Borderline personality disorder is a broad diagnosis.
Media outlets and some psychology websites paint patients with BPD as violent, impulsive, and prone to tumultuous relationships. But in reality, the disorder is far more complex. Its clinical definition includes nine symptoms, of which patients must have at least five. That calculates to 256 different symptom combinations — 256 ways, if you will, to have BPD.
Such diversity of symptoms within a single diagnosis can complicate treatment. That’s distressing, because BPD causes immense suffering and remains difficult to overcome. While some patients benefit from dialectical behavior therapy or medications like mood stabilizers and second-generation antipsychotics, the National Institute for Mental Health estimates that of about 3.8 million U.S. adults with BPD, 4 to 9 percent ultimately commit suicide and thousands are hospitalized every year for self-harming or suicidal behaviors.
A Harvard University analysis of 290 people hospitalized with BPD found that the vast majority did improve substantially over the 16-year study. But remission often took years, longer than for patients with other personality disorders. And full recovery eluded many.
Researchers are trying to refine BPD’s diagnosis, which could help improve treatments and better tailor them to patients’ needs. In a peer-reviewed study published last month, scientists at the University of Pittsburgh used statistical modeling to see which BPD symptoms were most likely to occur together. They found several interesting results. Patients with high levels of anger and aggression were almost always the ones who frantically tried to avoid abandonment. And contrary to popular beliefe, not all patients with BPD reported having identity problems or feeling chronically empty.
Based on their findings, the researchers categorized BPD into four subtypes: angry/aggressive, angry/mistrustful, poor identity/low anger, and prototypical (or classic) BPD. But researchers don’t agree yet on how best to subtype BPD. Previous efforts, for example, resulted in categories such as high-functioning internalizing, histrionic, depressive internalizing, and angry externalizing, depending on factors like how likely patients were to act out their feelings, or how prone they were to depressed mood.
Scientists are continuing their efforts to better refine BPD’s diagnosis. The best approaches may combine studies of symptoms, genetics and brain imaging.