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...in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) category, the definition of the term borderline has been resculpted to resemble that of the affective disorders, which has resulted in diffusion of the "border" between psychosis and neurosis from which the disorder is named (Kroll, 1993). BPD is conceptualized to a substantial degree in terms of maladaptive interpersonal behavior. The presence of significant, intense, disharmonious relationships is among the most useful criteria in identifying individuals with BPD (Widigen & Francis, 1989). Research has indicated that individuals with BPD have more hostile representations of significant relationships (Benjamin & Wonderlich, 1994) and seem to have a more insecure attachment style (Sack, Sperling, Fagen, & Foelsh, 1996).
Designations of normality and pathology have their origins not only in biological and psychiatric circles but also in sociocultural contexts. The characterization of BPD in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; APA, 1994), reflects a view that the individual experiencing borderline symptoms had a problematic early mother-child relationship resulting in the arrest of healthy boundary development. According to this view, the result is that an individual with BPD has an intense and irrational fear of abandonment, resulting in severe deformation of character. Posttraumatic stress disorder (PTSD), in contrast, is one of only a few diagnoses in the DSM-IV whose symptoms are attributed to situational causes alone. This more favorable language has made PTSD the diagnosis of choice with gender-sensitive counselors, who favor this "non-blaming" label and see it as a means of acknowledging the environmental origins of psychological distress faced primarily by women. Conversely, BPD, which is defined in sweeping language and using broad categories, has acquired a pejorative connotation. The underlying view characterizing an individual placed in one diagnostic category as "disordered" due to a character flaw versus another category that depicts an individual's symptoms as a consequence of circumstances has significant implications both for the counselor and the client. Becker (2000) characterized individuals diagnosed with BPD and PTSD as "bad girl" and "good girl" respectively.
In this article, I address issues of whether using the preferred label of PTSD rather than BPD actually holds promise for viewing "borderline" women in a developmental context. I also stress that the pejorative view of the BPD category has resulted in what some have termed a "caste system" of diagnosis and treatment that fails to adequately serve women labeled with BPD. Issues that I examine are the problematic result of labeling women as "borderline"; the subjectivity of BPD criteria; the overlapping comorbidity with BPD and PTSD; and the difficulties created by attempting to fit BPD into the category of trauma disorders.
NEBULOUS DIAGNOSTIC CATEGORY
The BPD category grew out of the original diagnosis of hysteria, which as a medical diagnosis dates back to the early 1800s. Originally, this term was used when the clinician was unsure of the correct diagnosis, because the client manifested a mixture of neurotic and psychotic symptoms. Many clinicians thought of these clients as being on the border between neurotic and psychotic, and thus the term borderline came into the diagnostic lexicon (Beck & Freeman, 1990). The DSM-IV reports that the lifetime prevalence rates for PTSD range from 1% to 14% (APA, 1994). Sperry and Mosak (1993) noted, "the borderline personality disorder is becoming one of the most common Axis II presentations seen in both the public sector and in private practice" (pp. 356-358). Beck and Freeman summed up BPD in the following hypothetical dialogue:
SUPERVISOR: Why are you having trouble with Mr. Schultz?
THERAPIST: Because he's borderline.
SUPERVISOR: Why do you consider him borderline?
THERAPIST: Because I'm having so much trouble with him. (p. 178)
Despite BPD's prominence as one of the most widely researched disorders, there is no consistent proof of either its reliability or validity (Becker, 1997; Francis & Widigen, 1987). Furthermore, it is a diagnosis that has been applied to women at a rate 7 times greater than for men (Schwartz, Blazer, & Winfield, 1990). Despite questions about efficacy, scores of books, professional journal articles, and numerous presentations at national conferences demonstrate that the mental health field continues to be mesmerized by this dubious diagnostic category, often depicting it in negative terms. Kernberg (1984) referred to BPD as a "psychological cancer" (p. 262), and Gilbert (1992), taking a cue from Kernberg, devoted an article to the immense strains that the "impulse ridden and raging borderline client" (p. 696) places on college and university counseling centers and suggested an approach more akin to containment than therapy.
Like many psychiatric diagnoses, BPD has been subject to society's shifting sociocultural norms. Criteria for the disorder have been sculpted in such a way that BPD could be viewed as an affective disorder, given its features of mood lability and dysphoria (Kroll, 1993). It may be no coincidence that this transformation began taking shape as interest in and funding for research on affective disorders has increased substantially over the past two decades (Kroll, 1993). Given that women report symptoms of major depressive disorders more frequently than do men (Kessler, Sonnegra, Bromet, Hughes, & Nelson, 1995), it is hardly surprising that the core of affective disorder criteria in DSM-IV has made the BPD diagnosis a more common diagnostic category for women (Becker, 1997).
Like PTSD, a diagnosis of BPD may be attained in numerous ways, further complicating the diagnostic profile. Stone (1990) outlined 93 ways to meet criteria for a BPD diagnosis (Diagnostic and Statistical Manual of Mental Disorders, third edition [DSM-III]; APA, 1980). Individuals with BPD are also likely to receive three or four other Axis I labels (Zimmerman & Mattia, 1999). The addition of a new criterion in the DSM-IV only adds to the bewildering, and perhaps disturbing, array of combinations currently possible. Given the broad range of criteria, there is little wonder that about 22% of patients carry a label of "borderline" (Stefan, 1998). Not surprisingly, BPD has become one of the most popular (and perhaps pejorative) psychiatric categories. There is an entire professional journal devoted to BPD (Journal of Personality Disorders) and numerous books, articles, and workshops focus on counseling the client with BPD. Recently, I received through the mail a 5-pound, 626-page book on the topic. In a recent excursion to a major bookstore retailer, I noticed that, in the psychology section, books dealing with BPD outnumbered those for other diagnostic categories. Given such mass marketing, one may well wonder if the diagnosis drives publication or whether publication drives the diagnosis.
Zanari et al. (1998) attempted to isolate characteristics of BPD. They identified "demandingness," entitlement, treatment regressions, and the ability to evoke inappropriate responses in one's therapist as significant behavioral characteristics of clients with BPD. Identification of these behavioral indices as support for BPD indicates just how far the profession is willing to go in accepting a diagnostic label. In an extreme variant on...
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