On the Reality of Borderline Personality Disorder

daniil/AdobeStock

It is inherent in human nature to consider a thing untrue if one does not like it.” — Sigmund Freud

Borderline personality disorder (BPD) is one of the most frequently diagnosed personality disorders (Figure).¹ Nevertheless, BPD continues to present a significant challenge due to its intricate nature, diverse clinical presentations, and the inherent difficulties encountered in treating patients. BPD is as valid a diagnosis as schizophrenia or depression, which is to say that it is a well-studied clinical phenomenon that lacks biological markers. It has a coherent clinical presentation that differs from affective disorders and posttraumatic stress disorder (PTSD), with a characteristic onset in adolescence and outcome in adulthood.^1,2 The term borderline is a point of contention in the fields of psychiatry and psychology, with varying interpretations leading to an unstable—and occasionally confusing—delineation of its boundaries.^3,4

FIGURE. Prevalence of Borderline Personality Disorder¹

What’s in a Name?

Borderline is used to describe a borderline personality organization, based on Otto Kernberg, MD’s 1975 conceptualization, which is considerably more expansive than DSM’s description of BPD.⁵ It is characterized by diffuse identity, predominant use of primitive defenses, and intact but fragile reality testing (ie, with the possibility of brief psychotic lapses in response to stressful situational events).

In addition, borderline is used in reference to BPD, ie, to a specific clinical syndrome introduced to the DSM in 1980 based on the pioneering work of John Gunderson, MD.² It is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity. BPD emerges during early adulthood and is present in a variety of contexts, as indicated by 5 or more of the 9 criteria. BPD represents only approximately 10% to 25% of the patients who would be considered to have borderline personality organization.²

Another interpretation of borderline places it as a schizophrenia spectrum disorder. This perspective gained traction in the 1960s and 1970s, emphasizing the proclivity of patients with borderline to experience transient psychotic episodes. Unlike those associated with schizophrenia, these episodes are typically brief, self-limiting, and triggered by situational stressors. Psychotic experiences may also be evidenced outside these discrete episodes.

Borderline is also used to describe an affective spectrum disorder. The historical description of affective instability in borderline psychopathology has prompted some clinicians to hypothesize a correlation with mood pathology or even to consider borderline personality psychopathology as an attenuated variant of bipolar disorder.

Borderline can be conceptualized as an impulse spectrum disorder because of the propensity for characteristic impulsive action. These are typically driven by an inner state (emotion or thought) that cannot be experienced at the level of inner experience, and that the patient feels the need to immediately express through action. Self-injury, suicide, substance abuse, and other risky behaviors are most concerning for clinicians, patients’ families, and social environments.

A sixth potential interpretation is that BPD may represent a chronic form of PTSD. The significant correlation between traumatic experiences in early childhood and the subsequent development of psychopathology in adulthood has been well documented. The inclusion of BPD in the trauma spectrum gives primacy to the relationship with childhood traumatic events, attachment disorders, and defensive mechanisms that are predominantly dissociative in nature and put in place in response to trauma, and to the symptomatologic manifestations that are more likely to be traced to a traumatic genesis.

Borderline is also used as a catch-all category for any condition that does not fit neatly into the established nosographic patterns. The establishment of dichotomous categories within psychiatric nosology has been observed to give rise to the reappearance of hybrid clinical entities that disrupt the established nosographic patterns.

Finally, borderline is used as a simplistic and inappropriate marker of failure, ie, when the clinician’s efforts are proved to be ineffective or unsuccessful (eg, admissions to services or psychotherapy pathways). This approach ignores the difficulties that patients with borderline may experience in forming relationships and the challenges that clinicians may face in managing and containing negative emotions (eg, hostility, anxiety, confusion, helplessness, and boredom), which are inherent to the intense and turbulent relationship with these patients.

