Vol 2 # 4

Alan Eppel


Borderline personality continues to be a major focus of mental health services.

This is in large part due to  the high rates of presentation to outpatient and inpatient psychiatric services.

The term borderline personality persists despite its anachronistic and clinically erroneous implications. Previous terminology included pseudoneurotic schizophrenia, emotionally unstable character disorder, hysteroid dysphoria, and rejection sensitive dysphoria.

Overtime it became obvious that the diagnosis  borderline personality disorder had more in common with an affective disorders then with psychosis.

Donald Klein and Hagoup Akiskal identified the significance of affective symptoms and Marsha Linehan placed emotional dysregulation as central to the disorder in developing Dialectical Behaviour Therapy.

DSM 5 offers an alternative framework for diagnosing personality disorders in an attempt to move away from some of the deficiencies of the current system.

The BPD diagnosis includes impairments in the following categories of personality functioning:


  1. Identity: poorly developed or unstable self image. Associated with self-criticism, feelings of emptiness and dissociation.


  1. Empathy: difficulty recognizing the feelings and needs of others. Interpersonal hypersensitivity i.e. easily feel slighted or insulted. Perceptions of others negatively biased.


  1. Intimacy: intense unstable and conflicted close relationships marked by mistrust, neediness and anxious preoccupation with real or imagined abandonment.


It is defined by four of the following personality traits at least one of which must be impulsivity, risk-taking or hostility.


  1. Negative affectivity in the form of emotional lability: frequent mood changes; emotions that are easily aroused, intense and are out of proportion to events and circumstances.
  2. Negative affectivity in the form of anxiety:  Feeling fearful, apprehensive, threatened by uncertainty. Feeling nervous tense panicky worry.
  1. Separation insecurity:  Fear of rejection or separation from significant others.
  1. Depression: Low mood, hopelessness, shame, low  self-worth suicidal thoughts and behaviour.
  2. Impulsivity:  Acting on the spur of the moment in response to immediate stimuli. Acting without planning or considering outcomes. Self-harm behaviours.
  3. Risk-taking: Engagement in dangerous and risky behaviours that regard for the consequences.
  1. Hostility: Persistent or frequent angry feelings; anger irritability in response to minor slights and insults.


All except one of these can be subsumed under the category of emotional dysregulation.

The item relating to separation insecurity is related to childhood attachment and represents insecure attachment.

Insecure attachment is associated with difficulties in close relationships. The items related to identity, empathy and intimacy are also derivatives of insecure attachment.

In other words the DSM conceptualization of borderline personality can be reframed along two dimensions:


I. Emotional dysregulation

II. Insecure attachment.

There is much empirical evidence to support this. Studies over the past three decades have identified childhood neglect and abuse in the history of patients with borderline personality disorder. Other studies have identified prolonged separations from caregivers during childhood.


Studies using the Adult Attachment Interview identified up to 75%  BPD patients were classified with the preoccupied attachment state of mind.  In a study by Barone only 7% of patients with borderline personality disorder had secure  attachment status (autonomous) compared to non-clinical controls at 62%.

In summary these studies indicate that patients diagnosed with borderline personality exhibit preoccupied, dismissing and unresolved attachment status corresponding to ambivalent, avoidant and disorganized childhood attachment categories.

Reconceptualizing borderline personality essentially as a disorder of mood and attachment will lead to more focused treatments, reduced artificial comorbidity diagnoses, reduced stigmatization. In addition it is more in keeping with the approach taken by the NIMH Research Domain Criteria (RDoC).

It recognizes that this condition is heterogeneous and operates along dimensional axes rather than heterogeneous categories.



Akiskal HS. The temperamental borders of affective disorders. Acta Psychiatr

Scand Suppl. 1994;379:32-7.

Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M, Bolinger JM.

Borderline: an adjective in search of a noun. J Clin Psychiatry. 1985


Akiskal HS. Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders in the “borderline” realm. Psychiatr Clin North Am. 1981


Barone L. developmental protective and risk in borderline personality disorder: a study using the adult attachment interview. Attachment and human development 2003 5, 64 – 77.

Fonagy P, Leigh T, Steele M et al. the relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of consulting and clinical psychology 1996. 64, 22-31.

Hoch P, Polatin P. Pseudoneurotic forms of schizophrenia. Psychiatr Q. 1949 Apr;23(2):248-76.

Klein DF, Liebowitz MR. Hysteroid dysphoria. Am J Psychiatry. 1982



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