Perspectives on the Borderline: The Most Disordered Personality

Dr. O'Leary discusses some of the history of the borderline personality, how different perspectives have attempted to explain its origin, how to treat it and how not to treat it.  He starts in 1947 with some colorful descriptions of patients living with borderline personality disorder that would never get published today, and highlights some of the ways in which we have made progress (or not made progress) in our understanding of this disorder over the next 75 years.  As usual, Dr. O'Leary also waxes philosophical about science or the lack thereof in certain perspectives or treatments.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Transcript

Welcome to PsyDactic, today is Thursday, Feb 1, 2024 and I am your Host, Dr. O’Leary.  This is a podcast about psychiatry and neuroscience that I have been doing for about 2 years now.  I am a 4th year psychiatry resident, which means that I am still young in my psychiatric career.  I also have no editorial board or fact checkers working for me.  I am not a journalist, but I do consider myself to be an amateur science communicator.  Everything I say here is my opinion and should not be mistaken for the opinion of the US Federal Government, the Department of Defence or any subsidiaries thereof.  In this episode, I am going to explore what might just be the most discussed psychiatric disorder in history.  There have been innumerable books published about Borderline Personality Disorder by psychiatrists, psychologists, individuals with the diagnosis, and individuals lucky enough to be a close family member or long term intimate partner of someone with the disorder.

I am probably not going to add much or anything to this discussion, but what I will do is discuss some of the more colorful ways this disorder has been historically characterized and treated and contrast this to more contemporary approaches.  Spoiler alert, the differences are, in many ways, more semantic than substantive.  That’s a nice way to say that we haven’t really made much progress in the last 80 years and that in and of itself is fascinating to me.

Let me start with a little history of the way borderline personality was portrayed in the early 1900s.  I entered “borderline personality” into Pubmed and found a few gems that I will share with you now.  The earliest study I found in PubMed was from 1947 and was titled, “The treatment of psychopaths and borderline patients.”  The author was Dr. Mellita Schmideberg.  She describes patients who appear to be on the line between what historically was classified as neurosis and psychosis.  I quote:

“Such patients are unable to stand routine and regularity. They

transgress every rule… They do not associate freely and often

do not talk at all. They refuse to lie on the couch. They often

come for analysis only under persuasion or pressure and even when

they come on their own, their insight does not last nor carry them

through difficulties. Even when they try to cooperate, they cannot

sustain the effort. In their lives something always "happens,"

usually on the spur of the moment, entirely out of the blue. If

they are poor, they are likely to become criminals. In general, if

they belong to the upper classes they manage not to break the law

too flagrantly or, at least, not to get caught. Money and background

provide a greater latitude for abnormality so that people

merely describe their behavior as “erratic.” Yet in many cases

their antisocial tendencies are only too obvious and, either by omission

or commission, they hurt those who become associated with

them.

…Such patients cannot be treated by classical analysis, and since

they cannot be cured by anything short of analysis, we must modify

the method.” [Unquote.]

She believed that all of these patients were destined for a diagnosis of schizophrenia and she probably has in her patient population many patient that we would recognize today as having borderline personality disorder, but additionally many patients with prodromal or low-level psychotic disorders, and paranoid or schizoid traits.  She writes like one long stream of consciousness outlining her unorthodox methods, which include, among others things, actually talking to the patient and even sharing personal details, history, and desires with the patient in order to encourage the patient to show up.  Dr. Schmideberg notes that traditional psychoanalysis is inadequate to make any progress with her patients and insisting on it will probably just drive them away from treatment.

The article concludes with response letters from her contemporaries, including one from a Dr. Fritz Wittels who writes, “Dr. Schmideberg follows a method of her own in psychotherapy. My impression is that what she presented here was rather a piece of art than of an established science. Dr. Schmideberg is a champion in the treatment of psychopathy and juvenile delinquency. One is delighted but one cannot duplicate it. It is not for the first time in my life that I regret this inability.”

