Consult-Liaison Education Medicine

Personality Disorders (VIII): The Definition of Borderline.

If you haven’t read the proposed etiologies of borderline personality disorder first, please do so. An understanding of its causes makes the criteria seem less… judgmental and harsh.

Following is the definition of borderline personality disorder according to DSM-4.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

The authors here focus on instability, not only when interacting with others, but also with oneself and one’s emotions.

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

The vast majority of people don’t want to experience abandonment. “Frantic”, given the context, is open to interpretation. Upon reading this, you may think of multiple, desperate phone calls filled with promises that cannot be kept. These efforts, however, can also refer to someone who abruptly stays in bed and doesn’t acknowledge any communications from the outside world. “Frantic efforts” are not required to be loud.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

“Alternating between extremes of idealization and devaluation” is often described as something like this:

January 15: “I love my doctor—she’s the best doctor I’ve ever had. She is smart and really understands what I’m talking about. Don’t see anyone else in that clinic; no one else there is as good as she is.”

February 1: “My doctor is terrible. She thinks she’s really good, but she’s not. I’m not sure why they let her graduate from medical school—she doesn’t know what she’s doing and her bedside manner is crap. I would not recommend her to my worst enemy.”

Recall the concept of “all good/all bad”.[1. This “all good/all bad” concept comes from object relations theory. Object relations is not my forte; I’m much too concrete.] That is reflected here.

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

Recall the experiences of invalidation children may experience while growing up. If you are regularly told that your thoughts, emotions, and behaviors are “wrong”, you, too, might have doubts about who you are, what you feel, and what you do.

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

This might speak to heightened “emotional sensitivity” (more intense emotions that last a longer period of time), which is considered a biological cause of this condition.

People also often confuse these behaviors with the hypo/mania described in bipolar disorder.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

This criterion was already mentioned twice before we got here! This is why some people use the mental shortcut of, “Well, she’s always trying to kill herself, so she must be borderline”.[2. Try this exercise if you work in health care: Describe your patients as people instead of medical conditions. No, he’s not “the liver cancer in bed seven”, he’s “Mr. Smith, the man diagnosed with liver cancer”. Yes, emotional distance can be useful, but if you habitually think of your patients as diagnoses, that might lead you to treat your patients as if they weren’t people.] Like many shortcuts, this can lead you to the wrong conclusion.

Remember that Little Suzie learned that people seemed to only really understand her internal distress when she did things like injure herself. This is the best way she knows how to get her emotional needs met. This is a skills deficit. (To be clear, you could say that “she’s manipulative”, but we all manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.)

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

This again refers to the “emotional sensitivity” discussed above in criterion 4. People also confuse this with mood fluctuations seen in bipolar disorder.

(7) chronic feelings of emptiness

This can be related to the “identity disturbance” described in criterion 3 above.

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(I encourage all to use the word “inappropriate” with caution. What is “inappropriate” strongly depends on the context.)

This, too, refers to “emotion sensitivity” and the impulsivity that may result from it.

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

This criterion explains the psychotic symptoms that can accompany borderline personality disorder. Some will recall the the name “borderline” came about because some theorists argued that these individuals are on the “borderline” between neurosis and psychosis.

Dissociation can be a skillful way of coping with stress. An extreme example is someone dissociating while getting raped. A more common example is someone dissociating a bit while at the dentist. Dissociation becomes a problem when it affects function (like dissociating while at a job interview).

Again, recall that a personality disorder is an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”. People who work in health care settings often start using the word “borderline” to describe someone who they feel annoyed and frustrated with. That’s unfair. Words matter.

Next up is dependent personality disorder… for which there is sparse data.