The challenges in diagnosing and identifying Borderline Personality Disorder

 1.  Introduction:

Annesta Hofer

In this article we explore the criteria in identifying and diagnosing Borderline Personality Disorder, also taking the problems and challenges during these processes into consideration. Borderline Personality Disorder is a classified complex personality disorder that has caused a great deal of both negative responses from professionals yet has led to one of the most intensively studied fields relating to personality disorders.

2.  DSM-5 diagnostic criteria for Borderline Personality Disorder:

The Synopsis of Psychiatry ( Sadock & Ruiz) mentions that the disorder has also been called ambulatory schizophrenia, as-if personality, pseudoneurotic schizophrenia and psychotic character disorder, and only in 1980 was it officially classified Borderline Personality Disorder. The disorder is different from schizophrenia on the basis that the patient with Borderline Personality Disorder lacks prolonged psychotic episodes, thought disorder, and other classic schizophrenic sighs. Borderline Personality Disorder is fairly stable, patients change little over time. Longitudinal studies show no progression towards schizophrenia but patients have a high incidence of major depression disorder episodes, therefore anti-depressants and anticonvulsants may improve global functioning for some patients.

According to the DSM-5; Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) a personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations from the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. The etiology of Personality Disorders is attributed to the development of immature and distorted patterns of personality functioning which leads to persistent maladaptive ways of perceiving, thinking, relating to others, and interacting in the world. There are 10 classified personality disorders in the DSM-5 describing Borderline Personality Disorder as characterised by a pattern of instability in interpersonal relationships, self-image, affect, and marked impulsivity.

The DSM-5 further describes that the enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture needs to manifest in two or more of the following areas:

  1. Cognition
  2. Affectivity
  3. Interpersonal Functioning
  4. Impulse Control

The enduring pattern is inflexible and pervasive across a board range of personal and social situations, leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning, the pattern is stable and of long duration and is tracked to adolescence or early adulthood. The enduring pattern is not a better accounted 3 for as a manifestation or consequence of another mental disorder or as a result of substance abuse. Borderline personality disorder causes distress, disability and health expense.

According to the DSM-5 (APA 2013) the specific criteria for Borderline Personality Disorder include:

  1. Frantic efforts to avoid real or imagined abandonment.
  2. A pattern of unstable and intense personal relationships characterised by alternating between extremes of idealisation and devaluation.
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating).
  5. Recurrent suicidal behaviour, gestures, threats or self-mutilating behaviour.
  6. Affective instability due to a marked reactivity of mood (irritability, anxiety, dysphoria).
  7. Chronic feeling of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger.
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Personality disorders need to be separated from other symptoms for instance mood or substance related disorders. Long term patterns of functioning over time and across different structures need to occur. At least 5 specific diagnostic criteria need to be present before diagnosing Borderline Personality Disorder.

Personality disorders have a reputation of being difficult to treat, recent evidence based therapies proven to be highly successful in treating individuals diagnosed with Borderline Personality Disorder.

Von Krosigk (2014) mentions that it seems as if a fear of rejection and abandonment, as well as intense unmet needs for affection and closeness, are central to this instability. There is tension between these two core functions. More key clinical features to this disorder include:

  1. Unstable mood which is characterised by severe depression, anxiety, and anger with no obvious environmental triggers.
  2. Unstable self-concept, which can range from episodes of extreme self-doubt to episodes of grandiose self importance.
  3. Feelings of emptiness which are often described as chronic boredom which can be as a result of difficulties with their own identity.
  4. Impulsive, self-mutilating and suicidal behaviour.
  5. Unstable interpersonal relationships which are characterised by switching from idealising a person to despising them for no apparent reason.

3.  Problems related to identifying Borderline Personality Disorder

Borderline Personality Disorder is poorly understood and difficult to treat. Many reports from various research studies and personal accounts from therapists mostly state that the Borderline Personality Disorder patient responds poorly to treatment and has great difficulty 4 in building a trusting and respectful therapeutic relationship with the therapist or team involved in treatment. Some therapists do not want to identify the traits or characteristics of possible Borderline Personality Disorder as there is a label on these patients that includes disliked patients and would rather not get involved or refer, leaving the patient undiagnosed and without help. Only recently the subject of Borderline Personality Disorder changed from a subject of almost no systematic study to one of the most intensively researched personality disorders in order to identify and diagnose more effectively.

