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See Inside January/February 2012

Diagnosis of Borderline Personality Disorder Is Often Flawed

True sufferers are often troubled—and yet time and treatment can often improve their lives



Stuart Bradford

THIS PAST JUNE renowned clinical psychologist Marsha M. Linehan of the University of Washington made a striking admission. Known for her pioneering work on borderline personality disorder (BPD), a severe and intractable psychiatric condition, 68-year-old Linehan announced that as an adolescent, she had been hospitalized for BPD. Suicidal and self-destructive, the teenage Linehan had slashed her limbs repeatedly with knives and other sharp objects and banged her head violently against the hospital walls. The hospital’s discharge summary in 1963 described her as “one of the most disturbed patients in the hospital.” Yet despite a second hospitalization, Linehan eventually improved and earned a Ph.D. from Chicago’s Loyola University in 1971.

Many psychologists and psychiatrists were taken aback by Linehan’s courageous admission, which received high-profile coverage in the New York Times. Part of their surprise almost surely stemmed from an uncomfortable truth: people with BPD are often regarded as hopeless individuals, destined to a life of emotional misery. They are also frequently viewed as so disturbed that they cannot possibly achieve success in everyday life. As a consequence, highly accomplished individuals such as Linehan do not fit the stereotypical mold of a former BPD sufferer. But as Linehan’s case suggests, much of the intense pessimism and stigma surrounding this disorder are unjustified. Indeed, few psychological disorders are more mischaracterized or misunderstood.

Fuzzy Borders
New York psychoanalyst Adolf Stern coined the term “borderline” in 1938, believing this condition to lie on the murky “border” between neurosis and psychosis. The term was a misnomer because BPD bears little relation to most psychotic disorders. The name may have perpetuated a widespread misimpression that the disorder applies to people on the edge of psychosis, who have at best a tenuous grasp of reality. Not surprisingly, the popular conception of BPD, shaped by such films as the 1987 movie Fatal Attraction (featuring actress Glenn Close as a woman with the condition), is that of individuals who often act in bizarre and violent ways.

An error committed by some clinicians is presuming that patients who do not respond well to treatment or who are resistant to therapists’ suggestions are frequently “borderlines.” Some mental health workers even seem to habitually attach the label “borderline” to virtually any client who is extremely difficult to deal with. As Harvard University psychiatrist George Valliant observed in a 1992 article, the BPD diagnosis often reflects clinicians’ frustrated responses to challenging patients.

In reality, BPD is meant to apply to a specific subgroup of individuals who are emotionally and interpersonally unstable. Indeed, Linehan has argued that a better name for the condition is “emotion dysregulation disorder.” Much of the everyday life of individuals with BPD is an emotional roller coaster. Their moods often careen wildly from normal to sad or hostile at the slightest provocation. As Linehan pointed out in a 2009 interview with Time magazine, “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin.” Their perceptions of other people are inconsistent, and they often vacillate between worshipping their romantic partners one day and detesting them the next. Their identity is similarly unstable; patients may lack a clear sense of who they are. And their impulse control is poor; they are prone to explosive displays of anger toward others—and themselves. [For more on the symptoms, causes and treatment of BPD, see “When Passion Is the Enemy,” by Molly Knight Raskin; Scientific American Mind, July/August 2010.]

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