Dancing on the Borderline

Part 2

by Alicia Potter

Though experts disagree on its exact nature, causes, and treatment, borderline personality disorder is recognized as a major mental-health problem in America today. About six million people are afflicted with BPD in North America, as many as suffer from schizophrenia and bipolar disorder combined; all told, BPD sufferers make up 20 percent of the inpatients and 11 percent of the outpatients in the mental-health system, according to the Journal of the California Alliance for the Mentally Ill.

BPD is hardly a new disease: the term "borderline" was first used in 1938 by psychiatrist Adolph Stern, and descriptions of borderline-type behavior date back to the "hystericks" of the 17th century. Stern used the term to describe a group of patients whose problems did not fall neatly into the primary diagnostic classifications of "neuroses" (mental disorders characterized by feelings of anxiety, depression, and insecurity) or "psychoses" (more severe disorders characterized by derangement of personality and a loss of contact with reality). They teetered on the borderline. His theory later lost favor, but the name stuck. So did the ambiguity. Even with breakthrough work by psychoanalysts Otto Kernberg in the 1960s and John Gunderson in the 1970s, the disorder eluded widespread recognition for more than four decades. Only in 1980 did it gain inclusion in the American Psychiatric Association's Diagnostic and Statistical Manual, the diagnostic bible of the psychiatric profession.

And BPD continues to flummox the psychiatric community. Legions of sufferers -- three-quarters of whom are women -- go without proper care because they are misdiagnosed with other illnesses. Meanwhile, many therapists shrug off the disorder as a "wastebasket diagnosis," slapping the label on any patient whom they eye as unusually difficult, or even unpleasant, to treat.

Pinpointing BPD is not as simple as checkmarking a list of behaviors (see "Borderline Personality Disorder: A Definition," this page). We've all had moments when we've lost our tempers or sunk into depression, only to snap out of it a few days later. But true BPD patients display chronic, intense behavior, not just a string of bad days.

BPD sufferers exhibit a hypersensitivity to the world that has led many clinicians to compare them to "emotional hemophiliacs." This makes for tumultuous, soap opera-scale relationships. Overwhelmed by the emotional demands of society, sufferers of BPD lash out at the ones they love, either by "acting out" (raging) or by "acting in" (punishing themselves with self-mutilation or other self-destructive acts). The combination of a BPD patient's hair-trigger rage and deep fear of abandonment often sends such mixed signals that the author of a popular book on the disorder titled it I Hate You, Don't Leave Me.

It's common for BPD to coexist with other disorders. A startling proportion of patients -- some say nearly 75 percent -- have survived acute trauma, most commonly physical, verbal, or sexual abuse. Many of those have been diagnosed with posttraumatic stress disorder. Sholeh, like many BPD sufferers, has also been diagnosed with attention-deficit disorder. BPD is famously difficult to isolate.

In some circles, in fact, BPD has been dismissed as the "women's illness of the '90s." Experts believe the gender disparity in BPD diagnosis exists, in part, because women are more likely than men to suffer abuse. Women, too, are more likely to seek psychological help; when men act out violently, their behavior may not be perceived as a sign of mental disorder, or it may land them on a cellblock cot instead of a therapist's couch.

BPD certainly folds all the vogue female traumata of recent years -- eating disorders, sexual abuse, drug and alcohol addiction, compulsive shopping, and depression -- into one convenient diagnosis. But John Gunderson, a clinical psychiatrist at McLean Hospital, in Belmont, and a pioneer in BPD research, believes that borderline personality disorder is a very specific illness -- not simply a response to trauma or a variation on more well-defined mental-health problems.

"These are people, usually women, who grew up feeling they didn't get the needed amount of attention and nurturing," Gunderson says. "They are angry about this and are searching for ways to make up for it in their relationships. They have high expectations and become angry, desperate, and self-destructive when let down."

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Alicia Potter is a freelance writer living in Boston.