Professional bias against the identifying and diagnosing as well as the stigmatization for those who suffer from it, that has hampered their progress in receiving professional help is being reduced by intensive research and new methods to treat the disorder. Gunderson (2009) mentions that classification of the disorder was tied to analyzable- and therefore treatable- yet those with psychoses were considered not analyzable- and therefore untreatable. The Psychiatrists most responsible for introducing the label/identification “borderline” were Stern and Knight. By identifying the tendency of certain patients to regress into borderline schizophrenia, these authors gave initial clinical meaning to the borderline construct.

The primary category to which these patients were “borderline” was schizophrenia. In 1967 Kernberg ( a psychoanalyst) defined borderline as a middle level of personality organization bounded on one side by sicker patients who had psychotic personality organization and on the other by those who were healthier and had neurotic personality organization. Borderline Personality Organization was a broad form of psychopathology defined by primitive defences like splitting, projective identification, identity diffusion, and lapses in reality testing.

Despite the doubts about the identification and recognition of borderline patients psychologists and psychiatrists observed certain recognisable patterns in behaviour including a stable instability, their desperate need to attach to others as transitional objects, their reliance on splitting and their abandonment fears. Borderline patients were seen to be interpersonally needy, very emotional, and with the exception of occasional lapses in reality testing they were definitely not psychotic. They were identified as the difficult patients and had considerable suicidal risk. They could book in and out of hospitals or rehabilitation centres in order to escape from responsibilities.

In therapy they are identified as very oppositional to treatment and experience negative therapeutic reactions due to counter transference hatred. Kernberg wrote that there is an unconscious sense of guilt, the need to destroy what is received from the therapist because of unconscious envy and eventually the need to destroy the therapist as a good object because of the patient’s unconscious identification with a primitive and sadistic object.

This by 1980 when Borderline Personality Disorder officially entered the DSM classification system, its validity rested primarily and still quite precariously on its clinical utility, and specifically on the ability of the diagnosis to predict a set of clinical dilemmas that were more or less specific to problematic behavioural traits. More research over the last decade 5 showed that the disorder was like a syndrome that was an internally consistent, coherent syndrome with a course that differed from those of schizophrenia and major depression and that there are moderate to inconsistent responses to classes of medication.

Another problem with identifying the disorder can be the link it has to childhood physical and sexual abuse. Therefore it can be seen as rebellious teenagers or oppositional defiant young adults who in fact can be unidentified borderline patients. Studies showed that childhood physical and sexual abuse was found in 70% of borderline patients. Another challenge to identify Borderline Personality Disorder according to Gunderson (2009) is that it has 30% comorbidity with PTSD. Yet treating borderline patients as victims of abuse or trauma or identify Adult Child Syndrome in them usually make their conditions worse, as it feeds into the resentment and transference hatred that they already have as traits.

Kernberg & Michael (2009), talks about two distinct views, the first, popular among psychotherapists and early psychoanalytic thinkers, emphasized early experience (pre-oedipal and separation-individuation) where parents are seen as unempathic, there had been traumatic experiences, the mother-child match was poor etc. This can feed and cause the development of Borderline Personality Disorder later on in life. Yet it can be difficult to identify these causes as the child/adolescent usually do not talk about these incidents and as seen in work with Adult Child Syndrome patients secrets and the development of roles to keep family secrets well hidden prevents correct identification or early warning sighs during the beginning of the disorder.

A second theme, more popular amongst psychiatric researchers, emphasized constitutional factors, genetic links to bipolar or affective disease, temperamental characteristics such as impulsivity or affective dysregulation, brain abnormalities, etc. Currently there have been several efforts to meld these two perspectives, causing a complexity and difficult dynamic in identifying it mainly as Borderline Personality Disorder as it can also easily be identified as Adult Child Syndrome or Post Traumatic Stress Disorder under theme one, and Bipolar Mood Disorder under theme two. The question of the interaction of nature and nurture is again relevant with the identifying of Borderline Personality Disorder, one or the other may predominate as the determinant pathology. Kernberg & Michael (2009) mentions on this particular point that the search for the relationship between surface features and underlying psychological or neurobiological structures lends itself to reductionist shortcuts that do not do justice to the complexity of psychopathological conditions.

The Borderline Personality Disorder patient has a hyperactivity of the amygdala and related structures of the limbic system, and, at the same time a lack of the capacity for cognitive contextualization and affect control, linked to decreased functioning of prefrontal and preorbital cortex and the anterior cingular area, represent significant neurobiological correlates of this pathology. The pathology of the brain systems causes consequential behaviour interactions with the environment that is problematic and dysfunctional and also persists across different structures and situations. The fact that neurobiology is also a cause for this disorder can make it more difficult to identify the personality disorder concept, as it can be seen as a medical and neurological illness due to an injury or imbalance in the brain 6 structure and at times the only outcome is prescription medication. More recent research led to attempts to develop strategies for identifying Borderline Personality Disorder patients before they had entered psychotherapy, this includes psychological tests, structural interviews, and diagnostic criteria.

