in which i reflect on some socratic psychiatry

where is the borderline? part 1.5

She's out of sync, she's a half step behind
She's out of luck, her body split from her mind
She's out of focus, she's a warp in time
She's discontinued, a break in the line
She's out of orbit, she'll never connect
She'll run out of time before she accepts she's out of sync
—DEVO, “Out of Sync”, 1982

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If you’re a new reader, welcome. I’m Sorbie. And I want to say up front that I’m not a clinician and I don’t have any formal training in psychology, psychiatry, or any related fields. What I am is a renegade independent scholar with interests in the history medicine, in philosophy of science, and in cultural criticism. Or, briefly, I’m a girl with a blog. This essay fits under the umbrella of my protracted series on borderline personality disorder though a critical lens. You can check that out here, here, and here—much more to come. In this installment, I’m actually going to tell you where I think the border is!

A brief editorial note: where I have included direct quotes from the socratic dialogue, I have taken the liberty of editing for clarity, mostly getting rid of words like “y’know”, and snipping away a few redundant phrases. If you’d like to hear the discussion in its “y’know”-filled glory, I will once again recommend giving it a listen on The Socratic Psychiatrist. You won’t be sorry.

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I recently came across a conversation among Martin Greenwald (the socratic psychiatrist himself), Awais Aftab (critical psychiatrist extrodanaire), and Gary Borjesson (a philosophically minded psychotherapist). The format of the discussion was a reader Q&A, aggregated by Dr. Greenwald from readers. The conversation was brought to my attention by Dr. Aftab, whom I’ve been following on Substack since I heard him on Riva Stoudt’s podcast last year. I highly recommend listening to the discussion in full. The good doctors tackle such topics as the bipolar spectrum (is bipolar VI real in a meaningful way?), the rising use of entheogens (psychedelics, for the despiritualized among us—“entheogen” is my word, not theirs) in psychiatry, the idea of medication stewardship in psychiatry, and, of course, the meaty subject of ADHD (what the hell is going on with the diagnosis rates, the moralizing about stimulants, and much more). If you have any interest in thinking remotely philosophically about mindwork¹, these guys said something of interest to you. I found the ADHD portion of the discussion to be especially fecund.

Of course, my interest was mostly piqued by a different section, the section alluded to in the title of this post. This wasn’t just any borderline discourse, oh no. Here’s the question from the reader that the doctors were tasked with responding to:

“It seems like complex PTSD and borderline personality disorder are the same thing, but that we give cPTSD diagnoses to people who won’t accept a borderline personality diagnosis. Is this true, and if not, what are the actual differences between them in practice?” (emphasis added)

Now when Greenwald presented this question to his colleagues, Aftab launched into some level-headed explanation of each diagnosis. It took me a minute to catch up to what he was saying, though, because my first thought was, somewhat tongue-in-cheekèdly, “there is nothing more borderline than refusing to accept that you are borderline”. In other words, the very premise of the question put me a bit on the defensive—you might call me an interested party. I’ll explain why a little bit later. For now I want to keep with the content of the discussion.

So, Aftab tells us about how BPD and cPTSD have a lot of overlap in symptoms, but that the number one distinguishing factor is what some call the “stressor criterion”: to qualify for PTSD of any kind, you have to have actually had a trauma in your life. (When the makers of DSM say “trauma” they mean things like rape, torture, being a prisoner of war, and stuff like that.) Complex PTSD (cPTSD) is a diagnostic category that’s not in the DSM but is widely accepted anyway, and it basically refers to certain psychopathology that can arise when you go through a lot of bad stuff over a long period of time and you can’t escape, usually during developmental periods—so things like repeated incest, severe neglect, and repeatedly witnessing domestic violence. “Repeated trauma has more lingering effects on personality development,” says Aftab. He tells us about how the cPTSD diagnosis conceptualizes maladaptive personality changes as being generated by the bad shit that went down. He goes on to tell us about how “borderline personality diagnosis does not require a history of trauma.” In other words, BPD, like most other diagnoses in the DSM excepting PTSD, does not make any claims as to etiology. Aftab does acknowledge, of course, that many many many BPD patients have a history of trauma, “something like 85 to 90 percent”. But not everyone. “There’s a minority of people with borderline personality disorder who have the personality characteristics, but do not have a history of trauma, by any reasonable, clinical definition of trauma.” (emphasis added). The overlap in symptoms, though, allows for flexibility. “We can choose to conceptualize the problem as borderline personality, or we can choose to conceptualize the problem as complex PTSD.” Aftab says that this choice can be made according to what makes most sense when it comes to treatment setting and treatment goals. He points out that in psychodynamic psychotherapy, it makes more sense to focus on the “personality mechanisms” underlying BPD.

