General BPD Resources

Borderline Personality Disorder -- What's In a Name?

According to the DSM-IV, a Personality Disorder is defined as the following:

"A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
� (1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
� (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
� (3) interpersonal functioning
� (4) impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.�
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.�
D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.�
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.�
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma)."

Current American diagnostic criteria (DSM-IV) for BPD

See my annotated Diagnostic Criteria for BPD

Current International Criteria (the World Health Organization's ICD-10, F60.31: Emotionally Unstable Personality Disorder, Borderline Type)

The most often-asked question when first hearing of this disorder is:
" ...on the borderline of what?!"

Understandably confused patients and their families have assumed this means "a marginal but not full-blown disorder" and sighed in relief. Yet it is a specific diagnosis, one of 10 personality disorders currently classified in modern psychiatry, and alongside Antisocial Personality Disorder, probably the most researched and studied.

The term Borderline, like the disorder it describes, is subject to constant lively discussion in the mental health community. The noted BPD researcher Dr. Hagop Akiskal has called it "an adjective in search of a noun." The name was introduced by the first psychoanalysts, who noted that certain patients actually got worse, not better, during the course of traditional Freudian 'talk therapy'. Countrary to Freud's hypotheses, these patients did not heal when past traumas were uncovered, but rather, the revelations led to brief flares of what appeared to be psychotic behavior. These patients were thus seen as standing on the 'border' of neurosis and psychosis, the two poles of mental illness as understood at that time: a psyche caught halfway between neurotic control and psychotic regression. Other, even less useful terms that have been historically used include "Ambulatory Schizophrenics", "Neurasthenics" or "Hysterical Neurotics."

Today it is believed that this misnomer was due to an incomplete understanding of the function of early trauma, the ego defense mechanisms, and attachment issues which are the hallmark of personality disorders. The term "Personality Disorder" itself has evolved from earlier terms such as "Character Disorder."
Even in contemporary times, the position occupied by personality disorders is not well understood by a public conditioned by Hollywood to view all mental health disorders as variants of schizophrenia. Modern therapeutic strategies focus on retraining the Borderline sufferer in healthier coping skills (although the debate over the therapeutic usefulness of processing early traumatic memories continues to this day). See my references on Trauma and Memory for more details on the proposed traumatic nature of BPD.

Unfortunately for the sake of clarity, the original label "Borderline" has stuck. Even more confusing: BPD is often mistaken for the acronym for Bipolar Disorder, or BP (manic depression) -- in fact, some researchers and clinicians consider BPD to be an affective mood disorder, a subdiagnosis of Bipolar Disorder.
For more on the Borderline/Bipolar connection, see my references on Comorbid Disorders: Bipolar Disorder.

For more on the history of the BPD diagnosis itself, see Dr. Michael Stone's excellent collection of Essential Papers on Borderline Disorders: One Hundred Years at the Border.

For a quick online overview, read an excerpt from this chapter on the history of the term from Dr. John G. Gunderson's 'Borderline Personality Disorder', 1984, provided by amazon.com. Gunderson is a leading researcher of BPD at Harvard Medical School.

With a very few exceptions, unlike physical medicine, mental health disorders are categorized on the basis of symptoms and behaviors, rather than on their proposed causes, or etiology. As psychology progresses into its "era of the brain", new information from modern technologies such as brain scanning and biological research such as the Human Genome Project are slowly changing this standard.

However, until such time as this research may be able to provide definitive etiological information (if it indeed can), professional debate over delineating the best way to categorize various symptoms will remain a lively part of mental health diagnosis.

Since the diagnosis 'Borderline Personality Disorder' was first officially included in the psychiatric diagnosticians' 'bible' in 1980, the Diagnostic and Statistical Manual of Mental Disorders (DSM), many theorists have suggested re-labelling it in order to better convey its specificity within the realm of mental illness.

In the 60's, Dr. Otto F. Kernberg, present Director of the Personality Disorders Institute of the New York Presbyterian Hospital, Westchester Division, and Professor of Psychiatry at Cornell, proposed the term Borderline Personality Organization, which is a bit broader-reaching than the definition eventually included in the DSM. BPO as a theoretical construct has evolved quite a bit since then and is preferred in certain therapeutic circles such as Transactional Analysis.

Dr. Marsha Linehan of the University of Washington/Seattle, and author of 'Cognitive Behavioral Treatment of Borderline Personality Disorder', 1993, (promoting Dialectical Behavioral Therapy, or DBT, a promising new form of cognitive therapy for BPD) prefers Emotional Dysregulation Disorder.