For these reasons, the patient with borderline represents a psychopathological figure in a state of perpetual suspension, traversing a series of positions and pathways whose significance can only be fully appreciated when viewed from an expanded perspective of individual episodes and the broader sequence of experiences and situations that shape the borderline condition. This fundamental aspect of borderline psychopathology renders it a true migrant within the field of mental health.⁴

The Essence of Borderline Psychopathology

The construct of BPD is internally consistent and more homogeneous than is commonly assumed.¹ Thus, several theoretical models have been put forth to elucidate the core features that underpin the observed phenotypic heterogeneity.^1,3,6

Is there a psychopathological core that enables the clinical identification across theoretical models and perspectives? As early as the 1950s, Melitta Schmideberg, MD, posited that the defining characteristic of borderline psychopathology is its inherent instability, calling it “stable in its instability.”⁷ This implies that the patient perceives instability as an inherent and fundamental aspect of their identity, establishing it as the bedrock of their own functioning. Consequently, this perception also influences the conceptualization of the pathology itself.

But what does instability mean from a clinical point of view? A relational-affective vulnerability may be identified, which can be further delineated into 3 subdimensions: (1) a pronounced predisposition toward distrust and resentment toward others; (2) an inability to regulate one’s internal states and to tolerate and manage emotions, particularly negative ones; and (3) ineffectual attempts to cope with and express this distressing internal experience.⁸

These experiences are often rooted in distressing and traumatic events that occurred during childhood. They function as a catalyst for overreactions to situational events, particularly those involving interpersonal variables, in a dynamic relationship between past and present, which is mediated by protective and risk factors.⁹ This response reinforces the patient’s traumatic experience of contact with the external world, particularly with other individuals.

From this perspective, the array of borderline symptoms can be seen as an external manifestation of this relational-affective vulnerability; this interpersonal focus incorporates Gunderson’s seminal contribution to the understanding of borderline psychopathology.² The relational-affective vulnerability that is solicited by contingent stressful events results in the patient experiencing painful emotional states, which they attempt to escape. This is discerned by pursuing 2 distinct paths: one that is organizing and one that is disorganizing, with each culminating in disparate acute phenomena.

Anger and nonsuicidal self-injury (NSSI) are the most illustrative examples of organizing internal painful experiences. Anger serves to eliminate a source of irritation or pain, remove an obstacle to gratification, and restore a sense of autonomy in the face of highly frustrating situations.^10,11 When anger is projected in the form of hostility, it temporarily rids the patient of these intolerable feelings about themself. Similarly, NSSI has the advantage of positioning negative emotions in a behavioral circuit that leads to a state of reduced tension.

In contrast, a state of disorganization and confusion about personal identity, corresponding to a series of painful experiences of emptiness, insubstantiality, and inauthenticity, is the most representative example of the failure of patients to organize painful internal experiences. When emptiness or aloneness is particularly intense, there may be an attempt to pursue an organizing path, often achieved through impulsive action, which provides a sense of cohesion and coherence to the self, restores a sense of vitality, and fosters hope.

It can be said that BPD is fundamentally a disorder of paradox, in which the patient is trapped in a need-fear dilemma,^12,13 which is a simultaneous need for and fear of closeness with other persons. Thus, the patient teeters back and forth like a yo-yo in interpersonal relations,¹⁴ placing the object in a classic double bind¹⁵: too far and the patient’s abandonment fears are triggered, too close and the patient responds masochistically by pushing the object away. This dynamic contributes to much of the interpersonal dysfunction observed in BPD.

Stigma and the Anti-BPD Movement

Patients and their caregivers/families frequently encounter structural stigma when accessing health services, resulting in poor health outcomes.^16,17

Klein et al explored the international literature on structural stigma associated with BPD.¹⁸ The review highlighted 3 commonly held myths that continue to impede its understanding: (1) uncertainty about BPD as a legitimate mental illness; (2) concerns about disclosing a BPD diagnosis; and (3) the perception of BPD as an untreatable condition. Consequently, individuals are frequently denied evidence-based treatment and excluded from the health care system through a process of demedicalization.¹⁸

This notion has been reinforced in recent years by Roger Mulder, PhD, MBChB, and Peter Tyrer, FMedSci, who have argued that BPD has no place in clinical practice and that the diagnosis should be abandoned because it is inappropriately used, provides little information, creates confusion and uncertainty, and generates enormous stigma.¹⁹ The authors state that BPD has no basis in the scientific study of personality and is used indiscriminately to describe a range of negative interactions in human relationships that have causes far beyond personality function. Their paper has become a manifesto for an anti-BPD movement, which is part of a broader movement against modern psychiatry in the US. It is not within the scope of this paper to comment on the merits of this wider movement, which one of us has covered elsewhere.²⁰

We argue that the anti-BPD movement can be dangerous for at least 2 reasons. Firstly, it contributes to the growing phenomenon of medical mistrust,²¹ which has sometimes resulted in attacks on medical staff by patients or their families. Secondly, it is attracting an increasingly large group of patients (and their caregivers/families) who are angry (understandably) at mental health professionals because of repeated and frustrating experiences of malpractice. This process of channeling borderline anger forcibly addresses the organization of painful internal experiences previously discussed as essential to borderline functioning. However, it does not allow for the opportunity to work with these experiences in an appropriate and beneficial way.

