Borderline Personality Disorder and Posttraumatic Stress Disorder: Time for Integration?

Within the last decade, the diagnosis of borderline personality disorder (BPD) in women has become a fixture in mental health circles (Becker, 2000). It has been suggested that the increase in such BPD diagnoses in women has its genesis in the revisions of the diagnostic code. Specifically, in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) category, the definition of the term borderline has been resculpted to resemble that of the affective disorders, which has resulted in a diffusion of the "border" between psychosis and neurosis from which the disorder is named (Kroll, 1993). BPD is conceptualized to a substantial degree in terms of maladaptive interpersonal behavior. The presence of significant, intense, disharmonious relationships is among the most useful criteria in identifying individuals with BPD (Widigen & Francis, 1989). Research has indicated that individuals with BPD have more hostile representations of significant relationships (Benjamin & Wonderlich, 1994) and seem to have a more insecure attachment style (Sack, Sperling, Fagen, & Foelsh, 1996). Designations of normality and pathology have their origins not only in biological and psychiatric circles but also in sociocultural contexts. The characterization of BPD in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; APA, 1994), reflects a view that the individual experiencing borderline symptoms had a problematic early mother-child relationship resulting in the arrest of healthy boundary development. According to this view, the result is that an individual with BPD has an intense and irrational fear of abandonment, resulting in severe deformation of character. Posttraumatic stress disorder (PTSD), in contrast, is one of only a few diagnoses in the DSM-IV whose symptoms are attributed to situational causes alone. This more favorable language has made PTSD the diagnosis of choice with gender-sensitive counselors, who favor this "non-blaming" label and see it as a means of acknowledging the environmental origins of psychological distress faced primarily by women. Conversely, BPD, which is defined in sweeping language and using broad categories, has acquired a pejorative connotation. The underlying view characterizing an individual placed in one diagnostic category as "disordered" due to a character flaw versus another category that depicts an individual's symptoms as a consequence of circumstances has significant implications both for the counselor and the client. Becker (2000) characterized individuals diagnosed with BPD and PTSD as "bad girl" and "good girl" respectively. In this article, I address issues of whether using the preferred label of PTSD rather than BPD actually holds promise for viewing "borderline" women in a developmental context. I also stress that the pejorative view of the BPD category has resulted in what some have termed a "caste system" of diagnosis and treatment that fails to adequately serve women labeled with BPD. Issues that I examine are the problematic result of labeling women as "borderline"; the subjectivity of BPD criteria; the overlapping comorbidity with BPD and PTSD; and the difficulties created by attempting to fit BPD into the category of trauma disorders. NEBULOUS DIAGNOSTIC CATEGORY The BPD category grew out of the original diagnosis of hysteria, which as a medical diagnosis dates back to the early 1800s. Originally, this term was used when the clinician was unsure of the correct diagnosis, because the client manifested a mixture of neurotic and psychotic symptoms. Many clinicians thought of these clients as being on the border between neurotic and psychotic, and thus the term borderline came into the diagnostic lexicon (Beck & Freeman, 1990). The DSM-IV reports that the lifetime prevalence rates for PTSD range from 1% to 14% (APA, 1994). Sperry and Mosak (1993) noted, "the borderline personality disorder is becoming one of the most common Axis II presentations seen in both the public sector and in private practice" (pp. …