Borderlinity: From Condition To Disorder

A Council, Voting and a Tie

It was the 1970s when Psychiatry was going through a crisis in its existence. I have written extensively about what these times were like for psychiatry in my posts about the Anti-Psychiatry movement and the work of Robert Spitzer in formalizing the field into what it is today. You should give them a read to have an extensive understanding of what was going on in psychiatry, particularly psychiatry as practised in the USA.

TLDR: People were tired of psychoanalysis and how slow and unreliable it was. They wanted something better and more scientific. The APA, which had been publishing the DSM (a list of all mental disorders) with a psychoanalytic view of mental disease until then, put Robert Spitzer in charge to improve the DSM and make it more scientifically reliable.

And that is where our story today begins.

What is Borderlinity?

The term ‘borderline’ was first used in 1938 to describe a person who lived on the border state between psychotic and neurotic states. Here psychotic does not mean the presence of hallucinations or delusion but a general breakdown of one’s relationship with objects and reality. Neurotic refers to psychological distress while maintaining the relationship with reality.

Clinicians at the time were confused with a particular typeset of patient they kept seeing. These people would usually portray neurotic symptoms but then suddenly have episodes of psychotic breakdowns. Some thought it was a primitive form of schizophrenia, others thought it was simply a mild form of it.

Consensus eventually emerged that these people live somewhere on the border of the two states. Borderlinity was discovered and formed, at the same time.

At the time, it was simply considered a condition descriptive of people’s relationships with others. Just as some people are secure, insecure some people were described as being borderline. They could go from 0 to 100 super quick and then back down to 0 equally quickly too.

Fast Forward to the 1970s

As the 1970s rolled around, every psychoanalytic construct was put under scrutiny. Is this a real thing or is this just something Freudians came up with to make the clinical process easier? Robert Spitzer hand-picked a task force, mostly of psychiatrists and a few psychologists to decide which disorder got to be in the third revision of the DSM and which one did not. He believed these people were committed to the cause of scientific objectivity and diverse enough to bring in differing viewpoints. (Funnily enough, this group was not that diverse culturally, racially, linguistically or even economically)

They then picked a disorder, looked at the research that existed on the disorder and decided whether it could be included in the DSM. The main criteria were, is it well described? Is it treatable? and how much consensus is there about the existence of such a disorder?

Consensus

That’s where that word comes in. Ultimately, the third revision of the DSM was a collection of disorders based on consensus, and not always empirical objective research. There were a lot of disorders for which there was very little research. So the task force would invite the opinions of clinicians on a particular disorder and see what their thoughts were.

This is what happened with Self-Defeating Personality Disorder. It was a proposed disorder where people would willingly stay in abusive situations or those that were against their best interests despite knowing the harm of it. After protests and criticism from some feminist circles, this disorder was dropped from the DSM-III (Feminists thought this would blame victims of domestic abuse for staying with their abusers) The official reasoning behind the dropping was the lack of a clinical consensus.

The Consensus of Borderlinity

When Borderline personality disorder was put under the vote, there was a lot of disagreement within the task force. Some said that borderlinity was not a disorder but a collection of characters which cannot be pathologized. Others were certain that it was a pathological pattern.

The debates on BPD lasted for nearly two years! And even after all this time, no one could say they had made some progress in changing the other’s mind. The motion to include BPD in the DSM was put to a vote. Democracy, after all, is the best system since it takes any form of individual responsibility away.

The 12 members of the task force voted.

It was a tie.

The deadlock still could not be broken.

Every matter of a tie went to the chairman of the task force, in this case, Robert Spitzer. His vote would ultimately decide if BPD was a ‘real’ disorder or not.

Bobby’s Choice

Imagine you are Robert Spitzer in this place. You have the power to decide whether a disorder is real or not. You have been given the responsibility of changing how psychiatry is practised in the western world. At this moment, you are at the peak of your powers.

What would you do?

Spitzer did what any other good academician would do. He passed the decision on to another academician.

He came across a study by Gunderson which listed six characteristics of a borderline patient. Immediately he thought, “Ayy this is nice. I can use this. We can put this in the book (DSM) and just put any blame of things going wrong on this Gunderson guy.” (May not have been his actual thoughts.)

And thus BPD was inducted into the DSM, albeit with minor adjustments.

One man passed the buck to another man, and BPD became a real disorder.

Why Is This Important?

You might wonder why I am still talking about DSM-III when we are already at DSM-V right now. Well, simply because DSM-V was made by building onto DSM-III, not by rechecking it. Most of the disorders exist today because they were also a part of DSM-III.

It is a very real possibility that we could have been talking about self-defeating personality disorder as a real disorder, we could have had awareness weeks or days about it and we could have had a ribbon for it. But we do not, because a council decided that it was not a real disorder.

Also, a little-known fact: Introverted Personality Disorder was renamed Schizoid Personality Disorder by the same task force for DSM-III. Schizoid Personality Disorder still exists in DSM-V today. Read the criteria for it here and it will suddenly make so much more sense.

So is Introverted personality disorder real or not? That is up to the council to decide.

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GiveAway Alert!

And that is it for this week! I hope you liked the article. I started this newsletter around 6 months back and am delighted that I reached 500 readers last week.

To celebrate, I will pick three random 5-star readers and gift them two books.

1. Shhh! Don’t Talk About Mental Health by Arjun Gupta and,

2. Any book of their choice! (Please don’t make it an academic one :P)

To become a five-star reader, you need to read at least 6 issues of this newsletter and leave a comment on a few of them to become eligible for the giveaway. Reply to this email to have a stronger chance of becoming a 5-star reader too. The results will be announced in the first issue of July!

Thank you so much for the love you have shown over the last few months. There is still a lot more to come.

Yours,
Arjun