The anti-BPD movement carries the risk of fueling mystification and chaos, as well as group defensive processes of splitting and projective identification. Borderline may be viewed as a witch to be burned at the stake, with clinicians who proffer this label becoming the perpetrators and those who proffer an antilabel becoming the saviors. There has been a proliferation of communities of angry patients on social networks that refer to the Mad in America website and exist to fight back against the pathologization and the use of labels. Such trends demonstrate en masse the very psychodynamics that characterize BPD.

What Can Really Help Patients?

The pervasiveness of the stigma associated with BPD within health systems highlights the necessity for a comprehensive approach to addressing the underlying issues and implementing effective solutions. These issues extend beyond the realm of the BPD diagnosis; they pertain to the culture and delivery of health services and care.¹⁸

It can be—and has been—argued that renaming is not an effective solution to the negative beliefs and discrimination that are prevalent in society.^9,22 Indeed, removing the borderline label would result in these patients being orphaned from a diagnostic framework, thereby compromising their access to evidence-based treatments. Renaming could potentially result in the obfuscation of the disorder’s complex and often challenging nature, which is relational in nature and manifests not only within the individual but also within the clinical relationship and even within the broader social reference community.

Similarly, categorizing BPD as a form of trauma and reducing it to a description of childhood adversity is an inadequate approach to the condition.²³ This fails to account for the complex developmental etiology and thus may reinforce victimization, failing to acknowledge the strong sense of agency that many patients possess.³

What, then, might be the most efficacious approach for assisting patients with BPD?^1,3,18,19

Firstly, clinicians must be provided with the requisite support in understanding the clinical complexity of the borderline condition, the role of situational interpersonal triggers (which are less well known than the impact of childhood traumas), the emotive burden associated with it, and the most effective treatments. Psychotherapy is the preferred treatment, whereas pharmacotherapy is recommended only for addressing discrete and severe comorbid disorders, such as severe depression or anxiety, or transient psychotic symptoms.²⁴ Furthermore, pharmacotherapy should be administered for the shortest feasible duration and solely as a crisis intervention.

Secondly, it is imperative to pursue further investigation into the disorder’s psychopathological core, which underlies the diversity of symptoms. This will facilitate a deeper comprehension of patients’ subjective experience. Research should be conducted on the developmental prodromes of adult-onset BPD, with particular attention to adolescence to facilitate the identification and treatment of high-risk clinical indicators for BPD before the disorder becomes disabling and thus challenging to treat.

Thirdly, disseminating information about generalist models is essential. Clinicians should receive training in at least 1 generalist model that incorporates features of specialized evidence-based treatments (eg, Gunderson’s good psychiatric management).²⁵ Treatments can be conducted by experienced clinicians, even without formal training in the specific treatment modality. In the absence of evidence-based psychotherapeutic modalities, experienced clinicians may employ psychoeducation or crisis management; these are also beneficial for family members of patients with BPD, who bear a significant burden. The generalist approach also holds promise for early intervention for personality disorders among youth.²⁶

Ultimately, further measures are necessary to reduce the stigma. It is not uncommon for individuals to delay seeking assistance, and when they do seek assistance, they are frequently confronted with stigma regarding the nature and treatability of their disorder. Given the considerable advances made in research and clinical practice, this situation is no longer tolerable.

Finally, it is essential to promote and reinforce the efforts of the civil rights movement (as opposed to antidisorder movements) in defense of the fundamental rights of individuals experiencing mental distress: the right to life; the right to health, dignity, and citizenship; and the right to live in an inclusive and supportive community.