The next responding psychoanalyst, Dr. Emil Gutheil, also proposes that Dr. S “triumphs more by her personality than by the rules of science.” Dr. Gutheil tries to make sense of her method of including family members in treatment as “establishing a multiple transference to fit the polymorphous personality of the patients.”  I love the term “polymorphous personality,” because it eloquently captured what we now describe as a “stably unstable” personality.

There are a few things to highlight here.  The first is how these analysts struggle to fit these patients into their tidy analytic formulations and so they all admit that traditional approaches are not effective.  Another thing to notice is that while Drs. Wittels and Gutheil are being very generous with their praise, there is also a little jab in there.  Let me paraphrase, “She does art, but we do science.”  What psychoanalysts considered science is not what most modern scientists would recognize as science.  They had a model formalized by Frued and his successors that was applied more or less arbitrarily by those who wielded it.  Because it was a systematic process, they called it science, but psychoanalysts did very little to test their hypotheses.

Long Term listeners may recognize that I have a tendency to criticize the psychoanalytic approach and its descendants.  I do this because, for so long in psychiatry’s history in the US, they held a stranglehold over our progress in a way that was obviously unscientific.  I also often feel like this tradition can never actually embrace a scientific approach because it would require that they abandon their rigid models. Recently, I was in a course with a psychoanalyst, who gave us a review article claiming to prove that psychodynamic therapy was far more effective than any newer methods, including cognitive behavioral therapy and psychopharmacology.  The review article was actually a review of a selection of prior meta-analyses, so I decided to look into some of the studies that had been included in the analyses, especially those that were claiming effects sizes as high as 1.8 for psychodynamic psychotherapy.  For those who don’t know, that is a relatively huge effect size in psychiatry.  Most treatments hope to get something between 0.5 and 1.0.

When I explored the studies included in the most impressive reviews it became immediately clear that the patients included in the calculations were those who had actually completed 50 sessions of therapy.  I was surprised (but also not) that an analysis that did not include patients who did not do well with the therapy even made it to publication.  Just to be explicitly clear here, if you only include patients who completed a full course of therapy and that course is a very long one, then you are, in essence, excluding any failures from your data.  This is a classic way to stack the data in favor of a large, statistically significant effect size, or what we call p-hacking.  We only include patients who do well.  This is called pseudoscience, when your methods have all the trappings of science, but instead more resemble misleading marketing campaigns than actual science.  It is easy to win when you refuse to count failures as real.

I need to be fair here and point out that psychoanalysts are not the only people out there overstating claims.  More recently, what is of considered to be scientific is more technological in nature.  For example, a 2023 study in Progress in neuro-psychopharmacology & biological psychiatry reports to have discovered “transdiagnostic inflammatory and oxidative biomarkers'' that have “predictive capacity of self-injurious behavior.”   They identified chemical markers on various assays that were statistically associated with the conditions that they were measuring.  At the end of the study they asserted that their data is “strong,” and will “lay the groundwork for developing screening tests for these biomarker components to rapidly detect biological risk factors for specific impulse control disorders and future self-injurious behaviors.”  Similar to the claims of the psychoanalysts, these sorts of statements by researchers claiming to practice “biological psychiatry” can also be interpreted more as marketing than as dispassionate reports of preliminary results.  This study included only 35 pts with a diagnosis of BDP and 23 controls.  I suspect their confidence in their results vastly outweighs the power of their study to make such claims.  There are many claims like this in the literature and the more I read them, them more I assign the probability that they will actually be useful in the future as very low.

The desire to explain BPD in whole or in part by whatever is the most available or novel tests of the time is a common thread in the literature.  As far as I know, none have been fully satisfactory.  Some have noted that BPD may not be a thing in and of itself, but instead represent a more generalizable syndrome, a kind of general personality functioning failure or more broadly a generalized psychopathology.  There are entities called the General Personality Pathology Factors or general factors of personality disorders and something else called the p-factor.  The p-factor is more generalized to psychopathology as a whole and the other two are focused on personality functioning in particular.  According to a 2018 review, these factors have been described in what appears to be 3 separate and independent literatures, but all of them have been used to explain BPD.