Dr. Theodore Millon, a major American personality theorist, would like to see BPD renamed Cycloid Personality Disorder.

Dr. Joel Paris of Montreal suggests using Emotionally Unstable Personality Disorder, as it is used in the International Statistical Classification of Diseases and Related Health Problems, or ICD-10, F60.31.

Dr. Judith Herman, a noted Associate Professor of Clinical Psychology at Harvard, suggests in her book Trauma and Recovery, 1992, that the name be changed to Complex Post-Traumatic Stress Disorder.
A spate of recent studies on trauma have prompted some researchers to re-evaluate BPD as a distinct aspect of Post-Traumatic Spectrum Disorder. (For an interesting history of PTSD, sexual abuse, and its related diagnoses, read As the Pendulum Swings.)

Dr. Leland Heller, a Florida family practitioner and proponent of biological etiology, promotes the name Dyslimbia, conveying information about the neurological operation of the disorder.

You might also want to take a quick gander at a useful chart of the major theoretical orientations to Borderline Personality Disorder.

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Playing Diagnostic "Where's Waldo?"

Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Bipolar II (Cyclothymia), Obsessive Compulsive Disorder, Depression, Dysthymic Disorder, Passive-Aggressive Disorder, Adult Reactive Attachment Disorder, alcoholism, hypothyroidism or even mercury poisoning: how is a concerned spouse or family member (to say nothing of the sufferer) to figure out what's what? And does a specific diagnosis really matter?

The benefits to having a mental health disorder "figured out" include both sufferer and loved ones feeling empowered to seek out properly oriented therapeutic intervention and medication. Personality disorders are also technically covered by Title 1 of the Americans with Disabilities Act, although it can be problematic to implement.
The disadvantages are that the sufferer (or their loved ones) may come to think of themself (or the diagnosee) as the disorder, rather than as a unique human being suffering from it. In the case of personality disorders, the symptoms of which are ego-syntonic (not viewed by the sufferer as unusual or contrary to their sense of self), an official diagnosis may actually play into the pathology itself, becoming a handy crutch, a catch-all evasion of personal responsibility.

Yet there is no denying that a proper diagnosis does help locate appropriate treatment, and with it (perhaps just as importantly) new hope for the sufferer and family/friends whose lives are also deeply affected. In the case of BPD, which carries a completed suicide rate upwards of 10%, appropriate treatment intervention can be literally life-saving.

With the criteria for the diagnosis of mental illness rapidly changing to reflect new research, it's tough to be a mental health professional out there in the trenches. Is BPD a traumatic or dissociative disorder (childhood sexual/physical/verbal abuse), an attachment disorder (insufficient bonding with caretakers in early life), an affective mood imbalance (a sub-form of Bipolar), a genetically inherited vulnerability related to ADHD or alcoholism, a sexist labelling of women who do not fit the norm -- or all of the above?

For excellent discussions of the theoretical troubles with diagnostic classification of adult mental disorders, see: Murmurs of Discontent: Treatment and Treatability of Personality Disorder by Gwen Adshead, or T.A. Widiger's more philosophically-oriented Adult Psychopathology: Issues and Controversies.

With each revision the DSM gets more complicated, and many psychological disorders (particularly personality disorders) undergo constant reassessment to ascertain that they do indeed make up a unique constellation of symptoms. Self-injurious behavior, for example, which was long considered a key diagnostic 'marker' of BPD, is not exclusive to the BPD community: it can also be found in autism, Bipolar II, Reactive Attachment Disorder, ADHD, or cases of traumatic brain injury. There are also Borderlines who meet virtually all the criteria but do not self-injure.
"Passive Aggressive Personality Disorder," to name another example, was elimated from newer versions of the DSM because of its high symptomatic overlap with BPD and Dependent PD.
BPD is found in both adoptive and natural chidren. Statistically, it is strongly correlated with childhood sexual abuse, but it is found in those who by their own account suffered no childhood sexual abuse, and there are questions as to the veracity of the abuse claimed to be suffered by some who remember it in personal narratives. It is found in some siblings and not others in the same family. From anecdotal accounts by thousands of spouses, it appears to occur almost as often in men as women, although it is overwhelmingly officially diagnosed in women, whereas men tend to be diagnosed with Antisocial Personality Disorder.
(For basic information on BPD behaviors and symptoms, please see Basic BPD Facts & Information further down on this page, or my page on Understanding the BPD Diagnostic Criteria.)

