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those on the possible biological and genetic roots of the syndrome, were extensively rewritten in order to incorporate the latest scientific research. Additionally, specific psychotherapeutic approaches and drug treatments have evolved to such an extent that it was necessary to include entirely new chapters on these topics. The book’s reliance on real-life case stories, to give the reader insight into what life is like for—and with—a borderline, continues in this edition, though the backdrop of these stories was altered to reflect the changes in American society from one century to the next. Perhaps the biggest change from the first edition is one of overall tone: whereas the prognosis for patients was understandably bleak two decades ago, it is now (based on numerous longitudinal studies) much more positive.

And yet, despite these advancements, it is disappointing to review the preface to the first edition and recognize that misunderstanding and especially stigma still run rampant. BPD remains an illness that continues to confuse the general public and terrify many professionals. As recently as 2009, a Time magazine article reported that “[b]orderlines are the patients psychologists fear most” and “[m]any therapists have no idea how to treat [them].” As Marsha Linehan, a leading expert on BPD, noted, “Borderline individuals are the psychological equivalent of third-degree burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.”1 Nevertheless, development of specific therapies and drugs targeted at the disorder (see chapters 8 and 9) has provided some relief from patients’ burdens, and perhaps more important, public awareness of BPD has grown significantly from what it was in 1989. As you will see in the Resources section at the end of this book, the number of books, websites, and support groups has proliferated. Perhaps the clearest sign of public acknowledgment occurred in 2008, when Congress designated May as “Borderline Personality Disorder Awareness Month.”

Still, huge challenges remain, especially financial. Reimbursement for cognitive medical services is shamefully, disproportionately small. For one hour of psychotherapy, most insurance companies (as well as Medicare) pay less than 8 percent of the reimbursement rate allocated for a minor outpatient surgical procedure, such as a fifteen-minute cataract operation. Research for BPD has also been inadequate. The lifetime prevalence rate of BPD in the population is twice that of both schizophrenia and bipolar disorder combined, and yet the National Institute of Mental Health (NIMH) devotes less than 2 percent of the monies apportioned to the studies of those illnesses to research on BPD.2 As our country tries to control health care costs, we must understand that investment in research will eventually improve the health of this country and thus lower long-term health care costs. But we will need to reevaluate the priorities we place on limited resources, and recognize that rationing may impact not only delivery of care but also advancements toward a cure.

Many in the public and professional realm have kindly referred to the original publication of this book as the “classic” in the field. After two decades, it has been a labor of love to revisit our work and update the voluminous data accumulated during this interval. It is my hope that by refreshing and refurbishing our original effort we can play a small part in rectifying the misunderstandings and erasing the stigma associated with BPD and retain the honor of being referenced widely as a primary resource.

—Jerold J. Kreisman, MD

NOTE TO READER

Most books on health follow a number of style guidelines (for example, Publication Manual of the American Psychological Association ) that are designed to minimize the stigma of disease and to employ politically correct gender designations. Specifically, referring to an individual by an illness (for example, “the schizophrenic usually has . . .”) is discouraged; instead, reference is made