The term “borderline personality” was first proposed in the United States by psychoanalyst Adolph Stern in 1938, an early proponent of Freudian psychoanalytic theory in this country followed by psychoanalyst Richard Knight who further promoted the concept. They described a group of patients who “fit neither into the psychotic nor into the psychoneurotic group” and introduced the term ‘borderline’ to describe what he observed because it ‘bordered’ between the twin pillars of Freudian theory of neurosis (mild anxiety and depression) and psychosis.  However, by “psychosis” what they meant was mostly dissociative and suspicious thinking when under the stress of couch psychoanalysis and but less so in real life, a point on which all psychoanalysts did not agree.

This generous definition of psychosis derives from Swiss psychiatrist Eugen Bleuler, in the early 20^th century, strongly influenced by Freud, who went on to broaden Kraepelin’s dementia praecox of adolescent onset with deteriorating course, to a new concept of schizophrenia, splitting of affect and thought, that could start at almost any time in life. Kurt Schneider extended Bleuler’s concepts to include voices in the 3^rd person which can also occur in states of manic psychosis leading to over diagnosis of schizophrenia.

A well-known study in 1970 of US. vs. UK psychiatrists showed that US psychiatrists diagnoses schizophrenia in the same patients that UK psychiatrists diagnoses Manic-Depressive Illness. This owes to the U.S. prediction to follow the Bleuler-Schneiderian criteria instead Kraepelin’s. This U.S. mindset favored by Freudian oriented psychiatrists, bled over into their dilemma of so-called borderline patients having “transient psychotic” symptoms.

This early conceptualization was later systematized into a concept called “borderline personality organization” by psychoanalyst Otto Kernberg (a prominent psychoanalyst of that era) in the late 1960’s and early 1970’s. (See Hannah Decker in references)

Robert Spitzer MD, the mastermind behind the new DSM-III in 1980, wondered if “borderline” should be used as an adjective or a noun. Thinking that it was more closely aligned with the large grab bag of the Schizophrenias listed in DSM-II, many of which did not require a psychotic episode, he suggested the term Schizotypal Personality disorder.

He did not like the word borderline and also proposed “Unstable personality disorder” instead.  However, Kernberg argued strongly, despite opposition, for his term “Borderline” which eventually prevailed because it was thought to be already familiar to most psychiatrists. Another well-known borderline proponent was Harvard psychiatrist/psychoanalyst John Gunderson MD (1942-2019) who also vigorously lobbied Spitzer for the inclusion of Borderline Personality in DSM-III.

According to historian Hannah Decker (The Making of DSM-III), the “borderline“ discussions consumed more time than any other personality disorder in the run up to DSM-III. Finally, Spitzer approved 11 psychoanalytically derived personality disorders without empirical validation and according to Decker “the clinicians desire for a popular disorder received primacy”.  Again, more sausage making than science.

A telling quote from Decker’s excellent research regarding the controversy amongst the members of the DSM-III Personality Disorders Task force comes from Donald Goodwin MD (1932-1999), who was one of the few non-psychanalytically trained psychiatrists of that era from the research-oriented Washington University in St. Louis; “The borderline syndrome is a mess… “Borderline” in the rest of medicine refers to early, mild or atypical cases of a presumed illness. We will never agree upon a diagnosis if the prototype for  the condition is based on early, mild or atypical cases…We are including under the rubric “borderline” early mild and atypical symptoms of a number of psychiatric conditions, including schizophrenia, affective disorders, obsessional neurosis and patients supersensitized  to their own mental content by an excess of psychotherapy (emphasis added)…In short, in my opinion,  the borderline syndrome  stands for everything that is wrong with psychiatry and the category should be eliminated and that simply renaming it will not help matters…I know  there are a substantial number of psychiatrists in the country who would agree with my points, and they all did not train under San Guze and Eli  Robbins” (both research oriented psychiatrists in diagnosis).

More Recent research on Borderline

 Clinical studies over the past 20 years however, help to shed new light, by careful analysis of the symptoms, course and genetics/family history of borderline and other personality disorders.

Studies show environmental heritability of classic PD’s is 66%. i.e. they are 2/3rds environmentally determined.

Borderline 37.1% and Antisocial 40.9% have the highest heritability of all  “personality disorders” (but nowhere near the heritability of Bipolar and schizophrenia at 85%).