Recent research studies have found that while BPD is one of the most often-diagnosed mental health disorders in frequent users of emergency treatment services, the general lifetime prevalence of BPD in the American population appears to be about 6.4%.

It certainly doesn't help that Borderline patients carry a long-standing stigma as "extremely difficult", "self-destructive" or "impossible to cure" (some of which is true in individual cases, and is a reflection of the deeply-ingrained pathology of BPD). Many psychiatrists are very reluctant to diagnose BPD, thinking it will merely add to the social burden of an already struggling patient. Some consider it to be a hodge-podge umbrella diagnosis with little actual justification for its own diagnostic category. Some also hold that it is countertherapeutic to reveal suspicions of BPD to a patient during treatment, since it may lead Borderlines to abruptly split the therapist 'bad' and jettison themselves out of treatment.

Compounding these difficulties even further, many American health insurance policies do not (yet) cover the treatment of personality disorders, but will reimburse for treatment of Bipolar or other disorders which are regarded as "biochemically based" and therefore, presumably, curable. Indeed, there are very intense professional debates over the status of BPD as a variant of Bipolar Disorder.

The issue gets even more confusing when one considers the various speculations theorists have made to the effect that BPD could possibly be subdivided into different groupings depending on which etiology one accepts as primarily causal. Deb Martinson comments that, according to Dr. Judith Herman's work on trauma, "when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD."

Here are the most recent DSM-IV-TR criteria (2000) for all mental health disorders. The DSM certainly isn't perfect, and it is constantly up for revision, but for now it's the governing standard by which professionals classify clusters of symptoms & behaviors.

For the curious, I also suggest checking out various online support forums for folks (or partners of folks) diagnosed with the disorder in question. It's not easy to distinguish between, say, the topics and concerns expressed in BPD support forums from those in Adult Reactive Attachment Disorder forums or even ADHD forums. Those diagnosed with rapidly cycling Bipolar II or Depersonalization Disorder also express similar feelings and behaviors. It's hard enough for the professionals. For the frustrated layperson, it's a veritable diagnostic "Where's Waldo?"

Therefore, if you are concerned about your or a loved one's (mis?)diagnosis, I urge you to speak in depth with the diagnosing professional. A good clinician will listen to your questions, be diligent about ruling out other causes of the symptoms, welcome some amount of feedback from loved ones and family, and above all be able to clearly state why they believe a particular diagnosis is or isn't applicable.
"If you don't self-injure, you can't be Borderline" or "I just don't believe in Personality Disorders" are not competent answers. There are many therapists out there, and it is your right to seek a standard of health care you are comfortable with.

All opinions on this page are personal views reflecting my understanding based on lengthy research of the topic. I am not a mental health professional and cannot guarantee the accuracy of any material off-site. Please rely on your mental health professional for specifics in your individual situation.

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Basic BPD Facts & Information

I recommend first reading as many of these general introductions as you can: forewarned is forearmed, and a broad understanding of the behavioral effects of this disorder is key to being a successful caregiver, not to mention simply coping with it as a non-sufferer.

Any of the many articles below is excellent to print out for disseminating information about your loved one to a sceptical world, especially legal advisors and the family court system. Please help spread the educated word in your community!

If you are already familiar with BPD and interested in more detailed research on specific symptoms & behaviors, see: Descriptive Research Studies of BPD Traits

If you want a glimpse into the mental world of a Borderline, read the excellent collection of articles by A.J. Mahari, a woman with BPD in recovery. These and many other readings on my Voices of BPD page are extremely helpful in getting 'inside' the BPD world-view.

For reviews of introductory books on BPD, please see: Recommended Books on BPD.

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Special Report: Borderline Personality Disorder: An Overview by John M. Oldham, M.D., Psychiatric TImes, July 2004

The Basics of Personality Disorders
Mentalhelp.net's excellent overview

Personality Disorders
Morton Silverman, M.D.

Masters of Denial
Jeffrey Kluger
A January, 2003,Time Magazine article on personality disorders in America; provides some solid facts & statistics.

What is Borderline Personality Disorder?
The facts and symptoms in a nutshell, described in clear language, from recovery-man.com.

BPD Chart
Extremely helpful chart summary of symptoms, treatment, etc, from the Dual Diagnosis Pages.

Borderline Personality Disorder
Very nice brief write-up of the behaviors and symptoms, from the Always Your Choice medical offices.