One of these factors, let’s call it the GFP, was derived to a large extent from the 5 factor model that I discussed in the previous episode.  The other factor, I can call the g-PD, is reportedly very similar to criterion A of the alternative personality disorder formulations that were proposed in the DSM 5.  Also see my last episode for a discussion of this.  What both of these factors appear to capture is severe dysfunction in both intrapersonal and interpersonal functioning.  That is, patients with BPD have especial difficulty displaying a coherent and stable identity that they can also see as distinct from the identities of the other people.  Instead, their identity and perceptions of other’s identities appears to frequently arise de novo and is reformulated in reaction to whatever affective state someone with BPD finds oneself in.

The p-factor that I mentioned has been proposed to represent a kind of general tendency toward any kind of highly prevalent psychopathology, including affective disorders, psychotic disorders, anxiety disorders, obsessive disorders etc.  The core features of BPD can be seen as representing many of these.  Another proposal is that concepts like the p-factor are just statistical phenomena related to the way that we describe or interrogate psychopathology, using for example, opposing features like agreeableness versus antagonism.  Although there is likely a broad continuum, given binary options, we will likely fall out more toward the extremes.  One quote that I liked very much is from a paper by Caspi and colleagues in 2014.  They note that it is at least possible that the p-factor is [Quote], “merely a statistical reductio ad absurdum.”  Aside from sounding like a spell in Harry Potter, what I think this means is that this p-factor (and I am going to generalize this to the other two factors I mentioned) might just be statistical phenomena and not particularly meaningful.  It could also mean that all these factors are merely measuring the consequences of psychopathologies and not their etiology.  They describe them instead of explain them, and the consequences of various pathological factors can be very similar.  Check out Oltmanns et al in my references that you can find in the transcript at PsyDactic.buzzsprout.com.

To understand BPD, especially the more severe aspects of it, it is often more meaningful to actually describe a patient.  Again, I am going to rewind to 1956 and quote Dr. G Hill in the Psychoanalytic review.  I like older reports because the language is generally more colorful and descriptive.  In a case report, Dr. Hill introduces a patient as “a narcissistic, affect hungry, infantile young woman of 26...” and goes on to to describe her recent history as “three suicide attempts following drunken, extramarital sexual episodes,” and then asks the question, “...what type of object relationship does this patient make…”  He then describes a long and torturous history of a sexually and emotionally abusive mother who also supplied the patient with excessive amounts of alcohol from a very young age.  Stick with me for a much longer quote that I think helps to capture many of the facets that are included in a borderline personality diagnosis:

“Jenny would fall into the group of ‘borderline states’. Both in psychological testing and in clinical appraisal there was defective reality testing. For example, immediately on waking from an afternoon dream of purchasing a dress, she went out and did so without regard to her budget or her responsibilities to her children or her apartment. Such impulsive behavior stemmed from strong wishful thinking illustrating her overpowering narcissistic orientation. There were eruptions of primary process in her assaultive outbursts. Further evidence of distorted thinking is depicted on an occasion when she described how her 3-year-old daughter had persuaded her to expose her genitals and then proceeded to masturbate the patient. Questioning reduced this incident to one in which her daughter had actually only wanted to look under Jenny's dress. This was not falsification; rather it was a lack of individuation between herself and her daughter, another peril of her narcissism. A constant problem was her feeling of emptiness which she equated with being depressed; it was an instinct-driven affect hunger compelling her to seek excitement in situations that brushed aside any resistance offered by the impulse barriers of her ego. Such forays into sexual aggrandizement and into alcoholic and narcotic channels showed the critical decompensation of her ego and its syntonicity with her impulses. This was the situation at its worst, spanned, however, by periods of calm etiquette, charm and intelligence.”