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.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida (UCF) College of Medicine in Orlando, Florida, and an adjunct assistant professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He currently serves as codirector of the psychotherapy track at the UCF/HCA Orlando Psychiatry Residency Program and is the founding editor of the Carlat Psychotherapy Report. He is a psychotherapist in private practice in Tampa, Florida.

References

1. Leichsenring F, Fonagy P, Heim N, et al. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry.2024;23(1):4-25.

2. Gunderson JG. Borderline Personality Disorder. American Psychiatric Press; 1984.

3. Zanarini M, Frankenburg FR. The essential nature of borderline psychopathology. J Pers Disord. 2007;21(5):518-535.

4. Rossi Monti M, D’Agostino A. L’autolesionismo. Carocci; 2009.

5. Kernberg O. Borderline Conditions and Pathological Narcissism. Jason Aronson, Inc; 1975.

6. D’Agostino A, Rossi Monti M, Starcevic V. Models of borderline personality disorder: recent advances and new perspectives. Curr Opin Psychiatry.2018;31(1):57-62.

7. Schmideberg M. The borderline patient. In: Arieti S, ed. American Handbook of Psychiatry. Basic Books; 1959:398-416.

8. Rossi Monti M, D’Agostino A. Dysphoria in borderline persons. In: Stanghellini G, Broome M, Fernandez AV, et al, eds. The Oxford Handbook of Phenomenological Psychopathology. Oxford University Press; 2019:827-838.

9. Paris J. Myths of Trauma: Why Adversity Does Not Necessarily Make Us Sick. Oxford University Press; 2022.

10. Kernberg O. Aggression in personality disorders and perversions. Yale University Press; 1992.

11. Kernberg OF. Aggression, trauma, and hatred in the treatment of borderline patients. Psychiatr Clin North Am. 1994;17(4):701-714.

12. Burnham DL, Gladstone AI, Gibson RW. Schizophrenia and the Need-Fear Dilemma. International Universities Press Inc; 1969.

13. Adler G. Borderline Psychopathology and Its Treatment. Jason Aronson Inc; 1985.

14. Grinker RR Sr. Diagnosis of borderlines: a discussion. Schizophr Bull. 1979;5(1):47-52.

15. Ruffalo ML. Heads I win, tails you lose: interpersonal aspects of borderline personality disorder. Bull Menninger Clin. 2025;89(1):52-69.

16. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harv Rev Psychiatry.2006;14(5):249-256.

17. Masland SR, Victor SE, Peters JR, et al. Destigmatizing borderline personality disorder: a call to action for psychological science. Perspect Psychol Sci.2023;18(2):445-460.

18. Klein P, Fairweather AK, Lawn S. Structural stigma and its impact on healthcare for consumers with borderline personality disorder: a scoping review. Int J Ment Health Syst.2022;16(1):48.

19. Mulder R, Tyrer P. Borderline personality disorder: a spurious condition unsupported by science that should be abandoned. J R Soc Med.2023;116(4):148-150.

20. Ruffalo ML, Pies RW. The reality of mental illness: responding to the criticisms of antipsychiatry. Psychology Today. August 19, 2018. Accessed April 22, 2025. https://www.psychologytoday.com/us/blog/freud-fluoxetine/201808/the-reality-mental-illness

21. Benkert R, Cuevas A, Thompson HS, et al. Ubiquitous yet unclear: a systematic review of medical mistrust. Behav Med.2019;45(2):86-101.

22. Gaebel W, Kerst A. The debate about renaming schizophrenia: a new name would not resolve the stigma. Epidemiol Psychiatr Sci.2019;28(3):258-261.

23. Ruffalo ML, Paris J. Borderline personality disorder and complex posttraumatic stress disorder: myths in diagnosis. Psychiatric Times. September 19, 2024. https://www.psychiatrictimes.com/view/borderline-personality-disorder-and-complex-posttraumatic-stress-disorder-myths-in-diagnosis

24. Leichsenring F, Heim N, Leweke F, et al. Borderline personality disorder: a review. JAMA.2023;329(8):670-679.

25. Gunderson JG. The emergence of a generalist model to meet public health needs for patients with borderline personality disorder. Am J Psychiatry. 2016;173(5):452-458.

26. Boone K, Choi-Kain L, Sharp C. The relevance of generalist approaches to early intervention for personality disorder. Am J Psychother. 2025;78(1):16-23.