Author: Nicole Fusco, M.S.
There is a rise in diagnosing borderline personality disorder (BPD) and with that comes a misperception of the essential elements of BPD. Therefore, it is critical to understand the historical origins of a borderline personality diagnosis, as well as the symptoms of BPD to properly diagnosis.
Historical Origins of Diagnosis
BPD was not recognized as a disorder until its inclusion in the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) in 1980 (APA, 1980). However, BPD was affecting people before 1980, but it was only a psychoanalytical colloquialism. During the psychoanalytic period, Adolph Stern (1938) created the label “borderline.” Later, psychiatrists Stern and Knight (1953) gave initial clinical meaning to the term “borderline states.” They said that these patients would regress into “borderline schizophrenia” states when in unstructured environments. During this time, individuals that were analyzed were classified as neurotic, whereas individuals deemed not analyzable were characterized as psychotic.
By 1967, the construct took a major step forward beyond the original theories when Otto Kernberg, a psychoanalyst put “borderline personality organization” in between psychotic and neurotic disorders. Kernberg (1967) defined “borderline personality organization” as identity diffusion, primitive defenses, and intermittent losses of reality testing which could be treated successfully by psychoanalytic psychotherapy. In terms of research, Roy Grinker an advocate for empiricism, was the first person to conduct research on BPD in 1968. In 1975, Gunderson and Singer published research on distinguishing criteria based on structured interviews to help diagnose BPD. As mentioned, in 1980, BPD was included in the DSM-III as its own disorder (APA, 1980). The inclusion of BPD as well as schizotypal personality disorder, added to the DSM-III, further solidified that BPD was not related to schizophrenia. Symptoms of BPD in the DSM-III included suicidality, impulsivity, anger, heightened affectivity, fears of abandonment, brief psychotic experience, and close relationships marked by idealization or devaluation (APA, 1980).
In 1994, the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) was published and defined further the symptoms of BPD required for diagnosis, adding stress-dependent and quasi-psychotic experiences. The criteria for BPD stayed consistent in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; APA, 2000) and in the DSM-5, with nine symptoms included (APA, 2013).
Diagnosis and Symptoms
In the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), BPD is categorized as a Cluster B personality disorder, along with antisocial, histrionic, and narcissistic personality disorders. According to the American Psychiatric Association (APA), a diagnosis of BPD involves evidence of a pattern of troubled relationships, extreme changes in self-image, and acting on impulse beginning in early adulthood and in multiple contexts (APA, 2013). To receive a diagnosis of BPD, an individual must exhibit at least five of the nine symptoms (APA, 2013). These symptoms include frantic efforts to prevent someone from leaving them, unstable and intense relationships that can drastically switch at any moment from loving and then hating the person, and extreme and frequent changes in self-image (switching between high self-confidence to very low self-esteem).
In addition, risky behavior prone to impulse and self-damage (substance misuse, driving recklessly, and risky sex) may be present (APA, 2013). There can also be a pattern of suicidal behavior or self-injury, intense bouts of being anxious or feeling sad (APA, 2013). Additional symptoms include feelings of emptiness and loneliness, intense anger beyond the scope of the issue or anger control problems, and stress-induced paranoid thoughts or feelings (believing people have bad motives or plans against them) or feeling detached from the self or the world (APA, 2013).
References:
Al-Alem, L., & Omar, H. A. (2008). Borderline personality disorder: An overview of history,
diagnosis and treatment in adolescents. International Journal of Adolescent Medicine
and Health, 20(4), 395-404. https://dx.doi.org/10.1515/IJAMH.2008.20.4.389
American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders,
(3rd ed.). Washington, DC.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders,
(4th ed.). Washington, DC.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders,
(4th ed., text revision). Washington, DC.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders,
(5th ed.). Arlington, VA.
Grinker, R., Werble, B., & Drye, R. (1968). The borderline syndrome: A behavioral study of ego
functions. New York, New York: Basic Books.
Gunderson, J. G. (2009). Borderline personality disorder: Ontogeny of a diagnosis. The
American Journal of Psychiatry, 166(5), 530–539.
https://doi.org/10.1176/appi.ajp.2009.08121825
Gunderson, J. G., & Singer, M. T. (1975). Defining borderline patients: An overview. Am J
Psychiatry, 132, 1–10.
Kernberg, O. (1967). Borderline personality organization. J Am Psychoanal Assoc., 15, 641-685.
Knight, R. (1953). Borderline states. Bull Menninger Clin., 17, 1–12.
Stern, A. (1938). Psychoanalytic investigation and therapy in the borderline group of neuroses.
Psychoanal Q, 7, 467–489