Speaking of which, now it’s Borjesson’s turn to respond to the question, and he’s a psychodynamic psychotherapist. What does he have to say on the subject? “I had no idea that there was even and argument that the two should be considered as possibly one.” Ah! Say more! He tells us that he has worked with many borderline people and many people with complex PTSD. Of borderline, he has this to say: “There’s a joke in analytic circles that being a teenager is a borderline personality function.” Borderline, I suppose I need not say, is characterized in large part by extremes of personality, emotional lability, and instability of self-concept; and when you think of it that way, of course teenagers are borderline. “What I think is instructive about that comparison,” says Borjesson, “is that in my own clinical experience, I do have patients who are presenting as borderline, but I really end up conceiving of their treatment in terms of arrested development—that they’re locked in to a stage of emotional dysregulation, self conflicts, [and] interpersonal conflicts.” He says that using the borderline label can often either give people a “false comfort” (this is just who I am and I don’t need to change), or a sense of false hopelessness (I am doomed to be and feel like this forever). “In some cases it’s a balance, clinically,” Borjesson says. “You don’t want to give people false hope if there are things that are more ‘baked in’.” He ties this all back to cPTSD by saying that because he does in fact conceptualize BPD as in some way developmental, it could easily be seen to be very similar to cPTSD, since trauma can have profound effects on personality development. Borjesson closes by telling us that that it would benefit patients for clinicians to let them know that there actually is often a lot that can be done to “attenuate what’s going on”.

Now it’s Greenwald’s turn. What say you, Martin? He says he is all in favor of using whatever clinical language helps make the best sense of a patient’s case. “I will say this though: I don’t think I’ve met a single patient who claims to have been diagnosed with complex PTSD who does not perfectly match the criteria for something like borderline personality disorder, and not one have them has been able to identify trauma or traumas that are even remotely convincing.” Ok king, claws out! Greenwald goes on to say that if someone really met the threshold for cPTSD, if their trauma really rose to the level of Bad Enough, they would actually be so messed up that they could be confused for someone with a neurodevelopmental disorder. Wow! Ok! This is the first I’m hearing of this. “When I hear things like ‘I’m not doing well in life because all the little traumas have added up and screwed me up’, I just have to raise an eyebrow…there’s just something a little too convenient about a trauma excuse where there’s no identifiable trauma. It’s just that you can’t deal. You’re built in such a way that you cannot deal with the trauma of everyday life. And look, I’m a psychiatrist, I know there are fragile people out there.” Damn! Yes king! Get those fragile people! Torch ‘em! (Perhaps it goes without saying that there will certainly be more on this later from me.)

Aftab chimes in, thankfully, “I would have to say in both cases that we have to exercise diagnostic judgment.” Nods all around. “I would say that for complex PTSD and even PTSD to retain any kind of meaningful value, there has to be genuine, out of the ordinary circumstances, abusive or traumatic experiences.”

“‘Dad wasn’t empathic enough’, that doesn’t cut it,” interjects Greenwald.

“Caution is warranted,” continues Aftab, “but I also think caution is warranted with regard to borderline personality disorder diagnosis too. I think that some clinicians, they find a patient annoying, or they find their questioning frustrating, it’s a quote-unquote ‘difficult patient’, and they say ‘borderline’.” Agreement from both Borjesson and Greenwald.

And that’s where they leave that portion of the discussion. They move on to talking about the DSM, which tickles me, given, you know, what they just talked about.

So here’s the part of the essay where I would like to give a bit of context. I don’t share this as a demand for you to defer epistemically to my lived experience—no, please keep your wits about you! I am choosing to share this because I think it will help you understand why I care about this, and why I think about these things the way I do. Some people who have stories like mine end up unabashedly “antipsychiatry”. That’s not me. I’m sure psychiatry has its place, just not really in my life. I am seeking to understand what happened to me and why. I hope my understanding can help add to our collective understanding.

