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Does this patient need psychiatric referral?

Borderline personality disorder is serious, life-threatening, and fairly common, yet it goes unrecognized by most physicians.

Lee Crandall Park, MD

Dr Park is Associate Professor of Psychiatry, Johns Hopkins University School of Medicine. Baltimore.

Borderline personality disorder (BPD) is a severe and life-threatening condition. Although it occurs relatively frequently, exacts an enormous toll in human suffering, and contributes significantly to national health care costs, this condition was not identified until quite recently. Because its nature and manifestations are only now becoming clear, BPD has remained obscure or unknown to most health-care professionals.

In the 1960s and 1970s, clinical studies of possible variants of schizophrenia revealed a sizable patient group that was difficult to classify.1,2 These patients were very disturbed at times and yet could be quite rational and perceptive at others. They were thought by most psychiatrists at the time to be on the verge of schizophrenia (hence "borderline") or to have a disguised form of the disease ("pseudoneurotic schizophrenia").

The seminal research of Gunderson in the 1970s1 identified objective diagnostic criteria that engendered many large-scale studies of BPD patients. These studies showed that BPD was not a variant of psychotic illness and did not progress to schizophrenia. As a result, it has been redefined as a personality disorder of unknown etiology.3 However, as will be discussed later, recent research suggests that BPD is not so much a personality disorder as a serious illness brought about by childhood trauma.


A 1990 epidemiologic study conducted by Swartz and colleagues found that BPD occurred in approximately 2% of a sample of the general population, 73% of them women.4 The data also revealed that approximately 50% of respondents with BPD had used some form of outpatient mental health service in the past 6 months and 19.5% had had an inpatient hospitalization in the previous year. The authors report that BPD occurs in over 10% of psychiatric outpatients, about 20% of inpatients, and more than 60% of in-patients in clinical settings where personality disorders predominate.


The current diagnostic criteria for BPD are given in the Table,3 although investigators continue to debate its core features.

BPD involves dramatic and severe symptomatology that pervades many aspects of functioning, including relationships, sense of self, mood, and behavior (see box, "Recognizing BPD in the Primary Care Setting"). Individuals with BPD live in almost constant psychic pain, burdened by self-hate; a great longing for intimacy yet distrust of others; intense, painful relationships characterized particularly by frantic efforts to avoid abandonment; potentially self-damaging impulsiveness; and chronic dysphoria that can quickly progress to severe depression and suicidal thinking and behavior. They have a pervasive sense of their badness, and their severely damaged sense of self manifests itself in great confusion about who they are, what they value, and what they want in life. They may attempt to relieve their anguish by inflicting physical injury on themselves.

When undergoing interpersonal stress, BPD patients easily become confused and enraged and, when this causes others to distance themselves, suffer extremes of emptiness and abandonment. Many BPD patients also have a heightened perceptivity of people's feelings and motives, which can manifest itself in a powerful manipulative influence over others, termed "projective identification."5,6 In another manifestation of this characteristic, the patient is remarkably appealing and compelling, which is sometimes associated with role-boundary violations by therapists, including sexual intimacy.7

Approximately 10% of BPD patients commit suicide, usually relatively early in their illness. One major study found that 38% of women who had BPD with comorbid major depression and alcohol abuse committed suicide.8


Numerous etiologic theories have been advanced about BPD,9 and specific clues are provided by two facts: the great majority of BPD patients also suffer from clinical depression, and approximately one third meet the criteria for post-traumatic stress disorder.10 Many recent studies have also reported childhood physical and sexual abuse in the majority of BPD patients,11-13 who tended not to recognize or report it spontaneously. However, since such abuse was not found in all cases of BPD, the search for a common etiologic factor continued.

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