In this description you might see how BPD can be characterized as generalized personality dysfunction or even an example of generalized psychopathology.  Now let’s take a look at how that description lines up with current DSM criteria.  The DSM describes the primary condition of BPD as “a pervasive pattern of instability of interpersonal relationships, of self-image, and affect as well as marked impulsivity.”  It then lists 8 additional criteria, 5 of which are required for a diagnosis.  These criteria do not appear to me to be independent of each other.

With regard to interpersonal relationships, patients with borderline PD may display “frantic efforts to avoid real or imagined abandonment,” or “a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.”  These traits often result in “inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of temper, recurrent physical fights.”

With regard to the description of Jenny, Dr. Hill also noted many assaultive outbursts and described a “lack of individuation between herself and her daughter.”  This lack of individuation means that Jenny has difficulty knowing the boundaries between who she is and what she wants and the identities and desires of her daughter.  This lack of a clear self-identity spills over into all her relationships.

A related feature of borderline personality disorder is the tendency to split, which the DSM calls extremes of idealization and devaluation.  In relationships, splitting may have to do with a transient feeling that someone else fills up that empty space inside, but then, invariably, the other person turns out to be, well, just an ordinary human.  This fact… their lover’s or friend’s or therapist’s humanness, is experienced in the borderline mind as a betrayal.

Whatever prevents Jenny from experiencing a coherent sense of self as distinct from others is also likely related to her tendency toward dissociative symptoms such as depersonalization or derealization, where she either loses a sense of the boundary between herself and her environment or experiences the world as if in a dream state.  Jenny’s sense of self and of companionship is fragile and she is able to lose her grip on them with the slightest stress.  For those of us who have never experienced this, it can be difficult to conceptualize: having such an undeveloped sense of self combined with instability of interpersonal interactions and apparently primitive skills at controlling emotions and impulses.

Jenny also describes chronic feelings of emptiness that she believes are signs of depression.  Jenny is also intermittently impulsive, which we might characterize as behavioral instability that could be related to whatever is resulting in her unstable identity.  She may go on unplanned shopping sprees, sexual escapades, substance use binges, etc.  Her behavioral instability is also complemented by affect instability, where her feelings in whatever moment appear independent of any wider perspective, and often, the result is assault, self-harm, or suicide attempts.  She may then experience intermittent periods of relative calm and composure.

One might see how borderline personality disorder got its name.  A patient appears, like many psychotic patients, to have disorganized thoughts and behaviors. They can also report transient perceptual disturbances, especially during dissociative episodes.  They may be gripped by a sudden paranoia and lash out at those around them under the assumption that they are being harmed or abused or used.  In addition to disorganized thoughts and behaviors, their mood appears equally disorganized.  Back when psychiatrists split symptoms into the categories of neuroses and psychoses, borderline patients appeared to suffer alternately from both.

Now that I have discussed a little of the historical ways BPD has been described and how those descriptions line up with current diagnostic criteria, I want to discuss some of the research into BPD that attempts to distinguish it from disorders with similar symptoms.  One similar disorder that appears in the ICD-11 but not in the DSM is complex PTSD which is also similar to a diagnostic entity called developmental trauma disorder.  The main idea is that BPD results from disrupted personality development that is the result of abuse, neglect, trauma, or instability during early development.  I have colleagues who agree that BPD should be moved to the trauma-related disorders in the DSM.  Given the imperfection of the DSM as it is, I am sympathetic to this view, as not perfect, but maybe better.  A review titled “Complex PTSD and borderline personality disorder” in 2021 concluded that PTSD, cPTSD, and BPD have distinct features but that are also highly comorbid and may represent a kind of continuum or spectrum disorder.