I am currently what one might call “sane”. I don’t have a borderline diagnosis. No one who knows my current case well or has known it well in the past few years could reasonably conceive of it that way. They could reasonably say I’m disarming, a tad grouchy at times, quite mistrustful of the mindwork apparatus, and that I feel both good and bad things very strongly. They could not (and do not) reasonably say that I’m highly reactive, that I’m self-destructive, that I have an unstable self-concept, that I fear abandonment in a generalized way, that I’m a “splitter”, or almost anything else that would count me borderline. But! There was a time and specific context in which some of those latter things were generalizably true. I used to be completely out of my mind, actually, and as such, I have an extensive psychiatric history, stretching from the time I was maybe 9 or 10 until I was 21. I think some of my behaviors and relational strategies could definitely have been called “borderline” starting when I was about 18 or 19. And in fact they were called borderline by hospital psychs. However, the borderline label was applied to me starting when I was much younger than that, long before I started being “borderline” by any commonly accepted understanding of the term. I was called “borderline” starting when I was a young teenager who was going through extremely intense shit in my home life and elsewhere. As Borjesson alluded to in the interview, basically all teenagers act a bit borderline, and that’s part of why it’s not considered good practice to diagnose very young people with personality disorders. Of course, I wasn’t “diagnosed” with borderline when I was a young teen; my psychiatrist/psychotherapist at the time did not conceptualize my case that way. The people who called me borderline were clinicians and others who did not know my case very well but who were very interested in locating my distress in my own head and DEFINITELY not my relationships or circumstances. I was never diagnosed with cPTSD, probably because, like I said earlier, it’s not in the DSM anyway. The last time a therapist billed the insurance company for my treatment, which was two years ago, the diagnostic code was F43.12, just good ol’ fashioned PTSD. That said, no hospital psych has tried to call my case a PTSD case. They have lobbed all kinds of punitive labels at me (bipolar II, borderline, and much more), because I was a pretty difficult, noncompliant hospital patient back in the day, and I was not about to open up about my extremely complicated trauma history while I was in the crazy person jail, sorry! At age 20 I was sent to a residential psychiatric program that specialized in treating BPD, and it was when I arrived there where they officially pronounced me not borderline, and instead christened me…autistic, which by the way, I don’t think I would meet the diagnostic criteria for if I were assessed today². (You can read more about all that here if you’re interested.)

All this to say that I had a very complex (read:difficult, extreme, unwieldy, frustrating, scary) case. And now I don’t. What of that? I don’t know. Now I read old timey analysts and post on Substack about it, I guess.

I would guess that all three clinicians from the Q&A would have conceptualized my case as borderline if they met me back in the day. I expect, based on their answers in this discussion, that one of them would have held that conceptualization loosely, one would have gripped it tightly, and one would have taken more of a wait-and-see approach. I find it really striking that this division maps so cleanly onto each clinician’s discipline (the psychodynamic psychotherapist holds it loosely, the hospital psychiatrist holds it tightly, and the critically-minded psychiatrist waits and sees). This is particularly of interest because I am in the process of writing up a history of the BPD nosology, and each of these doctors’ thoughts on the subject maps cleanly onto the historical approaches to BPD of each respective discipline. I will say here, as I am always saying, that borderline is a psychoanalytic concept at its core. The term was coined by an analyst and was used mostly by analysts for a while there…until it got its big break when it was included in DSM-III amid lots of drama. The medicalization of BPD is actually pretty incoherent, though I think I remember that it was daddy Gunderson himself that tried his hand at making the BPD diagnosis medically coherent by conceiving of it as “bio-psycho-social” in etiology. I wonder if our three good doctors might each have a different favorite among those three hyphenated terms. I find that psychiatrists tend, consciously or not, to see “bio-psycho-social” as a hierarchy listed in terms of importance, like “reduce, reuse, recycle”, though I really don’t think it was intended that way. But what do I know?

I would guess that two of the three interviewed clinicians would conceptualize my case as a mild PTSD case if they met me in a clinical setting today. And I would guess that one of these three clinicians would just call me fragile and send me on my way.

