Understanding Borderline Personality Disorder

Borderline personality disorder (BPD) is a complex mental health condition marked by intense emotional reactions, unstable relationships, and self-image issues. Use of the word “borderline” dates back nearly a century, yet it remains controversial in modern psychiatry. Exploring mental health terminology and how it has changed over time provides insight into how doctors perceive and treat mental health conditions today.

Causes and Symptoms

BPD is classified as one of 10 personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Unlike typical personality traits like being introverted or assertive, BPD features ingrained and disruptive patterns in thinking, feeling, and relating to others ^[1].

Symptoms frequently begin in adolescence or early adulthood and can lead to long-term difficulties in personal, social, and professional life. Strained relationships, difficulty managing emotions, an overwhelming fear of abandonment, and challenges in maintaining a stable self-image are just a few implications of borderline personality disorder.  

Researchers have not fully identified the causes of borderline personality disorder, but they believe a combination of genetic, environmental, and neurological factors contributes to its development. Early trauma, family history of mental illness, and differences in brain function or structure may all contribute to the development of the disorder ^[2]. Roughly 1.6% of the population experiences BPD. However, in mental health care, prevalence reaches approximately 10% and 20% in outpatient mental health clinics and psychiatric facilities, respectively ^[1]. 

Historical Context for BPD

The concept of BPD emerged in the 1900s when early psychiatrists observed patients who didn’t clearly fit into established diagnostic categories. At that time, psychiatrist Kurt Schneider coined the term “borderline” to describe patients who appeared to exist on the threshold between neurosis and psychosis ^[3]. 

During the 1960s and 1970s, clinicians began to recognize a unique group of symptoms, namely emotional instability, impulsivity, and relational difficulties, that didn’t align with other mental health conditions. By 1980, the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) recognized BPD as a separate diagnostic category. Over time, updates in later DSM editions refined the criteria for BPD, enhanced diagnostic accuracy, and helped solidify BPD as a legitimate mental health condition distinct from both psychotic and neurotic disorders ^[3].

Today, the DSM’s latest edition (DSM-5-TR) includes three clusters of personality disorders. The following cluster classification groups personality disorders based on similar characteristics ^[1]: 

• Cluster A: Characterized by unusual or eccentric behavior, conditions in this group include paranoid, schizoid, and schizotypal personality disorders. 
• Cluster B: Comprising disorders marked by intense emotions, unpredictable behavior, and difficulty maintaining relationships, Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders.
• Cluster C: Cluster C disorders are linked to high levels of fear and anxiety, including avoidant, dependent, and obsessive-compulsive personality disorders.

Although BPD is now clearly classified within Cluster B, the term “borderline” itself remains a topic of ongoing debate among clinicians and advocates.

Why “Borderline” is Controversial

Despite the evolution of BPD, the use of the word “borderline” has been controversial. An article in the Bristol University Press outlines the controversy. According to the piece, opponents of the term argue that it creates ambiguity, as the original concept of being on the “borderline” between neurosis and psychosis is no longer accurate. Rather, modern research views BPD as a distinct condition rather than a state between other disorders. Simply put, “borderline” was initially used to describe ambiguous symptoms that didn’t fit other definitions. However, BPD today is a specific, unambiguous disorder ^[4]. 

Critics also assert that “borderline” adds to the stigma surrounding the condition, as it may imply that it’s somehow less legitimate or defined than other mental health disorders. As such, they argue that it doesn’t capture the complexity of the disorder, and it can lead to negative stereotypes. Thus, “borderline” contributes to misunderstanding and makes it harder for those affected to get the support they need ^[4]. 

Evolving BPD Terminology

Given the controversy, patients and clinicians have periodically called for a name change to better reflect the reality of the condition and help reduce stigma. In a 2023 critique in the Journal of the Royal Society of Medicine, authors argued against the continued use of the term. The authors claimed that the term BPD is used loosely to describe various relationship problems that may have nothing to do with personality, suggesting that the diagnosis and concept lack a foundation in scientific research on personality. They further noted that the terminology contributes to stigma and can lead to reduced quality of care ^[5]. 

Not surprisingly, researchers and clinicians have proposed alternative names. However, renaming a diagnosis is no small task. It requires agreement from experts across the field and updates to official diagnostic manuals, which can be a long and complex process. Thus, these proposed changes have not been adopted in the DSM-5-TR, though the discussion continues among clinicians, researchers, and advocates.

Current BPD Diagnostic Criteria

While debate continues around the name and evolving understanding of BPD, its clinical diagnosis remains grounded in clear criteria set by the DSM-5-TR. It indicates that a person must meet at least five of nine specific criteria that reflect behavior, emotion, and relationship patterns. These criteria include ^[1]:

• Intense fear of abandonment
• Unstable or intense interpersonal relationships
• Identity disturbance
• Impulsive behaviors in areas such as spending or substance use
• Repeated self-harm or suicidal behavior
• Emotional instability, chronic feelings of emptiness
• Inappropriate anger
• Stress-related paranoia or dissociation

These patterns must be long-standing (typically beginning in adolescence or early adulthood) and cause significant distress or impairment in social, occupational, or other areas of functioning ^[1]. 

Symptoms of BPD can overlap with those of other mental health conditions, including bipolar disorder, complex PTSD, or anxiety disorders, so diagnosis requires careful evaluation. Mental health professionals often use structured clinical interviews and psychological assessments to rule out other conditions and better understand each person’s experiences. Ultimately, BPD is diagnosed based on how consistently and pervasively these symptoms affect a person’s functioning over time. 

Living with Borderline Personality Disorder

Regardless of terminology debates, BPD represents a significant challenge for those affected. However, effective treatments have been developed specifically for this condition, offering hope and pathways to recovery. 

While medications are used to treat symptoms such as anxiety and depression, the primary approach to treating BPD is psychotherapy ^[6]. The following therapies can help people manage symptoms ^[7][8]: 

• Cognitive-Behavioral Therapy (CBT): CBT tries to identify and change negative thought patterns and behaviors that contribute to emotional distress and relationship difficulties.
• Dialectical Behavior Therapy (DBT): Combining cognitive-behavioral techniques with concepts of mindfulness and radical acceptance training, DBT teaches skills in key areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. 
• Mentalization-based therapy: This therapy helps patients identify thoughts and feelings in themselves and others to reduce impulsive reactions, particularly during times of high emotion.
• Schema-focused therapy: This integrative approach focuses on identifying and changing dysfunctional patterns of thinking, feeling, and behaving that developed during childhood.
• Transference-focused psychotherapy: This approach examines how past relationships affect current interactions, helping people develop a more coherent sense of self and others.
• Systems Training for Emotional Predictability and Problem Solving (STEPPS): A manual-based group treatment program, STEPPS combines CBT elements with skills training.

Borderline personality disorder’s impact extends beyond symptoms to affect relationships, work, and overall quality of life. However, with appropriate treatment and support, many people living with BPD experience significant improvements and lead fulfilling lives.

Beyond the Terminology

The history of the term “borderline personality disorder” reflects the evolving nature of psychiatric classification and knowledge. From its origins as a description of patients who seemed to exist between established diagnostic categories to its current status as a distinct and treatable condition, BPD continues to spark debate among mental health professionals.

Despite related controversies, BPD represents a genuine set of challenges that affect real people. With proper diagnosis and evidence-based treatments, those experiencing BPD symptoms can develop the skills needed to manage emotions effectively, build healthy relationships, and create lives of meaning and purpose. The journey toward mental health may be challenging, but with appropriate support and resources, healing and growth are possible.