Controversies About the Borderline Diagnosis

Minggu, 03 Januari 2010

The term borderline originated from the psychoanalytic notion of a level of personality organization that was in between, or on the border of, the psychotic and the neurotic disorders. Although BPD has become of interest to mainstream psychiatry and psychology and is no longer solely a psychoanalytic construct, the name borderline has persisted; the search continues for other mental disorders that lie along the border with BPD.

An early hypothesis was that BPD represented patients with borderline schizophrenia. The Danish Adoption Study of Schizophrenia (Kety et al. 1968) identified a cohort of patients with a nonpsychotic form of schizophrenia who had a genetic relationship to schizophrenic parents.

Features describing these patients were included in Spitzer and colleagues’ (1979) empirical attempt to identify diagnostic criteria for BPD.

These traits of deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior eventually came to describe the characteristics of schizotypal personality disorder, whereas BPD itself continues to be associated more with the borderline concept that grew from the psychoanalytic literature.

The next wave of research raised the issue of whether BPD was an atypical form of mood disorder. Because of the rapidly shifting mood states that characterize individuals with BPD, the latest version of this controversy is that BPD represents a treatment-refractory, rapid-cycling form of atypical bipolar II disorder (with only hypomanic or low-level mania experienced, not full-blown mania). Although this theory has led to the frequent prescription of mood-stabilizing medications, which can be
helpful for the affective instability in some cases, the bulk of the evidence fails to support the equivalence of BPD and any mood disorder (Gunderson and Phillips 1991). Although it is certain that mood disturbance and diagnosable mood disorder may coexist with BPD, mood disorder alone cannot account for the fears of abandonment, the particular types of interpersonal relatedness, and the impulsivity of BPD patients.

Most recently, the interest in childhood abuse as an etiological factor in BPD and the prevalence of posttraumatic stress disorder (PTSD) as a comorbid (or co-occurring) condition have led to studies investigating whether BPD was a variant of PTSD. Here too, research has shown that PTSD and BPD have certain features in common but that the psychopathology and functioning of BPD cannot be reduced to a variant of PTSD (Gunderson and Sabo 1993; Zlotnick et al. 2003).

A corollary to the search for a border disorder for BPD has been the search for a new name. If it is true that BPD is not really a variant of or on the border with any other major mental disorder but is a major disorder in its own right, perhaps the borderline concept has outlived its usefulness and ought to be replaced with a more descriptively accurate and potentially more useful term. The term borderline has also been used pejoratively to describe patients who “misbehave” or are difficult to treat because of their extremes of behavior and the fact that therapists often become entwined in their interpersonal problems. The most commonly suggested alternative names are emotional dysregulation disorder and emotional regulation disorder, which have been suggested by those who consider affective instability to be the core disturbance of BPD; the name emotional/impulse (dys)regulation disorder has been suggested by those who argue that at least two core disturbances exist: affective instability and impulse control. Because the fundamental basis of the disorder is not understood, there do not appear to be clear scientific grounds to resolve the controversy over a name change. Therefore, because the diagnosis of BPD has acquired widespread clinical usage and is recognized by clinicians who deal with patients with personality disorder as a clinically useful construct, its name will probably remain unchanged for the immediate future.