Borderline Personality Disorder: Retaining the Name for Diagnostic Clarity

The diagnosis of borderline personality disorder (BPD) has been subject to repeated calls for renaming, motivated by concerns about stigma, imprecision, and historical baggage. Other terms such as emotionally unstable personality disorder (EUPD) are often offered as more humane or clinically neutral alternatives. While well-intentioned, these efforts risk misunderstanding the role diagnostic terms play in psychiatry. Names do not merely reflect social and cultural attitudes; they also carry theoretical, phenomenological, and clinical information.

Despite its imperfections, the term borderline should be retained. Changing the name of a psychiatric disorder does not change the nature or complexity of the underlying psychopathology. Moreover, borderline is not an empty or archaic label. It retains a specific meaning within contemporary object relations theory, captures clinically essential features of the disorder, and serves as an important reminder of patients’ vulnerability to transient psychotic symptoms, an aspect of the condition that is insufficiently emphasized in current diagnostic systems.

What Renaming Cannot Do

• Renaming does not eliminate stigma.

A recurrent assumption in renaming debates is that the label borderline has been employed in a pejorative way to refer to patients perceived as difficult or disruptive, often because of the intensity of their behaviors and the way clinicians can become drawn into their interpersonal dynamics.¹ For some, changing the name of BPD is seen as an almost magical solution that would eliminate the stigma associated with these patients.

However, there is no evidence that renaming a disorder prevents stigma from attaching to the new label.² Only a few generations ago, terms such as schizophrenia or cancer were considered unspeakable. These names were not abandoned; instead, public understanding of the conditions they referred to was gradually transformed. Today, we speak of comprehensive schizophrenia services and centers of excellence in cancer care. Therefore, before substituting one diagnostic term for another, a deeper understanding of the disorder itself is required.²

Another claim in the debate related to renaming is that diagnostic terms substantially shape the disorders they denote. This view implicitly treats psychiatric conditions as socially constructed entities whose nature can be revised by terminological fiat. While language certainly influences clinical attitudes and behavior, psychiatric disorders are not created (or dissolved) by changes in nomenclature. As has been argued elsewhere, diagnostic terms are consequential not because they create illnesses, but because they guide clinical reasoning, research programs, and treatment decisions.³

A change in name does not alter the basic phenomenology, longitudinal course, familial aggregation, or treatment response of the disorder itself.⁴ The question, therefore, is not whether borderline is a perfect term but whether proposed alternatives better capture the clinical reality they purport to describe.

• Renaming does not eliminate the psychopathological complexity.

Contrary to frequent claims, borderline is not a vague historical relic. Within contemporary object relations theory, it refers to a particular level of personality organization, characterized by identity diffusion, reliance on primitive defenses (particularly splitting), and generally intact reality testing.⁵ BPD is the prototypical clinical manifestation of borderline personality organization.

This usage is neither obsolete nor merely psychoanalytic jargon. It provides a coherent framework for understanding patients whose psychological functioning cannot be adequately captured by trait descriptions alone. The term borderline situates BPD within a broader model of personality structure, linking observable symptoms to underlying psychological organization.

Importantly, this conceptualization explains why BPD cannot be reduced to symptoms such as emotional dysregulation. Affective instability is prominent, but it is embedded within a broader syndrome of unstable self-representation, interpersonal hypersensitivity, oscillations between idealization and devaluation, and fluctuating mentalization capacity together with impulsivity and urge to act (rage or self-harming behaviors), that have the sense of organizing unstable and intolerable affects. The term borderline captures this structural complexity in a way that symptom-based alternatives do not.

• Renaming does not ease the challenge of vulnerability to psychotic symptoms.

One of the most clinically significant features of borderline pathology is patients’ vulnerability to transient psychotic symptoms under stress.⁶ These phenomena—paranoid ideation, delusional beliefs, dissociative experiences, and brief hallucinations—have been recognized since early descriptions of the disorder^7,8 but are only weakly represented in current diagnostic criteria.⁹

The term borderline serves as an important heuristic reminder of this vulnerability to stress-related psychotic regression and signals a condition that lies at the interface between neurotic- and psychotic-level functioning. Clinically, this has major implications for assessment, treatment planning, and differential diagnosis. By contrast, terms that foreground emotional instability alone risk obscuring this dimension of the disorder. When clinicians are insufficiently attuned to the psychotic potential in borderline pathology, misdiagnosis can occur, and patients may be either overtreated as having a primary psychotic disorder or undertreated when psychotic symptoms emerge under stress.

What Renaming Does

• Renaming could shift the focus of treatment on a part rather than the whole.

One of the common alternative labels that has been proposed instead of borderline is EUPD. As noted previously, this term highlights one aspect of BPD while neglecting others. Emotional instability is neither unique to BPD nor sufficient to define it. Mood lability is also seen in bipolar spectrum conditions, trauma-related disorders, and other personality pathologies.

By emphasizing affective symptoms, EUPD risks encouraging a treatment focus on mood stabilization at the expense of addressing personality structure and interpersonal functioning. In practice, this may lead to an overreliance on pharmacological interventions while diverting attention from psychotherapeutic approaches that target identity integration, mentalization, and interpersonal patterns.

Moreover, EUPD fails to capture core features such as splitting, unstable object relations, chronic emptiness, and intense fear of abandonment. These phenomena are not epiphenomena of mood instability; they are central expressions of BPD. A diagnostic term that obscures these features risks distorting both formulation and treatment.

Similarly, proposals to reconceptualize borderline personality disorder as complex posttraumatic stress disorder (C-PTSD) are not supported by empirical or phenomenological evidence, as such trauma-centered reformulations tend to rely on linear causal models, underemphasize temperamental and genetic factors, and fail to account for the fact that many patients with BPD do not have histories of significant trauma.¹⁰ Recent work has shown that C-PTSD does not more accurately capture the core structural features, longitudinal course, or psychopathology of BPD.¹¹

• Renaming could shape inaccurate clinical expectations.

Diagnostic language shapes clinical expectations. When the structural and psychotic-adjacent aspects of borderline pathology are deemphasized, clinicians may underestimate severity, misinterpret regressions in treatment, or misconstrue interpersonally-mediated symptoms as purely mood-related phenomena.

Retaining the term borderline encourages clinicians to think developmentally and structurally rather than symptomatically alone. It anchors treatment in models that recognize fluctuations in reality testing, the centrality of primitive defenses, and the need for carefully structured psychotherapeutic interventions. Abandoning the term risks losing this accumulated clinical wisdom without replacing it with a more adequate alternative.

The term borderline is imperfect, historically burdened, and sometimes misused. But it is not meaningless. It denotes a recognizable level of personality organization, captures essential clinical features of a well-validated personality disorder, and serves as an important reminder of patients’ vulnerability to psychotic symptoms.

Rather than renaming BPD, efforts would be better directed toward improving diagnostic clarity, educating clinicians about its structural features, and refining treatment approaches. Names do matter, but they matter most when they illuminate, rather than obscure, the realities of psychopathology.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando, where he is director of psychotherapy training in the adult psychiatry residency program. He is also an adjunct assistant professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts, and on the faculty of The New Jersey Institute for Training in Psychoanalysis in Teaneck, New Jersey.

Prof D’Agostino is an associate professor of clinical psychology at the University of Urbino Carlo Bo in Italy. She is a psychologist, psychotherapist, and Italian Psychoanalytic Society and International Psychoanalytic Association psychoanalyst.

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