On “Borderline” Diagnoses

In retrospect, it is ironic, perhaps, that it was within psychoanalysis that the category of the ‘borderline’ was invented. More specifically, it derived from the ego psychology of the US, which situated the borderline as a category of exclusion between neurosis and psychosis. There are strong grounds for concern about the aims, ethical underpinnings and conceptual rigour of ego psychology (see here for a brief summary). As I’ve tried to point out elsewhere, the blunders of ego psychology did not prevent it from having a formative influence on many other forms of North American psychotherapy, including those that prevail in the Anglophone world today. In general, for an idea to have emerged from ego psychology constitutes a serious objection to it; if it is also taken up by bureaucrats and panel-beaters of the psyche, this amounts to a refutation.

Still, the borderline category, as it exists in the psychiatric textbooks (the DSM-5 being the most recent) is relatively statistically robust, as far as reliability and validity are concerned. Conceptually, as we shall see, it is deficient, and of course there is far more to diagnosis and treatment than statistics, but in the context of the DSM, a statistically-sound concept is something of a rarity. One can but admire the degree of obtuseness required for concepts that fail both statistically and conceptually.

The endorsement from statistics means that, if several diagnosticians were to encounter a ‘borderline’ in the clinic, there would be a relatively high degree of agreement between them on the diagnosis and patient profile. This may have something to do with the construction of the diagnosis, which requires the patient to exhibit 5 of a possible 9 symptoms, all of which are vaguely defined. Unlike disorders of mood or anxiety, there is no sine qua non condition for diagnosis, which means that there can be vast heterogeneity in patient presentation and nevertheless the borderline category can still apply. Moreover, it is an elementary fact of psychology not generally admitted by its clinical practitioners that there is no unified, coherent concept of ‘personality’ in psychology, and by extension, no real conceptualisation of its being in disorder. The behavourist and psychometrician, the ego psychologist and Kohutian do not share the same referents for ‘personality’. Correlational statistics notwithstanding, the concept of a ‘borderline personality disorder’ does not look very sound.*

The individual symptoms are equally inadequate in definition. Like the predictions in the astrological pages of newspapers, the symptoms are presented with just enough detail to appear substantial, whilst retaining sufficient vagueness to be highly generalizable. These symptoms include attempts to avoid abandonment, ‘impulsivity’ and ‘intense feelings’, characterisations that would apply to practically anybody who has ever had a relationship. Then there is ‘inappropriate intense anger’, with inappropriateness here being defined by the clinician, not the patient.

Originally, neurosis in psychoanalysis referred to a subject in whom repression was operative. Psychosis could be understood as the absence of such repression (whether by ‘disavowal’, as Freud has it in the 1920s, or by foreclosure, as Lacan argued in the 1950s). Once you take vague and general ‘symptoms’ and reconstruct them as a ‘personality disorder’, you throw this categorical rigour out the window. ‘Inappropriate’ hysterics and psychotics alike can find themselves trapped in this diagnostic wastebasket. This is all the more ironic since, strictly speaking, it is the diagnostician (and not the patient) who is on the border here, sitting on the fence, spared the trouble of differential diagnosis, incapable of making clear categorical distinctions..

In this light, it is interesting to see how the diagnosis is put to functional use. Think of ADHD, for instance. No doubt some subjects have difficulties that roughly correspond to the descriptions of the textbooks. This is irrelevant to how the diagnosis is used, however, which, in the US, is principally as a means of regulating and disciplining the inconvenient behaviours of children.

The uses to which the ‘borderline’ label is put, as patients well know, is essentially to define a subject as unpleasant, ‘difficult’, or incurable. None of these implications are terribly surprising if one construes an entire ‘personality’ to be in disorder. In the Australian public health system, being a ‘borderline’ constitutes grounds for being refused emergency psychiatric treatment. In sexual politics, becoming a Mens’ Rights Activist means adopting a certain vigilance with respect to the possibility of encountering a borderline woman. Apparently, taking the red pill helps you to become hyper-aware of the problems that you situate in the Other, rather than yourself.

With all of this in mind, I encourage clinicians to abandon the borderline category, even if only provisionally, to see if you don’t gain by dispensing with it. It is a concept which is incoherent in its foundations, and abusive in its implementation, and clinical ethics and praxis can only continue to suffer through its perpetuation.

 

*A much stronger conceptualisation would conceive of ‘personality’ (or subjective position)  in terms of different kinds of ‘order’ or structure, rather than some normative drivel about ‘disorder’. For instance, in paranoid psychosis, the persecutory delusion is an attempt by the patient at recovery. The tortured mental circumlocutions of the obsessional neurotic might constitute so many stratagems for delimiting jouissance, and so forth.

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