During DBT (Dialectical Behavior Therapy) there is no focus on the childhood or the past, this is why the new and effective ways to treat Borderline Personality Disorder can’t co-exist with Adult Child Work or Psychotherapy where the focus is on past incidents and relationships. According to Valerie Porr (2010), the therapist helps the person to learn and apply new coping skills in the moment, not attached to past experiences. They need to learn how to radically accept their present moment and situation. Validation plays a huge role in working with borderline sufferers and a great deal of compassion and empathy is needed. The therapist’s main goal is to focus on the positive aspects of current behaviour and to find the nuggets of truth in their responses to various situations. Always validate success even if it does not meet with success in reality.

Therefore mindfulness is the cornerstone of working with borderline sufferers. People with Borderline Personality Disorder also usually view external help as an attempt to control them or as criticism of their behaviour, therefore it might be too much of a risk for the Adult Child or Psychotherapists to try and take the borderline sufferer to a past that they might have distorted memories of and can be counterproductive. Many therapists or psychologists might identify the risks in working with Borderline Personality Disorder as it might not fit in with their approaches and therapy methods leading to ongoing referring from one professional to another, building more distrust in the patient and years can pass without identifying or diagnosing the patient.

4.  Problems related to diagnosing Borderline Personality Disorder:

Kernberg & Michael (2009), mentions that patients diagnosed with borderline personality disorder does not have the chaos, disorganization, or defect in reality testing associated with psychotic patients, but also lacks integration, stability of relationships, and regulation of affect associated with neurotic patients. This is in terms of severity a middle group between psychosis and neurosis, diagnostically linked to more severe personality disorders and shifting, unstable, or polysymptomatic presentations of Axis 1 disorder yet is more of an Axis 2 cluster B disorder. The challenge is that most Psychiatrists have a fuzzy notion of where the disorder belongs and feel that it is somewhere between the two, with the psychoanalytically oriented being closer to the first view and the others being closer to the second.

The Borderline Personality Disorder diagnoses engender scepticism in many clinicians and investigators, and feelings of frustration in clinicians who work with such patients. The diagnosis has been challenged with the notion that it can be explained by other comorbid conditions, or as a variant of Axis 1 disorders such as mood or impulse control disorders (Goodman& Hazlett, et all, 2009). It further states that to have valid diagnosis increased evidence is needed with relatively specific genetic antecendents, treatment response, and characteristic outcomes.

The signature of borderline personality disorder is the exquisite sensitivity to the vicissitudes of interpersonal relationships, including profound feelings of abandonment upon disruption of these relationships. Goodman & Hazlett et all, further describes that it has been proposed that borderline personality disorder is a variant of bipolar disorder, however there seems to be a shift in borderline personality disorder, unlike bipolar II, oscillate between anger and dysphoria rather than from depression to elation and tend to be reactive to interpersonal context rather than endogenously driven. Therefore it can be seen as an impulse control disorder while impulsive-aggression is an essential criterion for this disorder and appears to have specific genetic underpinnings.

The overlapping with susceptibilities to Axis 1 disorders complicates diagnoses this disorder. The most important character trait can be sensitivity generated feelings of abandonment that drove the patient to attention-seeking behaviour, rageful outbursts and or self injuries behaviours. The Borderline Personality Disorder patient seems to be troubled, but not psychotic, and having a wide range of strong effects and intense relationships. Diagnoses will also assess that the patients become worse over time with little improvement when not in therapy.

Kernberg & Michael (2009), mentions that the frequent development in borderline patients of characterologically based depression, rage attacks, and affect storms in general, pervasive anxiety, and dissociative symptoms has stimulated the utilization of anxiolytic, antidepressant, and mood stabilizing drugs, and, more recently, the use of low-dose atypical neuroleptics. Some Borderline patients respond to medication, although only approximately 30% of these patients respond satisfactorily over an extended period of time. The difficulty in diagnosing Borderline patients is to keep in mind that medication only will most probably not have a positive outcome and dialectic behaviour therapy by a person specialising in such methods needs to be taken into consideration as after diagnoses a proper way forward or treatment plan needs to be given to the person. Transference-focussed psychotherapy and mentalization- based psychotherapy should also be highly recommended after diagnoses.

