mental illness this is as good as it gets for now. For personality disorders it is more arguable how distinct the ten disorders really are, and whether personality might be better described by the psychologists’ ‘big five’ personality dimensions of extraversion, agreeableness, openness, conscientiousness, and neuroticism. But the DSM sticks with its list, and so we psychiatrists have to as well.
Deidre had initially refused when told that my proposed treatment was psychotherapy rather than further medication trials. Then, over the succeeding weeks and months, we fought over whether she would or wouldn’t accept the referral. And I say ‘fought’ because at times it seemed like a battle. I would remain calm (at least externally) as I patiently set out the reasons for referral, and she would sometimes accept, and even do so enthusiastically, before returning in the next session and telling me that she had overdosed, she thought I was a fool, and that she refused to be referred elsewhere.
Such instability and inconsistency are hallmarks of a borderline personality disorder, and make the job of a clinician notoriously difficult. Countertransference is the Freudian word for how clinicians feel about their patients, and borderline personality disorder frequently creates a negative countertransference in someone’s healthcare team. Deidre’s suicide attempt in the ER was a good example of this. She had obviously put her life in real danger with the overdose, thereby requiring intravenous antidotes to rescue her. But at the same time she had organized her own rescue, by choosing the ER waiting room for an overdose, and making sure that she would be discovered by writing a sign. Such opposite and self-contradictory thoughts typify the disorder, and can make an inexperienced health care worker angry at the situation.
As I had completed Deidre’s charting on the medical ward, I overheard some of the usual phrases from staff such as ‘If she wanted help then why self-discharge from the ward?’, together with ‘If she really wanted to die then why make sure that someone found her?’ and ‘It’s such a waste of our time and resources.’ These reactions highlight the danger of diagnosing a personality disorder, because when healthcare workers see the label before meeting the patient, then they sometimes adopt these attitudes in advance, and it may bias their approach.
I know that I am not wholly free from such negative thoughts myself, but I have learned how to manage them. The best antidote to such a negative countertransference has been to fully understand the individual, and in particular learn about their childhood. Many people with a borderline personality disorder have suffered through a difficult upbringing, and Deidre was no exception. In the earlier days of our contact, she had told me about her father’s mercurial temperament, and how she never knew if she would be idealized as ‘my favorite daughter’, or dismissed as worthless and told she was doomed to failure in all she attempted. And worse, much worse, was how his positive endearments veered towards inappropriate intimacy, and how the negative ones sometimes led to violence. Such gross inconsistency in parenting leaves a mark, and is one route to a borderline personality disorder in adulthood. So, when I felt my anger at Deidre’s behavior rising, I only had to remind myself of her upbringing, and how she came by her borderline traits honestly, in order to calm down again and control my countertransference. At least, that’s what usually worked.
“Why is it taking so frigging long for DBT to start? Doesn’t the health service care about people with mental illness?”
“That’s a fair question Deidre, but I’m afraid that nine months is about usual for these referrals.”
“It’s prejudice against the mentally ill, that’s what it is. Especially against borderlines. Everyone hates us, don’t they?”
“That’s not fair. Remember that the wait for hip surgery is now over a year. I think all areas of healthcare are stretched.”
I meant what I said, and it was certainly true. Yet I also wondered how little mental health care was prioritized by our management. Over my career I have been pleased by the slow reduction in the stigma towards mental illness that I’ve seen, yet there is no doubt that there remains considerable discrimination against psychiatric patients. This is most notable outside healthcare settings, yet I wonder how much it still influences budgetary decision making in the board rooms that lie high above us, on the tenth floor. Keeping these worries to myself, I returned to the business at hand.
“It should only be another couple of months now Deidre, and I can give them a call to check up on the wait list if you like.”
“I guess. I’ve got over my indecision about the referral. But I still worry about what it’s going to be like. If they piss me off, then can I just come back here?”
“I’ll be expecting to see you when you leave the program, but that should be when you all agree that it’s finished. You probably will feel ‘pissed off’ at some stage won’t you, that’s something you struggle with.”
She smiled. “I’ve been pissed off with you before.”
“You certainly have. But the staff at DBT will expecting some of that. After all, they are the borderline personality disorder experts.”
“I’m worried that I’ll overdose again when things go wrong.”
“If things go wrong,” I said, though her choice of conditional word was probably as likely as mine. “You haven’t overdosed in what, six weeks now?”
She looked down.
“There’s one last week you don’t know about…” she said, leading us off into a further discussion of her current safety and recent stressors.
One of the many charges that the DSM has to face for classifying personality disorders is the lack of effective treatments for most of them. A scientist would answer that such classification is a necessary step to take even before a treatment is available, but that would be an unsatisfactory answer to the individual whose very nature has been labelled as a disorder, only to find that their psychiatrist wouldn’t be able to offer much to help. This sad situation applies to most of the personality disorders – paranoid, schizoid, anti-social, narcissistic, dependent, avoidant and others – but borderline personality disorder is the exception, with the most clearly defined treatment.
