Understanding Borderline Personality Disorder: Putting the Person First

The utility of the diagnostic criteria for borderline personality disorder (BPD) is that they reliably and fairly accurately identify a group of people that have some overlapping difficulties and needs, and about which some reasonable generalizations can be made. People with BPD have in common a life history and an internal experience that generally speaking is characterized by instability, with difficulty in establishing a strong sense of self and consistent, satisfying relationships with others. In general, the causes of these difficulties are multifactorial, and can only be understood through sorting through with great care the patient's personal, medical and psychological histories. In general, psychotherapy is more helpful than medication for these difficulties, although medications may help in managing the extremes of impulsivity and unstable emotions. In general, it is most helpful when psychotherapy can be long term, is conducted in an atmosphere of stability, trust and honesty, and is carried out by a practitioner who has experience in working with personality disorders. If we look at the diagnostic criteria, however, we see that there are literally hundreds of ways of selecting and combining the criteria to make a psychiatric diagnosis of BPD. For this reason, generalizations inevitably will break down, because no person who has BPD has exactly the same difficulty as another.

Borderline personality disorder is among one of the most commonly diagnosed psychiatric disorders, and many people come to Riggs with BPD as one of their diagnoses. BPD has been associated in the medical literature with problems experiencing benefit from treatments such as medication or psychotherapy. BPD has also been in the news in recent years, both in professional medical and psychological literature as well as the popular press. It's common to hear that various celebrities have or had BPD, and medical news stories report both problems in treatment of BPD and successful treatment interventions. Meanwhile, the medical literature also cautions us that borderline personality disorder is commonly associated with suicidal ideation, self-harm, and depression that may not always respond well to treatment. These various and sometimes conflicting messages can be confusing to someone trying to understand the disorder. How do we make sense of this information, and how do we use this information to think about what can help a patient struggling with borderline personality disorder?

A key concept I always return to in thinking about personality disorders is that they are syndromes, and not diseases. This may seem like a somewhat abstract distinction, but it's important. The difference is that a disease has a specific and identifiable cause; a syndrome is a recognizable grouping of signs and symptoms. Diabetes is a disease. We know very well what causes diabetes, and we can intervene with specific, effective treatments. Borderline personality disorder is a syndrome. Although there has been extensive research into the disorder over the past few decades and we know a lot about factors that may contribute to BPD, there isn't one single, identifiable, consistent cause. We do have treatments that can be helpful, but there isn't one single intervention that cures BPD, and one person with a diagnosis of BPD may have very different needs compared to someone else with the same diagnosis.

The term "chemical imbalance" is commonly used both by psychiatrists and by people struggling with mental health disorders. Many people don't realize that although there are a number of types of evidence supporting the hypothesis that dysregulation of neurochemicals contributes to mental illness, there actually has never been a set of clear, identifiable markers of neurochemical imbalance that differentiates people with specific mental illnesses. This is particularly true of borderline personality disorder, which has been more consistently connected with childhood adversity than with biochemical abnormalities. Does this mean that neurologic and neurochemical abnormalities have nothing to do with borderline personality disorder? That would be too absolute a statement. It is probably the case that some people with borderline personality disorder have difficulties regulating their mood and managing impulses that could be understood better using neuropsychiatric information. Is it the case that childhood trauma or an early invalidating environment "causes" borderline personality disorder? Both of these types of early adversity have been connected to borderline personality disorder, but again, to try to draw a straight line from one cause to this syndrome is too simple. The fact is, many people have severe early traumatic experiences and may have post-traumatic stress disorder, but don't meet criteria for a personality disorder, and many people with borderline personality disorder can't point to a simple environmental cause.

In thinking about borderline personality disorder, it's important to think about the individuality of the person carrying the diagnosis. A person with BPD isn't "a borderline," but is a person first and foremost. In making the diagnosis of a personality disorder, a clinician takes into account a full, thoughtful assessment not just of symptoms, but also of all the relevant psychological, social, and relational information. What is the person's history? How does he feel about himself? What are her relationships like? How does he handle stress? What is she particularly good at? What challenges was he not able to master as he developed from a child to an adult?

At Austen Riggs, we treat the person, not the diagnosis. In my view, this approach is particularly relevant to the treatment of borderline personality disorder and related conditions. Although this is a strong emphasis at Riggs, Riggs is not unique in focusing on interest and concern about the individual. Dialectical behavior therapy (DBT), mentalization-based treatment (MBT), transference-focused psychotherapy (TFP), and alliance-based therapy are just a few of the psychotherapeutic interventions developed to help patients with BPD, and all have in common the importance of a relationship with a therapist and other treaters that involves attunement to the particularity of the feelings, needs, and experiences of the individual. There are many types of treatments that may be helpful to a person with BPD; the key point in seeking treatment is to put the person first, not the diagnosis.