While trauma is a prerequisite for PTSD and cPTSD, it is not for BPD and not everyone with BPD reports a childhood or adolescent history of trauma, neglect or instability.  However, it is extremely common among patients with BPD.  Here is a quote from the review I just mentioned:

“Adults diagnosed with BPD have been shown to be three times more likely than adults with other psychiatric or personality disorders to have experienced childhood maltreatment, and 13 times more likely than adults with no psychopathology. Emotional abuse and neglect were particularly prevalent, with BPD associated with more than 30 times increased likelihood of the former and more than 20 times increased risk of the latter, as compared to non-clinical adult samples. Physical abuse and neglect, and sexual abuse also were more prevalent for BPD cohorts than non-clinical controls, with an approximately seven times increased likelihood among BPD-diagnosed persons.”

One might conclude from this that BPD is caused by environmental factors.  However, a very large prospective population level study in Sweden that analyzed data from 1.8 million people estimated the heritability of Borderline personality disorder at 46%, meaning that genetic components account for a little less than half of the variability in whether someone is diagnosed with borderline personality disorder or not.  This study looked at BPD as a binary variable and not as continuously varying traits.  It also reported that variation that could be attributed to environmental factors determined by the family itself (including things like socioeconomic status or religion) was insignificant both in magnitude and statistically in their best fit model.  Of those diagnosed with BPD, 85% were women and the authors caution the reader against generalizing the results to men.  It could be that men with traits of BPD are more likely to get diagnosed with something like antisocial personality disorder instead, because they are seen as more threatening and when they act impulsively or out of anger, this is characterized as a violation of the rights of others instead of as self-harm or quote “histerical” behaviors.  We just don’t know for sure.

What appears to be the case is that there is a strong genetic by environmental interaction that results in the features of BPD that reach diagnostic significance.  In the Swedish study, I could also not find a description of how they assessed for trauma exposure explicitly.  They did report that they would consider this to be an individual risk factor and not a familial one.  It remains unclear what correlation there is between genes and environmental exposure.  What I mean by that is whether genetic components might increase the rate of behaviors that result in trauma or contribute to unstable environments, and these feed back on themselves to greatly increase the risk of BPD.  We don’t have good data for that.  We also don’t know what the particular genetic components are that contribute to a diagnosis of BPD and exactly how these are shared with other disorders of affect and behavioral regulation.  There are papers that identify some candidate genes that are common in multiple diagnoses, but I don’t have time to get into that.

BPD that results from, is instigated by, or associated with a trauma history may be a distinct cluster within the possible BPD symptom combinations.  According to a 2017 paper that attempted to find these clusters, there are two hundred fifty-six possible symptom combinations that can result in a BPD diagnosis.  Their analysis resulted in a proposed 3 separate clusters.  One of these clusters which they called the extravert/externalizing cluster were composed of those patients with symptoms shared by other cluster B diagnoses, including histrionic, narcissistic and antisocial personalities.  Another cluster, which was less common, were patients with a large degree of schizotypal and paranoid features.  The most common cluster, though, was composed of what they consider to be “core symptoms” of BPD, and this cluster had the most severe features including identity disturbance.

Statistically, it makes sense that not everyone who is diagnosed with BPD will have a trauma history.  Most likely the group of patients with a BPD diagnosis have variable pathologies and etiologies for their particular traits.  However, it is clear that developmental trauma puts people at a much higher risk of developing the core features of a borderline personality.

I am getting near the time limit I have set for myself for my ramblings.  Before I end, I want to highlight a bit about the treatment of BPD.  The early psychoanalysts were right when they supposed that these patients need therapy, but that their kind of therapy was not well suited for the job.  The frequency of crises or what Dr. Schmideberg described as “something alway happens” in the lives of BPD can make it seem difficult to make progress in any therapeutic regimen.  Life-threatening behaviors are common and of course, they take priority over everything else, but a large part of the therapy for BPD includes reducing the frequency and intensity of these crises.  It can seem like a daunting task to evaluate for suicidality in someone with chronic relapsing and remitting suicidal behaviors, and these patients may suffer from the fact that people in their lives may stop taking these behaviors as seriously as they should be taken.

