Thanks to Dan Hartung for pointing me to this proposal to change the name of Borderline Personality Disorder. Diagnostic categories in mental health work both impose a tyranny and an opportunity, even when used with elegance and precision, which, as readers of FmH know, I have long felt is rare in modern psychiatric practice. DSM-IV, the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, the bible of acceptable psychiatric diagnoses and their criteria, has defined a number of personality disorders on a separate ‘diagnostic axis’ than the major mental disorders. I have long taught about how to understand and treat borderline personality disorder, which is the most controversial of these axis II disorders. Even though I feel classifying someone with that label with precision serves a useful purpose in clinical communication as a shorthand for a number of characteristics a clinician might expect to find in treating them, the term is often applied freely to anyone who ‘feels like a borderline’, in other words patients when they are angry toward us, have self-destructive tendencies, are irritating and challenging to treat, or inspire dislike, anger, disdain, avoidance or hatred in their treaters. This makes the diagnosis meaningless, a sort of acting out by the clinician which defeats our best efforts at both clinical clarity and avoiding pejoratives. A masterful modern psychiatrist, George Vaillant, used to give a lecture to psychiatric trainees entitled something like “The Beginning of Wisdom: Never Call Anyone a Borderline.” Others, such as the essayist linked here, feel that because the way the term is used is often pejorative, we should change it. I think that is a fruitless proposition. Since whatever replaces the term ‘borderline’ will continue to reference a class of patients who have some attributes we find disagreeable, any sufficiently disagreeable patient will be diagnosed with that label in the same off-the-cuff manner. Whatever term it is will lose its clinical precision and assume the same disparaging connotations the current term has. Even if the language is new or different, a pejorative is a pejorative. People can readily recognize cursing or name-calling even in a foreign language they do not speak.
There is nothing special about psychiatric pejoratives either. Consider for a minute how powerful our vernacular terms for excrement are, and how rapidly they generalize as references not precisely to deposits of stool but to anything for which we have sufficient distaste or contempt.
But hold on; if the name of the condition were more precisely reflective of its description, if it were more ‘experience-near’, could that itself encourage greater accuracy and precision every time we used it? So say some proponents of a name change. They certainly have a point that, if it is worth describing this condition for purposes of clinical communication, it is worth describing it well, and ‘borderline personality disorder’ is a poor choice of name. For one thing, objections are raised to the ‘borderline’ moniker, which is a historical anachronism hearkening back to an outmoded, discredited and useless notion that these patients were on the borderline between neurosis and psychosis.
And objections also arise to calling it a personality disorder. The original notion was that the main axis, axis I, of DSM (-IV and its predecessors) listed the mental conditions that had a biological origin, in other words illnesses or diseases. In contrast, axis II contained a catalogue of different personality styles which endured over a person’s life and which, taken to an extreme and rigid extent, caused distress or dysfunction in the person’s life and thus warranted being called personality disorders. On axis I were intended to be placed disorders which were treatable with biological approaches such as medicines, whereas one approached personality problems with psychotherapy. In a sense, axis II was a concession and a shrinking pied á terre for the increasingly disenfranchised psychoanalysts, who were rapidly losing the battle for the future of psychiatry to the biological psychiatrists.
However, the placement of borderline personality disorder on this axis II has seemed increasingly problematic, as many psychiatrists have come to see its core features more as on a continuum with axis I mental illnesses in the areas of mood, impulse and thought disorders. And the enormous expenditure of psychiatric effort on trying to treat these extremely distressed and vexing patients has included alot of medication treatment. Although this is a controversial assertion, many find the borderline condition vey responsive to medication treatment. (I myself think borderlines can be judiciously medicated to their benefit, but usually they are blasted with everything in the pharmacological armamentarium at once in desperation and frustration — both the patient’s and the prescriber’s).
In a larger sense, the hard and fast distinctions between biologically- and personality-based distress in general are melting down, and many of the other personality disorders on axis II are subject to pharmacological as well as psychotherapeutic approaches with some degrees of success. So, many of us find the entire distinction between axis I and axis II (not just the issue of the placement of the borderline condition on the latter and thus whether it should be callled a personality disorder) to be specious and clinically meaningless. Furthermore, if there is a rationale for describing personality structure and style alongside mental illness, many have come to feel that a pigeonholing (categorical) approach might not be as good as a dimensional one. (Take the descriptive power of the Meyers-Briggs test, for example.)
Another reason for a Diagnostic and Statistical Manual is to facilitate research into mental health conditions. It should go without saying that if the members of a diagnostic category are heterogeneous, no meaningful research conclusions can emerge from studying them as if they had something in common. So sloppily diagnosing very different sorts of people as ‘borderlines’ (or whatever else you might want to call the condition) will result in inconclusive findings when research is done to try to figure out what is wrong with them. This inconclusiveness then feeds back into the discussion as to whether the diagnostic category is meaningful. When, all along, it is not so much a matter of what you call them as how carefully, accurately and precisely you apply the existing diagnostic criteria, no matter what the condition is called.