Psychiatrists might find diagnosing more easier than remaining hopeful for these patients as feedback might show that regardless of short or long term intensive treatment, their behaviour can still show impoverishment of their personality: a lack of satisfaction and motivation in their lives, in their work and professions, and a lack of stability in intimate relationships, in establishing families and in overcoming social isolation. Studies also show that it appears as if there is no capacity in the amygdala to combine positive and negative affects, while at the level of the limbic-cortical brain area, the possibility of such integration and mutual toning down of contrasting affects in the context of cognitive integration exists.

Dialectic Behavior Therapy was introduced by Linehan, a self-described radical behaviourist. It places emphasis on validation, skill-building, and here-and-now interventions: its provision of around the clock availability and its definition of the role of the therapist as coach seems to have proven an effective model of treatment. Regardless of new interventions and research borderline personality disorder remains terribly and unfairly stigmatized. Most mental health professionals want to avoid- or actively dislike borderline patients. Therefore a large number of people with the disorder are undiagnosed and untreated.

On the research field there is a lack of young investigators and researchers. Still unknown are the public health costs of this disorder, but given borderline patients heavy utilization of the psychiatric services and medical complications, involvement in divorce and child-rearing lawsuits, and violence and sexual indiscretions, the cost can be tremendous. Oldham (2009) confirms that borderline patients emerged within clinical settings as an angry, volatile patient prone to reject help, blame others, and behave self-destructively.

When diagnosing it is important to keep in mind that borderline can be seen as pathology and a part of its cause can be explained involving brain abnormalities that can be identified by brain imaging techniques. New studies shows inherent hyperactivity of the amygdala and overreaction to negative or even neutral facial expressions, possibly correlated with interpersonal hypersensitivity and will therefore over anticipate and overact to real criticism or rejection, but they may also negatively personalize disinterest or inattention from others. With newly found neurological studies we also know that intensive and prolonged psychotherapy is a form of long-term learning and memory which indeed changes the brain. Effective psychotherapy takes time, commitment, and persistence and this is often the biggest hurdle to overcome as the borderline patients seems more focussed on instant gratification than delayed achievement.

The Synopsis of Psychiatry ( Sadock & Ruiz) mentions that biological studies may aim at the diagnoses as some patients with Borderline Personality Disorder shows shortened REM latency and sleep continuity disturbances, abnormal DST results, and abnormal thyrotropin- releasing hormones. Those changes are however also seen in patients suffering from Bipolar Disorder.

5.  Conclusion:

Borderline Personality Disorder, despite its negative connotations and constructive criticism, has grown from a under-researched and misunderstood Personality Disorder to a well known and now more easily understandable disorder. It is the duty of Psychiatrists and Psychologists to research and stay on top of the new and innovative approaches and methods in identifying, diagnosing and treating people suffering from this disorder. Borderline Personality Disorder patients have the right to receive the best practice models from informed and qualified professionals in order to be assisted and guided to a better way of functioning, due to improved cognitive functioning and consequently an improved emotional and behavioural balance in their lives.

Article compiled by Annesta Hofer.


American Psychiatric Association, (2013). Diagnostic and Statistical manual of mental disorders: Fifth edition (DSM-5). Arlington VA: American Psychiatric Association.

Goodman, M. , Hazlett, E.A., New, A.S., Koenigsberg, H.W., & Siever, L. (2009). Quieting the affective storm of Borderline Personality Disorder. American Journal of Psychiatry, 166, 522-528.

Gunderson, J.G. (2009). Borderline Personality Disorder: Ontogeny of a diagnosis. American Journal of Psychiatry, 166, 530-539.

Kernberg, O.F. & Michels, R. (2009). Borderline Personality Disorder. American Journal of Psychiatry. 166, 505-508.

Sadock, B.J., Sadock, V.A. & Ruiz, P. (2015) Kaplan and Shadock’s synopsis of psychiatry. Wolters Kluwer.

Oldham, J.M. (2009). Borderline Personality Disorder comes of age. American Journal of Psychiatry, 166, 509-511

Porr, V. (2010). Overcoming Borderline Personality Disorder; a family guide for healing and change. Oxford University Press. New York.

Von Krosigk, B. (2014). Abnormal Psychology: A South African Perspective. (Personality Disorders). Oxford University Press South Africa: Cape Town.

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Annesta Hofer                                                                                

Behavioural Therapist/ Clinical Social Worker

BSW Honours (Social Work and Psychology)


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