Personality, Interrupted


If the post-holidays are bad for a lot of us, to those phoning Valerie Porr’s Soho loft—which serves as ground zero for a major national hotline and referral service for sufferers of borderline personality disorder (BPD)—weathering January can be like a two-step through the fourth ring of hell.

BPD—a psychiatric disorder characterized by crippling emotional neediness that often leads to self-injury (like cutting), intense, volatile relationships, impulsiveness, and a host of related symptoms—is one of the most misunderstood disorders. Clinicians observe that sufferers seem to consistently process what other people do and say in a skewed, self-referential way. They then take their faulty perception as fact, and act on what they think is reality. If, for example, you say “pass the butter” to a person with BPD, that person may hear, “Why are you hogging the butter, Fatty?”

Often deceptively high-functioning and successful, BPDs drive their friends and lovers crazy if they don’t drive them away, while at the same time carrying around intense levels of fear and self-doubt. This could apply to many of us, of course, but for BPDs it’s everyday New York neurosis times 10.

In 1980 BPD was accepted as a legitimate diagnosis by the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatric diagnosis, but it had already earned the reputation of being difficult, if not impossible, to treat. Sufferers seemed to get worse with traditional psychotherapy, and medications didn’t seem to have much effect. Private therapists were reluctant to treat patients because of their relatively high rate of attempted suicide. BPD patients were often thought to enjoy manipulating their doctors’ emotions in the same way they were accustomed to treating their loved ones. Thus BPDs became the pariahs of the mental health community.

Enormous progress has been made toward understanding BPD since then, and there’s a mountain of data to show that with specialized treatments like dialectical behavior therapy—a type of cognitive therapy that focuses on mental skills rather than free association—symptoms can go into full remission. Nevertheless, research can take a long time to actually be put into practice.

In the meantime, there’s the issue of the name. There’s no such thing as a likable psychiatric diagnosis, and to have a therapist say you have any kind of “personality disorder” can be upsetting. But unlike the descriptive terms applied to BPD’s cousins— antisocial, narcissistic, histrionic—the word borderline is so meaningless that the emphasis necessarily falls on the “personality disorder” part. There is a renewed effort to call BPD something less stinging—if only the shrinks could agree. Many would just as soon leave well enough alone, but others don’t mind flexing their creative muscles.

“Emotional regulation disorder” is the term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy, but “impulse disorder” or “interpersonal regulatory disorder” would be equally valid alternatives, says Dr. John Gunderson of McLean Hospital, near Boston. The most colorful suggestion so far is “mercurial disorder,”
proposed by Harvard’s Dr. Mary Zanarini.

Another issue is insurance. Because personality disorders have been traditionally viewed as hopeless, advocates say that those diagnosed with BPD often have trouble getting their insurance to cover treatment. With that in mind, there is a parallel movement to pluck BPD from its current grouping among other personality disorders and move it to the more optimistic shelf shared by the mood disorders.

Changes are unlikely to happen soon—the next volume of the DSM
is not due out for another five years. Maybe by then the American Psychiatric Association will have decided to stop calling personality disorders “personality disorders” altogether. At least that’s what some clinicians hope. “Instead of attacking the core of who patients are,” says Dr. Roger Peele, a trustee of the APA, “it seems more therapeutic and more humane to separate them from their illness.”