Quick clear medical metaphor of how to conceptualize an Axis II Personality Disorder
by Theodore Millon, PhD.

Borderline Personality Disorder: an Overview
Excellent overview from the Personality Disorders Institute.

"Dancing on the Borderline"
by Alcia Potter, The Boston Phoenix 9/25/97
A newspaper report on BPD. Very accessible for the absolute BPD novice or younger reader, although a bit popularized.

National Mental Health Association's Description of Personality Disorders

On The Edge
By Gloria Hochman
I consider this among the best up-to-date introductory articles for those first learning about the disorder and its effects on both family and the afflicted.

Borderline Personality Disorder
by Anne Brown and Kristi Dodson 1999
Excellent overview of the way mental health professionals are thinking about BPD today. A NARSAD fact sheet.

How are all the Personality Disorders Interrelated?
by Sam Vaknin

Understanding And Working With Borderline Personality Disorder
by Luciano Anthony Picchio, M.D.
Good summary of one specialist's broad perspective on working with BPD.

Borderline Personality Disorder
by Deb Martinson
Excellent job of explaining various theories of BPD and its accompanying symptoms/behaviors. Clear and smart. ~recommended!

Personality disorder: The Origins of the Concept: Nature and Nurture
by Michael Shooter
An excellent British article discussing the history of the personality disorder concept.

Download a radio interview transcript on BPD from The Infinite Mind
Informative interview with Marsha Linehan and other BPD experts

Borderline Personality Disorder and Pediatrics
by Elizabeth A Finley-Belgrad, MD, Emedicine journal 7/3/01
Excellent thorough and current article which discusses some of the childhood precursors/symptoms of BPD.

Myths about BPD

What is a Personality Disorder?
by Dr. Paul Hannig

Resources on Personality Disorders in Teens
Set of links and articles, very helpful.

RENT or purchase two Documentary Films about Borderline Personality Disorder:
'Borderline Syndrome: A Personality Disorder of Our Time' Interviews with 5 Borderline Women (narrated by Maureen Stapleton!) 1989
'Beyond the Borderline' 6 years later, interviews with the same women on progress and feelings
Both by Olive Tree Productions
Available through Filmakers Library: Filmakers.com

Order the Borderline Personality Issue of the Journal of the California Alliance for the Mentally Ill
This back issue costs $10, but is worth it. You can order by mail or online using their secure order form.
This url takes you to the index; check it out. Scroll down to the bottom of the page and find the ordering link in tiny print.

Trouble In Mind: Borderline Personality Disorder
part of a 1999 series of short informative videos on mental health, narrated by Jaclyn Smith.

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Major BPD Informational Sites on the Web

BPDCentral
Owned/operated by Randy Kreger, the co-author of Stop Walking on Eggshells.
Excellent comprehensive site, a great first stop for friends/family/loved ones.

BPD411
Has a fabulous 'resources' index with dozens of essays written from the perspective of NonBP experiences: great place to begin reading for validation and explanation of the key components of BPD behaviors and their effects on loved ones.

NonBPD.org
This web site has good resources, especially when leaving a BP relationship.
(Their server tends to have troubles; keep trying)

Path To The Light
"Insights On Recovery for Non-BPs in Chosen Relationships"
Inspirational essays, biography, philosophical resources from a man who saw it all in 17 years of marriage to a wife with BPD/alcoholism, and has come through shining. Of particular interest to men who are concerned about divorce/custody issues with a dysfunctional Borderline wife.

Kathi's Mental Health Review: BPD page
Kathi Stringer, diagnosed with DID, runs this informative site. Good collection of articles on various mental health diagnoses.

Mental Health Today
A veritable plethora of message boards for every conceivable interest group, and a large collection of online articles about BPD. The site's owner, who suffers from the disorder, believes BPD to be neurological in origin, therefore these articles emphasize medical treatment.

Laura Paxton's Borderline and Beyond
Paxton, herself once diagnosed with BPD, is now a therapist and the author of a workbook and flash card treatment system for BPD.
(for more info, see the Treatment section on this site)

Dr. Leland Heller's Biological Unhappiness Site
Heller, a family practitioner, is an experienced albeit controversial advocate of medication regimes for treating BPD.

