COMMENTARY

The Biology of Borderline (and a Diagnostic Tip)

Derick E. Vergne, MD

Disclosures

March 23, 2015

In This Article

Background

Diagnosis in psychiatry continues to be based on observation. However, economic forces are driving the norm of inaccurate diagnoses after an initial interview lasting less than an hour. To that extent clinicians are taught to rely heavily on the history documented in a patient's medical chart, the diagnostic information found in all records is the result of the same short interview, followed by even shorter follow-up visits. When external influences curtail information-gathering rather than allowing sufficient time for diagnosis, the information will often be incomplete and potentially inaccurate.

Psychiatrists are best served by a keen understanding of the natural history of disease and its many facets, coupled with thorough observation of behavior (ie, mental status), to arrive at an accurate diagnosis. More than 100 years ago, Kraepelin and colleagues[1] taught us to use proper observation as a guiding light in diagnosis:

...after the first thorough examination of a new patient, each of us had to throw in a note [in a "diagnosis box"] with his diagnosis written on it. After a while, the notes were taken out of the box, the diagnoses were listed, and the case was closed, the final interpretation of the disease was added to the original diagnosis. In this way, we were able to see what kind of mistakes had been made and were able to follow-up the reasons for the wrong original diagnosis.

The importance of gathering sufficient information for diagnosis is particularly important for borderline personality disorder (BPD), which encompasses multiple symptoms that overlap across many diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM), making its identification challenging.[2]

Defining Borderline Personality Disorder

The DSM-5 defines BPD as "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following"[2]:

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization 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 (eg, substance abuse, binge eating, and reckless driving).

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Perhaps a more global description of BPD would be that the inner lives of people who suffer from it are chaotic and characterized by anger or rage directed both outside (ie, to others via unstable interpersonal relationships) and inside (ie, to self via impulsivity, poor decision-making, or drug use, for example).

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