![]() Importantly, it is defined by underlying psychologic structure, not by surface phenomenology. ![]() This is, in terms of severity, a middle group between psychosis and neurosis, diagnostically linked to more severe personality disorders and shifting, unstable, or polysymptomatic presentations of axis I disorders. There are two quite different notions of the clinical meaning of the term “borderline.” The older one, that goes back to its earliest use in the psychoanalytic literature, refers to a broad category of patients whose underlying psychology does not have the chaos, disorganization, or defect in reality testing associated with psychotic patients, but also lacks the integration, stability of relationships, and regulation of affect associated with neurotic patients (1). This issue of The American Journal of Psychiatry includes papers that advance the dialogue by exploring our current understanding of the borderline concept. There is also the residue of professional bias against the diagnosis and, unfortunately, stigma for those who suffer from it, that has hampered progress in the field. That is the good news, but there is also much that is not yet good news-questions to be answered and things that we have yet to learn. However, we have made tremendous strides in only a few decades, beginning with a theoretical concept in psychoanalysis that was ridiculed by most other psychiatrists, and progressing to a widely recognized clinical entity from a pejorative label for disliked patients to a carefully defined diagnostic category from the subject of almost no systematic study to one of the most intensively researched personality disorders-in terms of diagnosis, epidemiology, genetics, developmental psychology, biological correlates, pathophysiology, and treatment-and perhaps most important, from a hopeless prognosis to a hopeful one, and particularly one for which we have several evidence-based effective treatments. It is difficult to treat (both in the sense of responding poorly and as personally troubling to the therapist and the treatment team) and poorly understood. Borderline personality is a serious psychiatric disorder, with a prevalence of about 4% in the community, but as high as 20% in many clinical psychiatric populations, and significant morbidity.
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