Post by Former NIMH Director Thomas Insel: What’s in a Name? — The Outlook for Borderline Personality Disorder
In Shakespeare's "Romeo and Juliet," the question is posed to illustrate that a name doesn't define a person's feelings or intent. In psychiatry, the same may be said of that which we call borderline personality disorder. Noted primarily for symptoms such as impaired mood regulation, unstable relationships with others, and self-harming behaviors, the name "borderline personality disorder," fails to capture the essence of this serious mental illness.
As currently defined, borderline personality disorder is considered a reflection of an essential aspect of a person's character that influences his or her way of seeing and being seen in the world. Recent research, however, has shown that symptoms of the disorder aren't constant and may not always be as enduring as some researchers and clinicians may think. Yet fluctuating moods and behavior also happen to define another mental illness, bipolar disorder, with which borderline personality disorder may be confused.
Symptoms that overlap with other illnesses, as well as the high rate of co-occurring psychiatric and substance use disorders often seen in people with borderline personality disorder, create challenges for proper diagnosis and treatment. According to data from the NIMH-funded National Comorbidity Survey Replication, about 85 percent of people with borderline personality disorder also meet the diagnostic criteria for another mental disorder,1 including:
- 61 percent also have at least one anxiety disorder, most commonly a specific phobia, or social phobia
- 49 percent have an impulse-control disorder, most commonly intermittent explosive disorder
- 38 percent have a substance abuse or dependence disorder, most commonly alcohol abuse or dependence
- 34 percent have a mood disorder, most commonly dysthymia (mild, chronic depression), or major depression.
One of the most tragic outcomes for any mental disorder, suicide, presents an especially high risk in this population. As many as 80 percent of people with borderline personality disorder have suicidal behaviors,2 and about 4-9 percent complete suicide.2,3
Despite these overwhelming statistics, proper treatment can help reduce or lessen the severity of symptoms. Treatment may mean short-term hospitalization, especially when there is an immediate threat to a person's life, such as from suicidal behaviors and alcohol or drug dependence. But in most cases, psychotherapy, or "talk therapy," is effective in helping people to manage even the most destructive symptoms of the illness. For example, an NIMH-funded study of 101 women with borderline personality disorder showed that dialectical behavior therapy (DBT) reduced suicide attempts by half compared with other types of psychotherapy. DBT also excelled at reducing use of emergency room and inpatient services and retained more participants in therapy, compared to other mostly traditional approaches to treatment.2
Aiming to improve the way we think about and study borderline personality disorder and other mental illnesses, efforts to reclassify these disorders are underway, including NIMH's own RDoC project. In particular, the goal of RDoC is to examine basic categories of mental function, such as fear or working memory, which cut across traditional disorder definitions. This approach will allow researchers to link the genetic and social underpinnings of a particular mental function with their associated biochemical and neural processes and resultant behaviors or other symptoms. Whatever the outcome of reclassification efforts, however, we must keep in mind the essence of the question — that "borderline personality disorder" by any other name would still be as real, as disabling, and as necessary to treat, as other serious mental illnesses.
1. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Sep 15;62(6):553-64.
2. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul;63(7):757-66.
3. Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up. J Personal Disord. 2005 Oct;19(5):505-23.