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Diagnosis of Borderline Personality Disorder Is Often Flawed

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

Further fueling the stigma attached to BPD is the assumption that nearly all individuals who engage in self-cutting, such as wrist slashing, are so-called borderlines. In fact, in a 2006 study of 89 hospitalized adolescents who engaged in cutting and related forms of nonsuicidal self-injury, Harvard psychologist Matthew Nock and his colleagues found that 48 percent did not meet criteria for BPD. The lion’s share of these individuals exhibited other personality disorders, such as avoidant personality disorder, which is associated with a pronounced fear of rejection.

Once Borderline Always Borderline?
Two allied myths about BPD are that patients virtually never improve over time and are essentially untreatable. Yet a number of recent studies indicate that many patients with BPD shed their diagnoses after several years. In a 2006 investigation, for example, psychologists C. Emily Durbin and Daniel N. Klein, both then at Stony Brook University, found that although 16 percent of 142 psychiatrically disturbed adults initially met criteria for BPD, only 7 percent did after a decade. Moreover, the average levels of BPD symptoms in the sample declined significantly over time. Work by psychologist Timothy J. Trull and his colleagues at the University of Missouri–Columbia similarly suggests that many young adults who display some features of BPD do not exhibit these features after only a two-year period, indicating that early signs of BPD often abate.

BPD is not easy to treat. Yet Linehan has shown that an intervention she calls “dialectical behavior therapy” (DBT) is modestly helpful to many sufferers of the condition. DBT encourages clients to accept their painful emotions while acknowledging that they are unhealthy and need help. It teaches patients specific coping skills, such as mindfulness (observing their own thoughts and feelings nonjudgmentally), tolerating distress and mastering negative emotions. Controlled studies, reviewed by Duke University psychologist Thomas R. Lynch and his colleagues in 2007, indicate that DBT somewhat reduces the suicidal and self-destructive behaviors of patients. Lynch and his collaborators also found that DBT may lessen feelings of hopelessness and other symptoms of depression. Still, DBT is not a panacea, and no clear evidence exists that DBT can stabilize patients’ identity or relationships. Preliminary but promising data suggest that certain medications, including such mood stabilizers as Valproate, can alleviate the interpersonal and emotional volatility that characterize BPD, according to a 2010 review by psychiatrist Klaus Lieb of University Medical Center in Mainz, Germany, and his colleagues.

A Continuing Challenge
Not all BPD patients improve on their own or with treatment, and even those who do typically continue to battle the demons of emotional and interpersonal volatility. Nevertheless, the extreme negative views of this condition are undeserved, as is the mislabeling of a wide swath of the psychiatric population as borderline. It is also undeniable that many clinicians must become more judicious in their use of the BPD label and avoid attaching it to virtually any patient who is oppositional or unresponsive to treatment.

Fortunately, there is room for cautious optimism. As psychiatrist Len Sperry of Barry University noted in a 2003 review, BPD is the most researched of all personality disorders, a fact that remains true today. The fruits of that work promise to yield an improved understanding of BPD, which may reduce the stigma surrounding this widely misunderstood diagnosis. If so, perhaps the day will soon come when successful people who once struggled with BPD, such as Marsha Linehan, are no longer perceived as exceptions that prove the rule.

This article was originally published with the title "Facts & Fictions in Mental Health: Grief without Tears."

(Further Reading)

  • Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD. Robert O. Friedel. Da Capo Press, 2004.
  • A Biosocial Developmental Model of Borderline Personality: Elaborating and Extending Linehan’s Theory. Sheila E. Crowell, Theodore P. Beauchaine and Marsha M. Linehan in Psychological Bulletin, Vol. 135, No. 3, pages 495–510; May 2009.
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