Marsha Linehan, an American psychologist, developed dialectical behavior therapy (DBT) in the 1970s. It is an intensive program of psychotherapy, requiring individual and group therapy sessions multiple times per week. It focuses on themes of tolerating distress, recognizing and managing one’s emotions, and increasing interpersonal effectiveness. Describing it like that makes it sound dry and academically detached, but when evidence emerged that it would substantially reduce overdoses and hospitalizations, then the mental health community sat up and paid attention, resulting in DBT clinics in most major cities.
The program is intensive for a few months, and then gradually enters a phase of stabilization, with less frequent sessions, allowing someone to hopefully resume a more normal life, such as returning to work. The response rate to treatment is as high as fifty percent, though there is no shortage of people self-discharging from the program, or only benefitting a little. But if DBT provides one way out of this most debilitating condition, then I was long enough in the tooth to have seen another.
Borderline personality disorder has many traits that appear immature, in that they might be expected in someone much younger. Young children have unstable moods and anger, and people just accept that, without looking for any label of mental illness. In that way borderline personality disorder can be viewed as a disorder of immaturity, maybe because the natural process of growing up has been so disrupted by their background. This allows the passage of time to be another therapeutic factor in an individual’s recovery. A decade or two may make a difference to the intensity of someone’s symptoms, and if that time has been spent in more stable relationships, and included DBT training, then I have indeed seen the chances of recovery approach the published 50%.
This makes borderline patients the most treatable of all personality disorders, though a fifty per cent recovery rate after many years would hardly strike anyone as spectacular, particularly when psychiatry can manage 80% recovery rates in a few months in its most common disorders of mood and anxiety.
*****************
“That’s a new book,” said Deidre, pointing over to the side of my desk where the DSM sits, ready for quick reference. “It used to be red.”
“You’re pretty observant today. It’s a new edition of the DSM. DSM-5. And, as you can see, it’s purple.”
“How often do they change it?”
“Every ten or fifteen years. I can’t remember if you were seeing me when DSM III was current. That one was blue.”
“I haven’t been seeing you that long. Sheesh.”
“Sorry, I tend to forget.”
“Well, I don’t. I first saw you ten years ago. Then we took a break while I did DBT, and I’ve been back again for 4 years now.”
It was true that I tended to forget just how long I had been in practice, and how long some patients had been seeing me. Continuity of care is an important factor in helping someone stay well, and I tend to keep seeing patients for the long term if they have been more severely ill, or suffered with frequent relapses. I have to see them much less frequently in order to allow space for new referrals, but I do have a lot of long-term patients on my books.
I felt a little parental, and proudly parental at that, so I paused to better savour a good outcome to a most challenging journey, before dropping a small diagnostic bomb.
“Hopefully they’ve thrown out borderline personality disorder as a diagnosis. I still hate the label, even after all these years.”
“No, it’s still there. Though interestingly, the whole chapter on personality disorders almost got replaced.”
“Really? Why didn’t it?”
“The suggested replacement was thought to be too complicated for daily use by clinicians, though it was certainly a better classification in many ways.”
“Did the alternative chapter still have ‘borderline’?”
“Yes, though the criteria were spelled out on different dimensions of personality. More complicated, like I said.”
“Whatever. I was hoping that I could lose the damn label by now.”
“Well, let’s see if you can.”
“What do you mean?”
“Why don’t we go through the criteria again and see how much they fit?”
Deidre looked nervous.
“Do you think I don’t fit?”
“I’m not sure. You’re obviously much less troubled by it. Maybe I couldn’t even make the diagnosis now.”
“OK. Let’s do it.”
I opened the book, found the right page, and started to read.
“’Frantic efforts to avoid real or imagined abandonment.’”
“You mean they still say ‘frantic’. Haven’t you psychiatrists learned anything about non-discriminating language?”
“Apparently not. But how about the meaning of the symptom? Does it still apply? I can’t think of many recent examples.”
“I stayed in bed for a week after Cheryl left me, and tried to call her every day. Does that count?”
“Hmm. It’s nothing like you used to do. Maybe a half symptom at most.”
“How many symptoms are needed for the diagnosis?”
“Five. Out of nine.”
“What’s next?”
“’A pattern of unstable relationships…’”
And so we worked our way through the nine dismal criteria. She still had some difficulty with unstable relationships, impulsivity, and sudden anger, though none of these were anything like their previous severity. But her attempts at suicide and self-harm had stopped, and none of the other symptoms fitted.
“Four symptoms at most. And some of them probably aren’t severe enough to count anymore.”
Her face lit up.
“So, I’m not borderline anymore!”
I smiled too, enjoying the moment with her. I felt a little parental, and proudly parental at that, so I paused to better savour a good outcome to a most challenging journey, before dropping the small diagnostic bomb.
“As it happens Deidre, we don’t actually remove the label. We just annotate it to say, ‘borderline personality disorder – in remission’.”
“What! You bastards! I need the label removed.”
“OK, OK.” I smiled. “I’ll change it. Just for you. I’m writing it in the chart now. ‘No longer diagnosable as having a borderline personality disorder.’”
All names and other identifying details have been changed to protect patient confidentiality.
JP Sutherland 