Initially, it was suggested that borderline disorder bordered on, or overlapped with schizophrenia, non-schizophrenic psychoses, and neuroses such as anxiety and depressive disorders.3 Because it seemed to resemble other psychiatric diagnoses, it was commonly believed to be a “wastebasket” diagnosis, lacking in diagnostic precision and validity, and only useful for patients who did not fall clearly into other diagnostic categories. It also was observed initially that the disorder responded very poorly to treatment with psychotherapies, and to medications when they first became available. Unfortunately, a large number of mental health professionals, even those in academic settings, apparently unfamiliar with the scientific literature published on borderline disorder over the past 50 years, still think that this is true.
However, a substantial number of research studies have now shown that borderline disorder does have diagnostic validity and integrity.3 Some studies indicate that the disorder does not overlap with schizophrenia. Also, the disorder does appear to be a distinct diagnostic entity, although it co-occurs frequently with other mental disorders such as major depressive and bipolar II disorders, attention deficit hyperactivity disorder (ADHD), substance use disorders, post-traumatic stress disorder (PTSD), and with several other personality disorders.3
Most importantly, medications and specific forms of psychotherapy have been shown to be effective in the treatment of borderline disorder, thereby providing substantial hope to those who suffer from it, and to their families and friends.
The following is a historical review of the major advances in our understanding and treatment of borderline disorder.
- Descriptions of individuals demonstrating the symptoms of borderline disorder were first mentioned in the medical literature almost 3000 years ago.4
- In 1938, the American psychoanalyst Adolph Stern published one of the most important articles to appear on borderline disorder, then or since. In it, he described in detail most of the symptoms that are now considered diagnostic criteria of the disorder.5 He correctly suggested the likely causes of the disorder, and listed the fundamental principles of what he believed to be the most effective form of psychotherapy for these patients, many of which are currently in use. Finally, he named the disorder by referring to patients with the symptoms he described as “the border line group.”
- The psychoanalyst Robert Knight, in the 1940s, introduced the concepts of ego psychology into his description of borderline disorder. Ego psychology deals with mental functions that enable us to realistically perceive events, successfully integrate our thoughts and feelings and to develop effective responses to life around us. He suggested that people with borderline disorder have impairments in many of these functions, and he referred to them as “borderline states.” 4
- The next major contribution in the field was made by the psychoanalyst Otto Kernberg. In the 1960s, he proposed that mental disorders were determined by three distinct personality organizations: psychotic; neurotic and “borderline personality.” Kernberg has been a strong proponent of modified psychoanalytic therapy for those patients with borderline disorder who are able to benefit from it. 4
- In 1968, Roy Grinker and his colleagues published results of the first research conducted on patients with borderline disorder, which he referred to as the “borderline syndrome.” 4
- The next major advance occurred in 1975 when John Gunderson and Margaret Singer published a seminal and widely read article that synthesized the relevant, published information on borderline disorder, and proposed its major characteristics. Gunderson then published a specific research instrument to enhance the accurate diagnosis of borderline disorder. This instrument enabled researchers over the world to verify the validity and integrity of borderline disorder. Subsequently, borderline personality disorder first appeared in DSM-III as a bona fide psychiatric diagnosis in 1980. 4
- In 1979, John Brinkley, Bernard Beitman and Robert Friedel provided anecdotal evidence that medications, specifically low doses of neuroleptics (now referred to as antipsychotic agents), are effective in reducing some of the symptoms of borderline disorder.6 Friedel’s research team published support for this proposal in 1986 in one of the first two placebo-controlled studies of any medication in subjects with borderline disorder. A similar finding was reported in the same journal by Paul Soloff’s research team with a different medication in the same class. Since then, other controlled studies of similar agents have supported and extended the original finding. In addition, medications in other classes have been reported to have efficacy in treating the symptoms of borderline disorder. 27
- In the 1980s, the first of a large number of neuroimaging, biochemical and genetic studies were published indicating that borderline disorder is associated with biological disturbances in those brain areas related to the symptoms of the disorder.23
- In 1991, Marsha Linehan introduced Dialectical Behavior Therapy (DBT), a specific and now well-documented form of psychotherapy for patients with borderline disorder prone to increased anger, self injurious behavior and who require and request frequent, brief hospitalizations. 34 Since then, other forms of psychotherapy have been developed that are specifically designed for borderline disorder.
- More recent advancements in the field of borderline disorder have been a marked improvement in understanding its prevalence and disabling effects, its fundamental nature, and the development of specific and effective methods of pharmacological and psychological treatment.
- Over the past twenty years, a number of lay support and advocacy organizations have been founded, or expanded their interest, to enhance awareness of, knowledge about, and treatment for borderline disorder. The most prominent ones include the Borderline Personality Disorder Resource Center, the National Education Alliance for Borderline Personality Disorder (NEA-BPD), the Treatment and Research Advancements Association for Personality Disorder (TARA APD), and the Black Sheep Foundation (BSF). The missions of these organizations are to increase the awareness of borderline disorder and its treatments, provide the names of clinicians skilled in the diagnosis and treatment of borderline disorder, and provide support and educational opportunities to those suffering from the disorder and their families and friends. In the last decade, the National Alliance on Mental Illness (NAMI) added BPD to its list of high priority mental disorders.
For example, the Borderline Personality Disorder Resource Center was developed to assist individuals who may have borderline disorder and their families in locating clinicians skilled and experienced in the diagnosis and treatment of borderline disorder and to provide other helpful information. The Black Sheep Foundation was recently organized to increase federal and private research funding dedicated specifically to BPD, and to decrease the stigma associated with the disorder. Since 1987, the Brain Research Foundation has awarded more than $1 million for research on borderline disorder research in addition to research on other mental illnesses. See Chapter 13 in my book Borderline Personality Disorder Demystified for more information about the importance of research on borderline disorder and what you can do to help.