The Mystery of Borderline Personality Disorder

People with borderline personality disorder are some of psychology's hardest cases. Many commit suicide. But recent treatment advances are unlocking what was once a mystery illness

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Photo-illustration for TIME by Andree Kahlmorgan; Images by iStockphoto

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Still, the rise in borderline diagnoses may illustrate something about our particular historical moment. Culturally speaking, every age has its signature crack-up illness. In the 1950s, an era of postwar trauma, nuclear fear and the self-medicating three-martini lunch, it was anxiety. (In 1956, 1 in 50 Americans was regularly taking mood-numbing tranquilizers like Miltown — a chemical blunderbuss compared with today's sleep aids and antianxiety meds.) During the '60s and '70s, an age of suspicion and Watergate, schizophrenics of the One Flew Over the Cuckoo's Nest sort captured the imagination — mental patients as paranoid heroes. Many mental institutions were emptied at the end of this period. In the '90s, after serotonin-manipulating drugs were released and so many patients were listening to Prozac, thousands of news stories suggested, incorrectly, that the problem of chronic depression had been finally solved. Whether driven by scary headlines, popular movies or just pharmacological faddishness, the decade and the disorder do tend to find each other.

So, is borderline the illness of our age? When so many of us are clawing to keep homes and paychecks, might we have become more sensitized to other kinds of desperation? In a world so uncertain, maybe it's natural to lose one's emotional skin. It's too soon to tell if that's the case, but BPD does have at least one thing in common with the recession. As Dr. Allen Frances, a former chair of the Duke psychiatry department, has written, "Everyone talks about [BPD], but it usually seems that no one knows quite what to do about it."

Inside the Mind
To have coffee with Lily (a pseudonym), you wouldn't get much sense of how she has suffered. She is 40 but could pass for 30. She has blue eyes and long blond hair that falls across her shoulders in slightly curly tendrils. On the December day we met at a diner outside Seattle, she wore a pink wool cap pulled down tight and an Adidas jumper zipped all the way. She was friendly but not terribly expressive, and she carried an aura of self-protection.

At one point in the late '90s, Lily was taking five drugs that doctors had prescribed: three antidepressants, an antianxiety medication and a sleeping pill. Borderline patients are often overmedicated — partly because therapists see them as difficult — but for Lily, as for most borderlines, the meds did little. "Drug treatment for BPD is much less impressive than most people think," Paris writes in Treatment of Borderline Personality Disorder.

As a teenager, Lily felt little self-confidence. "Junior high and high school just sucks, right?" she said, laughing. "But I had a propensity to take it a little more seriously." With the help of therapy, she made it through high school and college, but in her late 20s, she became dissatisfied with her job selling specialty equipment. One October day, as she headed out for a mountain-biking trip, she looked at the dun sky and had the feeling that something was wrong. Bleakness massed around her quickly, much faster than it had when she was younger. Soon, nothing gave Lily much joy.

She recalled a talk show in which girls had discussed cutting themselves as a release, a way to relieve depression. "I was so numb," she said. "I just wanted to feel something — anything." So she took a knife from the kitchen and cut deeply into her left arm.

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