Controversies persist within the mental health community about the borderline diagnosis. It is easy and not uncommon to misuse this diagnosis, and this possibility remains in large measure a result of the emotional responses such patients engender.
Some psychiatrists believe that the foundations of our diagnostic system should be more biologically based than is the borderline diagnosis. They believe that dynamic considerations are superficial and that the major therapeutic importance of diagnosis is to guide pharmacotherapies.
The term 'borderline personality disorder' was initially suggested in the 1930s by therapists as a means of identifying a group of clients who did not fit into the usual categorizations at the time. Back then, people-in-recovery were broadly categorized as either 'neurotic', including what we now refer to as anxiety and depressive disorders, or 'psychotic', including what we now refer to as bipolar disorder and schizophrenia.
The essential features of BPD represent a pervasive pattern of marked impulsivity and instability in interpersonal relationships, self-image, and affects (moods and emotions). As with all personality disorders, these problems usually have their onset by late adolescence or early adulthood and are manifested in a variety of situations and life contexts.
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.
The emotional features of the borderline diagnosis make recurrent suicidal behaviors extremely common. Feeling chronically empty and worthless, experiencing extremes of emotions, and being impulsive are a certain recipe for these behaviors. They frequently take the form of what psychiatrists call suicidal gestures. These are attempts at self-harm that are unlikely to cause death, but rather seem to be intended to send someone a message.
Usually people with BPD cannot conceive of being angry and loving toward the same person in the same moment. Similarly, they cannot imagine accepting themselves exactly as they are and viewing their "dysfunctional" behaviors as actually containing a bit of wisdom and functionality. When a person with BPD can truly embrace opposite concepts, ideas, and feelings in the same moment, a synthesis has occurred, and in this synthesis is the basis of healing from the disorder.
Dialectical behavior therapy focuses on developing skills for handling stress, regulating emotions, tolerating negative emotions, and improving relationships. DBT was developed specifically to treat borderline personality disorder, and research has shown it to be an effective approach.
Borderline personality disorder afflicts about 2 percent of the general population, according to the Diagnostic and Statistical Manual, and it is twice as common as a much better-known disorder, schizophrenia. (Other studies suggest the prevalence is as high as 6 percent.) Many borderline patients hurt themselves, and 10 percent die by suicide.
There are several theories about why the number of borderline diagnoses may be rising. A parsimonious explanation is that because of advances in treating common mood problems like short-term depression, more health-care resources are available to identify difficult disorders like BPD. Another explanation is hopeful: BPD treatment has improved dramatically in the past few years. Until recently, a diagnosis of borderline personality disorder was seen as a "death sentence," as Dr. Kenneth Silk of the University of Michigan wrote in the April 2008 issue of the American Journal of Psychiatry. Clinicians often avoided naming the illness and instead told patients they had a less stigmatizing disorder.