Abstract
To the Editor
In the clinical setting I have had my share of difficulty addressing boundaries and overlaps between borderline personality disorder (BPD) and bipolar disorder, but that’s what makes our work interesting. I’ve never had any difficulty distinguishing the concepts, and would endorse Basset (2012) and most others before him who conclude that, despite some overlapping features, they are different things. I am perplexed that Coulston et al. (2012) (and others before them!) struggle to define ‘potential areas of discrimination’. Is this ‘not seeing the wood for the trees’?
The patients I see don’t seem to have the same difficulty. Those without PD (or their families) can usually recall a time before the onset of their illness when life worked better. Those with PD cannot. Of course there are exceptions – problems with recall and self deception, the issue of ego-syntonicity – but it is a practical starting point. Some people of course have experienced the onset of a chronic Axis I condition early in life and for them personality development is inextricably tied to their illness, and some have both.
Coulston et al. repeat Tyrer’s (2009) assertion that BPD ‘fundamentally does not belong’ on the PD axis, a position quite adequately refuted by Paris et al. (2009) and others in that journal at the time. Tyrer, like many contemporary writers on PD, focuses on traits, and fails to address personality as an integrative, adaptive function: ‘an emergent organisation that integrates traits and other mental states and mechanisms to accomplish basic tasks’ (Wakefield, 2008). What we see as the ‘maladaptiveness’ of BPD has enabled its sufferers to reach adulthood and reproduce, despite difficult backgrounds. It is the failure to relinquish or vary those strategies in potentially new, altered circumstances that constitutes PD, and in that respect I can’t see that BPD is any different from most other PDs. An enduring behavioural repertoire, entrenched in procedural memory from childhood, and gradually modified or relinquished in middle adulthood, is a very different thing from an episodic illness.