So, genetics do not differentiate between various personality disorders but some environmental factors may differentiate between the clusters. (The Structure of Genetic and Environmental Risk Factors for DSM-4 Personality Disorders – A multivariant Twin Study.  Kendler et.al. Arc. Gen Psych 2008 65;(12): 1438-1446.)

Using the diagnostic hierarchy framework, as do other medical specialties, we start with the diagnostic categories with the most explanatory value, so mood disorders can also have psychosis, anxiety, dissociative states, alterations in attention and personality and past histories of abuse, so it is not necessary to list each of these as separate diagnoses, i.e. if you treat the mood disorder you will be treating all of these other symptoms as well.

A corollary of this hierarchy is that a “personality disorder” should not be diagnosed in the context of any mood episode, hypomanic/mixed/manic or depressed or in the 20% of the general population that has a mood temperament.

Hierarchy of Diagnosis

1. Mood Disorders – Bipolar & Unipolar or mood temperament – hyperthymic/cyclothymic/dysthymic.
2. Psychotic Disorders – Schizoaffective & Schizophrenic Spectrum
3. Anxiety Disorders – OCD, PTSD
4. Other – Personality Disorders – ADHD

                                                                           PG Surtees, RE Kendell. Br J Psych, 1979, 135:438-44

Nassir Ghaemi believes that only borderline and antisocial personalities have more valid differentiation in their symptoms than do the other personality disorders.  (Advanced Diagnostic Course 2021 – psychiatricletter.net)

DSM-5 BPD criteria (virtually unchanged since 1980)

Ghaemi’s analysis:

1. Fear of abandonment (unvalidated traditional Freudian theory)
2. Difficult interpersonal relationships (also occurs in hypomania/mixed/mania and the mood temperaments of Cyclothymia & Hyperthymia)
3. Uncertainty about self-image or identity (unvalidated traditional Freudian theory)
4. Impulsive behavior (also occurs in hypomania/mixed/mania and the mood temperament of Cyclothymia & Hyperthymia)
5. Recurrent suicidal behavior, gestures or threats or self-injurious behavior – (more unique to BPD)
6. Emotional changeability or hyperactivity (also occurs in hypomania/mixed/mania and the mood temperaments of Cyclothymia Hyperthymia)
7. Feelings of emptiness (unvalidated traditional Freudian theory)
8. Difficulty controlling intense anger (also occurs in hypomania/mixed/mania and the mood temperaments of Cyclothymia & Hyperthymia)
9. Transient stress related paranoid ideation or severe dissociative symptoms (more unique to BPD) (predominantly suspiciousness and disconnectedness i.e. “soft psychotic symptoms)

So only # 5 and #9 have modern empirical validation for a diagnosis of Borderline Personality. Pre-DSM-III trauma was considered the raison d’être by psychoanalysts as a cause of BPD. But to be atheoretical it was left out, leading to an over diagnosis of BPD with mostly non-specific criteria.

In 2007, four hundred members of two international associations, the Association for Research on Personality Disorders, and the International Society for the Study of Personality Disorders, were asked to take a 78-item web survey. the major results are as follows:

• 88% felt that Personality Disorders are better conceived of as personality dimensions or illness spectra, than as categories.
• The most frequently endorsed alternative system for PDs was a mixed system of categories and dimensions.
• Most experts preferred the PDs to remain on Axis II.
• Only 31.3% wanted the term, “Borderline Personality Disorder,” retained in the DSM-V. (The nearly 70% who did not want BPD retained thought it had come to be used frequently as an epithet and also due to its unverified Freudian origins).

 Conclusions: A clear majority of the PD experts were dissatisfied with the current diagnostic system for PDs. David P. Bernstein, PhD et.al., OPINIONS OF PERSONALITY DISORDER EXPERTS REGARDING THE DSM-IV PERSONALITY DISORDERS CLASSIFICATION SYSTEM Journal of Personality Disorders, 21(5), 536–551, 2007.

Part of their wish came true with the inclusion of a personality trait model, albeit placed less prominently in Section III – Emerging Measures and Models as “Alternative DSM-5 Model for Personality Disorders”. Apparently, the upper echelons of the American Psychiatric Association has difficulty extricating itself from the term “disorder”

As most psychologists know the well-researched personality traits since Eysenck in the 1950’s followed by Cloninger and many others are considered to be normative in humans and only problematic at the extremes.

Next post will be: Empirical criteria that differentiating between Bipolar Illness and Borderline Personality Disorder.