Handbook of personality disorders
Chapter 23
Clinical features of borderline personality disorder

Critiques of the borderline personality disorder construct

The borderline personality disorder suffers from heterogeneity and fuzzy boundaries.

Critics of borderline personality disorder would like to define it as a variant of mood disorder. This is based on symptoms of affective instability. But this is not consistent with research literature. Patients with borderline personality disorder experience continually abnormal mood for years, may in a different mood from hour to hour, are likely to have every mood, and have a different neurobiological profile than bipolar disorder. Mood symptoms are only one of the primary symptoms of borderline personality disorder.

Patients with borderline personality disorder do not have manic or hypomanic episodes.

One-third of people with borderline personality disorder develop symptoms without experiencing serious childhood adversity.

Making the diagnosis

In the DSM-5, nine criteria for borderline personality disorder are listed, with five required to make a diagnosis. These criteria include 1) affective symptoms 2) impulsive symptoms 3) interpersonal problems 4) an unstable identity 5) cognitive symptoms

The most characteristic symptom of borderline personality disorder is affective instability. Hypersensitivity to the environment leads to rapid changes of mood in response to interpersonal events, with slow recovery from distress. This doesn’t fully account for the disorder.

Other characteristic behaviours are chronic and recurrent overdoses and/or self-harm. These are usually precipitated by interpersonal conflict.

Suicidality in borderline personality disorder is a way of being heard when one does not see any other way for a message to get through.

Patients with borderline personality disorder have a pattern of unstable close relationships that involve clinging attachment, fear of abandonment, and intense conflict with intimate partners.

Some patients with borderline personality disorder experience hallucinations. They do not develop delusional elaborations of these experiences.

Etiology and development

Borderline personality disorder can best be understood in the light of diathesis-stress theory. Temperamental vulnerability is a necessary condition. These make people more sensitive to their environment and produce vicious cycles in which negative perceptions of other people lead to further instability.

The majority of people with borderline personality disorder report childhood adversities. Childhood adversities by themselves do not necessarily lead to borderline personality disorder.

Borderline personality disorder usually becomes clinically apparent during adolescence.

Outcome and course

Borderline personality disorder has a good prognosis. Most patients stop meeting diagnostic criteria before middle age. Impulsive symptoms tend to remit early, while affective symptoms are slower to change.

Many patients continue to show residual psychosocial dysfunction.