HealthyPlace.com Personality Disorders site
A selection of resources and online conference transcripts

About.com's Personality Disorders Page
Nice collection of articles and links to all things PD

Dr. Ivan Goldberg's List of BPD resources
from the Depression Central website (not often updated)

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Mental Health Organizations Offering BPD Resources

NIMH's Concept for Borderline Personality Disorder Initiative
The National Institute of Mental Health brought out this statement to support and encourage professional research into BPD.

How Advocacy is Bringing Borderline Personality Disorder Into the Light
Updated article by Valerie Porr, M.A., on the latest on BPD advocacy in the USA.

National Education Alliance for Borderline Personality Disorder (NEA-BPD)
"To empower those with borderline personality disorder and their families by providing them with current scientific information about the course and features of this serious mental illness through the sponsoring of a yearly conference and a web site; to initiate and collaborate on family research; to establish regional centers that offer family mentoring services, all with the ultimate goal to dispel the myths that surround BPD and bring hope for a better life."
NEA-BPD offers free 12-week FAMILY CONNECTIONS programs in the NY/CT area, for families with a member who suffers from BPD.
For more information, phone: (914) 835-9011

TARA-APD: Treatment & Research Advancements Association for Personality Disorder
"People with family members suffering from Borderline Personality Disorder (BPD) may find help and information from TARA APD. TARA APD has initiated a successful national campaign for inclusion of BPD in the National Comorbidity Survey-Replication. TARA APD maintains a NYC Personality Disorder Resource And Referral Clearinghouse. To raise awareness of BPD, we sponsor workshops, symposia and grand rounds and provide family education and support groups."
Call TARA's national hotline at 1-888-4-TARA APD

Upcoming Conferences on Borderline Personality Disorder
Anthony Walker, author of The Courtship Dance of the Borderline, keeps this updated list of conferences for families & consumers as well as professionals.

Find your local National Alliance for the Mentally Ill affiliate
NAMI holds regular regional workshops for families/friends of the mentally ill. Their "Family to Family" education program is a free 12-week course taught by trained family members experienced in caregiving for the mentally disordered (offered across the USA and in 2 Canadian provinces). Find a course location near you at this link. NAMI has recently included a unit on BPD in the Family-to-Family curriculum.

Find your local National Mental Health Association affiliate
NMHA lists resources and support groups in your area.

National Association of Mental Health Planning and Advisory Councils
"What is NAMHPAC? NAMHPAC (pronounced like nam-pack) is an association of people involved with State mental health planning across the country. With the support of the federal Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA), these advocates, parents and consumers, joined together to meet common needs for information, training and mutual support. NAMHPAC was formed in 1995.
What are State Mental Health Planning and Advisory Councils? In 1986, a Federal law was passed that required states to do mental health planning as a condition of receiving federal mental health funds. It further required that the planning process include various stakeholder groups�consumers of mental health services, parents of children with emotional disturbances, and family members. U.S. States and Territories then formed these councils which now exist in every state.
What do these councils do? The purpose of the planning councils in each State and Territory is to meaningfully involve concerned citizens in planning and evaluating the mental health service delivery in their states. Defined by Federal law, these councils:
* Review community mental health block grant plans and make recommendations to the State administration.
* Monitor, review and evaluate all mental health services throughout the State or Territory.
* Serve as advocates for adults with serious mental illnesses, children with severe emotional disturbances, and others with mental health needs."

Borderline Personality Disorder Research Foundation
The first well funded, far-reaching private international foundation for serious BPD research.

Personality Disorders Foundation of Connecticut
Regional information and links to clinics/treatment programs in Connecticut. Excellent resource for CT locals!

International Society for the Study of Personality Disorders (ISSPD)

Help for Partners of Those Touched By Mental Illness
Wonderful site; informative articles about the impact on families, spouses, children of the mentally ill. Great coping tips! Offers help in locating regional support groups.

Federations of Families for Children's Mental Health

New England Personality Disorder Association
Brand new; still under construction
For more information, contact Missy Cunningham at: [email protected]

Bazelon Center For Mental Health Law
Legislative updates on American mental health insurance; advocacy.

Treatment Advocacy Center
"The Treatment Advocacy Center is a nonprofit organization dedicated to eliminating legal and clinical barriers to timely and humane treatment for Americans with severe brain disorders who are not receiving appropriate medical care."

The Impact of Psychiatric Diagnosis and Family System Relationship on Problems Identified by Families Coping with a Mentally Ill Member
by David E. Pollio, Family Process, Summer, 2001
Interesting article examining the use & effectiveness of family support groups.

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This Page Last Updated: August 30, 2003

Helen's World of BPD Resources

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