Borderline. The very idea seems to bring a chill to the minds of most clinicians everywhere. If anyone needs proof of the power of words, simply mention such a word to many mental health professionals and watch the hairs on their arms raise. I hear colleagues noting "I've got a real bad borderline on my caseload now". And other colleagues give a knowing look, an empathic nod of sorrow and a chagrined "good luck" smile. How unfortunate.

For clinicians to speak of "Borderlines" as if the word were a simple entity is misleading. Yes, the DSM defines this category, and while the DSM may be rather neutral about the implications of the diagnosis, we all know that for most it is a diagnosis of hopelessness. Calling someone "borderline" is to label them difficult, if not impossible, to treat, unwanted, and a general pain in the keister. It seems a diagnosis of indignance - a pejorative term used to denigrate the holder as an undesirable. A human being goes from a person in pain lacking the skills or maturity to function fully in society to a schlub best left alone.

Older or well read clinicians know this term was first used to denote the boundary between neurosis and psychosis (see Knight or Hoch and Cattell from the 40's). It was a rather broad concept, with much room for discussion. And most importantly, it lacked the negative valence it has earned in later years. A valence that besmirches a very useful construct.

I cringe when patients tell me they've been diagnosed "Borderline Personality Disorder". What worse term could we call someone, without refererencing expletives? Many of them seem unaware of the meaning of what they are saying, or the feeling it will engender in professionals who use the word in its now common vernacular. Some even feel they carry it as a badge of infamy, a notoriety they can't possibly fully appreciate.

A simple request. Let's go back to using "Borderline" in its original definition. E.g. "the patient is functioning in the borderline range". No objection if we speak of patients as "difficult" "recalcitrant", "resistant" or "tough to enjoy working with". Or if we wish to use descriptions such as "the patient uses splitting as a defense mechanism" or "the patient has inadequate coping skills, makes self-harmful choices, lacks good judgment in relationships, struggles to control impulses" etc. These are self-descriptive terms, and while they are not nice things to say, they don't carry the built in downgrade that the term borderline has come to carry.

Perhaps our best bet might be to simply stop using the term "personality disorder" at all. Insurance doesn't pay for this diagnostic category, and we are just as able to convey the information with concepts like "traits" or "features". These still aren't lovely things to say about someone (e.g. "he has narcissistic traits" is not something I look forward to hearing), but at the least they don't define a whole person's personality as deviant; they allow room for some positive things to be said, rather than a sweeping damnation. It just seems dehumanizing to call someone a narcissist or a borderline as a general description, and the current health care climate is already doing all it can to dehumanize our profession - no need for us to assist them any further.

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