History of Borderline Diagnosis, Denial of Dissociation, & the Research Evidence

This session is not available for CE credits.

Abstract
Should borderline personality disorder (BPD) should be reconceptualized as a dissociative spectrum disorder, perhaps reclassified under the trauma- and stressor-related disorders in the DSM? Does the current personality disorder classification deflect attention from the history of complex trauma and pervasive dissociative symptoms prevalent in BPD? Does the preponderance of females diagnosed with BPD signal continued gender bias? Might the listing of a wide variety of problematic behaviors in the criteria contribute to the long-standing stigma associated with this diagnosis?

Since its earliest formulations, BPD has confounded clinicians. Initially, it was neither neurotic nor psychotic, and the relevant question was whether it was analyzable, and thus treatable. Later, Kernberg considered it the result of developmental failure and an innate excess of aggression, and prone to negative therapeutic reactions. Houck referred to BPD sufferers as “the intractable female patient.” Psychoanalytic treatment failures were attributed to the patient’s pernicious motivations. In 1980, DSM III defined BPD according to observable criteria. Biological psychiatry began to replace psychoanalysis, and persons with BPD were enrolled in numerous medication trials, as attempts were made to define the disorder as a genetic vulnerability.

With the growing understanding of posttraumatic stress disorder (PTSD), Judith Herman reported that 70% of persons with BPD had histories of childhood physical and sexual abuse. Feminists suggested that male clinicians’ gender biases were blaming the victim by pathologizing women. With the growing understanding of posttraumatic dissociation, studies have continued to find from 30-80% co-occurrence of BPD with dissociative disorders. Recent studies have found neurobiological evidence for a wide spectrum of dissociative symptoms in persons with BPD as well as PTSD and dissociative identity disorder.

Unlike the criteria for the dissociative disorders, the DSM 5 definition of BPD is multiply determined and non-specific, requiring only five of nine complex criteria, describing a wide variety of relational, affect regulation, impulse control, substance abuse, and self-harm symptoms. While the trauma and stressor-related disorders have been updated to reflect current understanding, the BPD criteria have remained nearly the same, with only the addition of “transient, stress-related paranoid ideation or severe dissociative symptoms,” in the DSM IV.

Nevertheless, recent reviews reveal that a majority of persons with BPD experience a range of dissociative phenomena, including depersonalization and derealization, amnesia, identity disturbances, decreased pain perception, and auditory hallucinations. Significant proportions of persons with BPD qualify for diagnoses of OSDD or DID. Because a spectrum of dissociative symptoms occur in persons with BPD, there is no bright line distinguishing it from DID.

These dissociative symptoms contribute to non-suicidal self-injury and suicide risk, impaired executive function and social perception, and poorer response to psychotherapy. Failure to address dissociative signs in BPD denies these persons adequate treatment for their suffering. It also contributes to the widespread medical and societal misunderstanding of complex trauma. Reformulating the diagnosis of BPD with regard to its traumatic history and dissociative nature, and classifying it with similar disorders, could help guide treatment.