BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder



Borderline Personality Disorder

Introduction

The term 'borderline personality' was proposed in the United States by Adolph Stern in 1938 (most other personality disorders were first described in Europe). Stern described a group of patients who 'fit frankly neither into the psychotic nor into the psychoneurotic group' and introduced the term 'borderline' to describe what he observed because it 'bordered' on other conditions. The term 'borderline personality organization' was introduced by Otto Kernberg (1975) to refer to a consistent pattern of functioning and behavior characterized by instability and reflecting a disturbed psychological self-organization. Whatever the purported underlying psychological structures, the cluster of symptoms and behavior associated with borderline personality were becoming more widely recognized, and included striking fluctuations from periods of confidence to times of absolute despair, markedly unstable self-image, rapid changes in mood, with fears of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Transient psychotic symptoms, including brief delusions and hallucinations, may also be present. The characteristics that now define borderline personality disorder were described by Gunderson and Kolb in 1978 and have since been incorporated into contemporary psychiatric classifications.

Diagnosis

Borderline personality disorder is one of the most contentious of all the personality disorder subtypes. The reliability and validity of the diagnostic criteria have been criticized, and the utility of the construct itself has been called into question. Moreover, it is unclear how satisfactorily clinical or research diagnoses actually capture the experiences of people identified as personality disordered. There is a large literature showing that borderline personality disorder overlaps considerably with other categories of personality disorder, with 'pure' borderline personality disorder only occurring in 3 to 10% of cases. The extent of overlap in research studies is particularly great with other so-called cluster B personality disorders (histrionic, narcissistic and antisocial). In addition, there is considerable overlap between borderline personality disorder and mood and anxiety disorders. This guideline uses the DSM-IV diagnostic criteria for borderline personality disorder (APA, 1994), which are listed in Table 1. According to DSM-IV, the key features of borderline personality disorder are instability of interpersonal relationships, self-image and affect, combined with marked impulsivity beginning in early adulthood.

A stand-alone category of borderline personality disorder does not exist within the International Classification of Diseases, 10th revision (ICD-10; World Health Organization, 1992), although there is an equivalent category of disorder termed 'emotionally unstable personality disorder, borderline type', which is characterized by instability in emotions, self-image and relationships. The ICD-10 category does not include brief quasi-psychotic features (criterion 9 of the DSM-IV category). Comparisons of DSM and ICD criteria when applied to the same group of patients have shown that there is little agreement between the two systems.

For example, in a study of 52 outpatients diagnosed using both systems, less than a third of participants received the same primary personality disorder diagnosis. Further modifications in the ICD and DSM are required to promote convergence between the Borderline personality disorders.

A stand-alone category of borderline personality disorder does not exist within the International Classification ...