A full assessment for intent and means should always be conducted and exploration of ways to address whatever triggered the current episode.  Although it is no longer common practice and it is NOT standard of care for most suicidal patients to make a no-suicide contract where the patient agrees not to commit suicide and then signs a paper, it may be necessary to have BPD patients make commitments to not engage in self-harming or suicidal behaviors while in treatment as a means to keep the treatment going.  These contracts should never be seen as legitimate risk reduction tools or as legal release forms that protect the therapist from liability.  Therapists are still responsible for a thorough safety evaluation.  Instead they are tools to communicate to patients that their treatment cannot progress in the midst of constant crisis.

Alternative ways to deal with the stress besides self harm or suicidal acts or threats in the moment have to be provided and in some cases I have seen or heard of therapists giving personal phone number to patients as a way to provide them with an outlet.  I am not recommending that therapists do this, or making any other recommendation.  I am just reporting that I have seen it done.

Psychotherapy is the only thing shown to be effective for BPD, although nearly all patients being treated for BPD will find themselves on one or more psychotropics.  Many will be on multiple medications including antidepressants, mood stabilizers, sedative-hypnotics, anxiolytics, or antipsychotics.  About 1 in 5 patients with BPD will be on 4 or more medications.  Current recommendations stress avoiding medications unless a clear comorbid condition is identified.  Even then, psychotherapy focused on that particular symptom cluster may still be the best way to start.

For medical students taking their qualification exams, dialectical behavioral therapy or DBT is generally the right answer, but other forms of therapy can be used with similar results.  These include mentalization-based therapy, transference focused psychotherapy, and schema therapy.  Finding therapists that specialize in these treatments can be difficult and many, at least in my region, will not accept insurance.  Those that do are often in the inpatient setting, where limited gains can be seen because the patients are not dealing with their issues in real time.  The characterization by Drs. Wittels and Gutheil in 1947 of the treatments for borderline being more an art than a science doesn’t ring as true today, though both DBT and schema therapy are rather eclectic, they are not anything approaching the seat of the pants therapy that Dr. Schmideberg described.  However, the instability of BPD patients requires a level of improvisation and adaptability on the part of a therapist that can be described as an art form.

Although BPD is often severely disabling and difficult to treat, many patients will remit with therapy or at least make substantial improvements.  Time itself often changes the character of BPD, with depressive and avoidant symptoms becoming more dominant with age, whereas impulsive risky behaviors may have been more common in youth.  

I also have not yet addressed the stigma resulting from both a diagnosis of BPD and from reactions to some of its core characteristics such as self-harm, suicidality, idealization followed by devaluation, and impulsivity.  Also, BPD patients through time often become more and more intense medical resource utilizers with many vague and difficult to treat somatic complaints along with higher rates of chronic medical conditions.  As they age, these patients also frequently become increasingly isolated.  Part of a psychiatrists job, especially in consult and liaison roles is to educate other providers about the severe disability associated with BPD and encourage providers in the hospital to not take personally the actions, words, or accusations of these patients.  It can be difficult to insist on healthy boundaries, while at the same time not just avoiding interactions with borderline patients, while at the same time continuing to provide them with excellent care.  Part of this balance includes encouraging empathy in both directions, from the patient to providers and provider to patient.

Thanks for hanging with me today.  For a more structured and complete review of borderline personality disorder, I suggest you go to PubMed and type in Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies.  This is an article officially dated February 2024.  I would also appreciate any feedback you might have.  I have a form you can complete at psydactic.com and I also have a YouTube channel.  You can search for me @Psydactic and leave a comment on a particular episode.  I am excited to bring you an interview next week with Dr. Jon Lindefjeld who will have a conversation with me about HIV psychiatry.  Tell your friends and your mom to tune in.

Thanks again for listening, I am Dr. O and this has been an episode of PsyDactic.

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