It seems to me that one of the key distinguishing factors of borderline is its difficulty. In fact, in the very first sentence of the very first paper in which the term “borderline” was ever used, way back in 1938, we see that “this border line group of patients is extremely difficult to handle effectively by any psychotherapeutic method” (emphasis added). It seems to me that clinicians who would hand out this diagnosis in a haphazard, punitive way would, in so doing, seek to reprimand patients for externalizing³ their psychopathology. Maybe if those damned borderlines would stop being so fucking crazy, then we could give them a nicer diagnosis! Maybe if they stopped trying to kill themselves all the damn time and started just having nightmares instead, then we could give them a good girl diagnosis like PTSD. But noooo. As long as they’re being messy, the diagnosis stays. But it also seems to me that there is a punitive thread that runs though the diagnosis and always has. Whether clinicians are trying to punish patients or not, the contempt for this patient group is baked in to the diagnosis itself. Those difficult borderlines. What are we gonna do with ‘em? What we’re NOT going to do, it seems, is kowtow to borderline patients’ desire to be called something else. In the original question from the discussion, the reader frames it somewhat pejoratively. These patients are SO DIFFICULT, in fact, that they won’t accept the Difficult Patient diagnosis. Something I haven’t yet mentioned is that the question asker is a medical resident; in other words, they are a psychiatrist-in-training. This means that they are interacting with patients in a hospital setting. Well, as I mentioned before, I have extensive history with psych hospitals. I think I am qualified to say that psychiatric hospitalization can be a crazymaking experience. There is basically nowhere in the world (save a few particular relationships) that brought out the borderline in me like the psych hospital. I really believe that psych hospitals can and often do exacerbate people’s symptoms. I also that almost everyone in the world has enough of a kernel of borderline relating to behave in borderline ways under he right kind of high-stress circumstances. I believe that psych hospitals can generate false positives for borderline personality disorder. In such cases, it is appropriate for patients to reject the borderline diagnosis. However, doing so constitutes being oppositional, and that is something that only a borderline would do!

It’s trendy among some these days to deny the existence of borderline. I’m not necessarily following that trend, I don’t think. I believe that there is a border of some kind and that some group of patients walk that border. I don’t think all patients who walk that border are doomed to walk it forever, but maybe some are. The border that was first delineated was between neurosis and psychosis. But I’m really not sure that that’s the most useful border to picture when thinking about the essence of the diagnosis.

When I picture “the border”, I picture a topographical map. A person on the border is walking the line between two very different altitudes: she is walking along the edge of a cliff. She is wobbling as she walks, teetering. She grabs on to things as she walks, she pulls HARD on them to keep herself upright. If she meets people as she walks, she grabs them, too, and they teeter and wobble with her. These people don’t like being grabbed, they don’t like wobbling. But she doesn’t know this; she is not open to perceiving this. She is focusing on staying upright. She is absolutely desperate not to fall.

Enough waxing poetic. Let’s get back to the issue at hand.

“Is cPTSD really BPD?” is actually less of a simple nosological question and more of an ontological question. Are BPD and cPTSD the same kind of nosology by any stretch? What counts as trauma? Can quotidian life problems be sufficient to generate severe psychopathology, and if so, does such psychopathology point to a patient’s fragility? What constitutes a maladaptive pattern? If borderline is really a personality disorder, can it really be possible to fall below the clinical threshold at any point after you’ve been diagnosed? There are so many more questions directly below the surface of the one posed in the socratic dialogue. I really hope more people can get a little more curious about those.

One last thing—Dr. Greenwald, if you’re reading this, I hope you’ll forgive me for being a little snarky with you. I’m grateful for your socratic psychiatry, and you can bet I’ll be listening to more.

1. I don’t use the phrase “mental health” for reasons I’ve alluded to elsewhere but will really dig into one of these days. I like to use specific terms like “clinical psychology” or “psychotherapy” or “pharmacotherapy” or “patient advocacy” when they apply, but I don’t think any of our big-tent terms accurately encompass all of these. “Mindwork” it is.

2. I really wish more psychs were talking in a serious way about the crazily stretched criteria for autism spectrum disorder in DSM-V. Speaking of diagnoses that are applied with seemingly no diagnostic judgment! Do not fucking talk to me about “neurodivergence” when you’re talking about the damn psychology manual (or actually any other time)! Bring back the eccentrics!

3. I actually have big beef with the “externalizing/internalizing” distinction when it comes to psychopathology. I’m sure it’s useful enough for clinical work (there is actually a big difference between a patient who mostly gets headaches and cuts her wrists in secret and a patient who screams and throw things at everyone). But it’s also pretty limiting. The same patient can have a mix of “internalizing” and “externalizing” symptoms. Also, internalizing symptoms don’t stay internal. That’s how we know about them and are able to consider them symptoms at all. More some other time.