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Though borderline personalities suffer a tangle of painful symptoms that severely disrupt their lives, only recently have psychiatrists begun to understand the disorder and treat it effectively. What is a “personality disorder”? What exactly does borderline border? How is borderline personality similar to and different from other disorders? How does the borderline syndrome fit into the overall schema of psychiatric medicine? These are difficult questions even for the professional, particularly in light of the elusive, paradoxical nature of the illness and its curious evolution in psychiatry.

One widely accepted model suggests that individual personality is actually a combination of temperament (inherited personal characteristics, such as impatience, vulnerability to addiction, etc.) and character (developmental values emerging from environment and life experiences)—in other words a “nature-nurture” mix. Temperament characteristics may be correlated with genetic and biological markers, develop early in life, and are perceived as instincts or habits. Character emerges more slowly into adulthood, shaped by encounters in the world. Through the lens of this model, BPD may be viewed as the collage resulting from the collision of genes and environment.1, 2

BPD is one of ten personality disorders noted in DSM-IV-TR: in DSM terminology personality disorders are categorized on Axis II. (See Appendix A for a more detailed discussion of categorization in DSM-IV-TR.) These disorders are distinguished by a cluster of developing traits that become prominent in an individual’s behavior. These traits are relatively inflexible and result in maladaptive patterns of perceiving, behaving, and relating to others.

In contrast, state disorders (Axis I in DSM-IV-TR) are usually not as enduring as trait disorders. State disorders, such as depression, schizophrenia, anorexia nervosa, chemical dependency, are more often time- or episode-limited. Symptoms may emerge suddenly and then be resolved, as the patient returns to “normal.” Many times these illnesses are directly correlated with imbalances in the body’s biochemistry and can often be treated with medications, which virtually eliminate the symptoms.

Symptoms of a personality disorder, on the other hand, tend to be more durable traits and change only gradually; medications are, in general, less effective. Psychotherapy is primarily indicated, though other treatments, including medication, may alleviate many symptoms, especially severe agitation or depression (see chapter 9). In most cases, borderline and other personality disorders are a secondary diagnosis, describing the underlying characterological functioning of a patient who exhibits more acute and prominent symptoms of a state disorder.

Comparisons to Other Disorders

Because the borderline syndrome often masquerades as a different illness and is often associated with other illnesses, clinicians often fail to recognize that BPD may be an important component in evaluating a patient. As a result, the borderline often becomes, like Carrie, a well-traveled patient, evaluated by multiple hospitals and doctors and accompanied throughout life by an assortment of diagnostic labels.

BPD can interact with other disorders in several ways (see Figure 2-1). First, BPD can coexist with state (Axis I) disorders in such a way that borderline pathology is camouflaged. For example, BPD may be submerged in the wake of a more prominent and severe depression. After resolution of the depression with antidepressant medications, borderline characteristics may surface and only then be recognized as the underlying character structure requiring further treatment.

Second, BPD may be closely linked and perhaps even contribute to the development of another disorder. For example, the impulsivity, self-destructiveness, interpersonal difficulties, deflated self-image, and moodiness often exhibited by patients with substance abuse or eating disorders may be more reflective of