You'll get better, as long as you don't die in the meantime

If you're relatively young, female, and had repeated admissions to psychiatric wards or hospitals, it's quite likely that you've attracted the diagnosis of Borderline Personality Disorder (BPD) at some point. In theory, BPD is diagnosed on the basis of exhibiting at least five out of the following nine symptoms, which form "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts":

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

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 (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

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

6. affective instability due to a marked reactivity of mood (e.g., 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 (e.g., frequent displays of temper, constant anger, recurrent physical fights)

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

However, despite the enormous amount of committee-sitting and controversy that surrounds each revision of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), from which this list has been taken, I doubt that psychiatrists rely too heavily on its decision-making trees, pre-empted diagnoses or even the specific criteria for a particular 'disorder'. Diagnosis in practice tends to be done intuitively, and is subject to the same kind of confirmation bias that affects any other kind of decision-making. Hence, psychiatrists may fixate on the expression of one or two of the above symptoms and extrapolate from there, particularly if the symptoms are considered 'cardinal' with respect to the diagnosis. In the case of BPD, "self-mutilating behaviour" (Criterion 5) would almost certainly lead your average psychiatrist to diagnose BPD, possibly by employing selective attention to any possible manifestations of the other criteria, at the expense of obtaining an overall picture.

The term "borderline" was introduced by psychoanalysts to describe an intermediate state between neurosis and psychosis characterised by the use of "primitive defenses" such as splitting (seeing someone or something as all good or all bad), and by lacking "object constancy" (the capacity to take a longitudinal view of a relationship, as opposed to focusing on the most recent interaction). It is also used in a psychoanalytical context when postulating that a patient has a too-permeable "border" between his/her conscious and unconscious, with primary process thinking "seeping through" in the form of quasi-psychotic phenomena. Psychoanalysts will claim that this rather metaphysical use of the word is merely descriptive and non-judgemental in nature.

However, there is no doubt that in a mainstream psychiatric context, the diagnosis carries a great deal of baggage, with perceptions on the part of staff that the labellee is "difficult", "manipulative", "attention-seeking" and "not really that sick" (as opposed to those carrying a diagnosis of schizophrenia or manic-depression). On the other hand, its recipients often feel that they have been put in a "diagnostic trash can" or that BPD really stands for "Bitch Pissed Doc". (At least one psychiatrist is on the record as stating that his preferred treatment for those labelled with BPD was simply to "refer them.") Samuel Shem's book Mount Misery (about the experiences of a young trainee psychiatrist) offers a hilarious caricature of an erratic, explosive and narcissistic BPD specialist, who bullies his young, female patients (and trainees) into a state that combines "inappropriate, intense anger" (Criteria 8) with all the symptoms of Stockholm Syndrome (Criteria 1 & 2). As he explains to the trainee, after badgering his depressed patient into storming out of ward rounds:

"My friend, you'll get used to it. We all start out oversensitive. These darn borderlines make us oversensitive, make us feel sorry for 'em. Beginners like you always get drawn in - overconcerned, trying to rescue them - these gals are seductive. The things they get us to do for 'em - give 'em meds, find 'em places to live, even loan 'em money! This one - Zoe - she's the kind who'll even show up at your home. You unlisted?... Seduce the pants off us, given half a chance. Incredible talent they have, to somehow pick up on your weakness and go for it - like they have a special radar or something."

A key tactic of the survivor/ex-user/consumer movement is to highlight research that shows that many people who are labelled with BPD have experienced significant physical, emotional or sexual abuse early in life, usually from a primary caregiver. While I believe that the findings of such research are crucial to developing an understanding of the causes of the symptoms associated with BPD, this tactic may meet with some resistance, especially from those who wish to distance themselves from any deterministic account of their problems, whether it be psychosocial or biogenetic in nature. Likewise, those who primarily identify as survivors of childhood abuse (without any specific reference to ensuing psychological difficulties) may resent the perceived promulgation of the idea that child abuse inevitably leads to mental illness as an adult. It may also lead to an implicit 'silencing' of those labelled with BPD whose childhood experiences, although problematic, do not fit neatly into the various categories of child abuse. It is worth remembering that most of the damage we do to each other is not covered by any statutes or prohibitions, and that "that's life".

It also doesn't necessarily follow that mental health professionals would be more enthusiastic about engaging with those labelled with BPD as a result of adopting psychosocial causal beliefs - again, anything that smacks of determinism promotes pessimism with regard to recovery, and their attitude may well be "We're sorry, but you were screwed, and now you're screwed." With few exceptions, the psychiatric system has an appalling track record of acknowledging and dealing with the aftermath of childhood trauma. New Zealand psychologist John Read has extensively researched the nature and prevalence of this inadequacy, particularly with regard to patients diagnosed with psychotic disorders. Others who have written constructively on the subject include psychiatrist Judith Herman, who in her book Trauma and Recovery integrates the symptomatology of BPD with that of dissociative and psychosomatic disorders to propose a new diagnosis, Complex Post-Traumatic Stress Disorder, which is apparently being considered for inclusion in DSM-V, and Canadian researchers Barbara Everett and Ruth Gallop, whose book The Link Between Childhood Trauma and Mental Illness: Effective Interventions for Mental Health Professionals provides more practical advice for practitioners.

I can posit what I consider to be three basic truths about BPD (assuming it has construct validity):

1. In most cases it has developed as a response to some kind of interpersonal trauma;

2. In particular, it may be largely iatrogenic in nature (the trauma being the person's induction into the psychiatric system, particularly at a young age, and being subject to inappropriate and unprofessional behaviour from mental health professionals); and

3. People who meet the criteria for BPD are often bloody difficult to be around, no doubt about it. But with psychiatrists either justifying 'tough love'-style treatments on the grounds that the worse thing you can do is to be nice to them, or declaring them to be 'unengagable', often with respect to unmodified cognitive-behavioural therapies that implicitly blame the patient for his or her emotional states, this shouldn't be surprising. I was once told that there is little you can do for patients diagnosed with BPD in their late teens, but "that are always going to get better, as long as they don't die in the meantime."

So what to do? The disentangling of the models and concepts of causation and all their connotations is an ongoing project, with health professionals, the survivor/ex-user movement and the general public alike only recently beginning to recognise that environment and behaviour influence biology, as well as the other way around, thus rendering the phrase "biological determinism" less redundant than it previously was. In an ideal world "mental health literacy" would have more to do with critical thinking and a rough appreciation of some aspects of philosophy than it would with being able to parrot the prevailing medical model descriptions of causes, symptoms and treatments.