In the late 1980s, the ICD-10 Working Party on Personality Disorders had little evidence on which to base its decisions and, understandably, followed the lead of the DSM, with its well-funded and popular third and subsequent editions.

When the Working Party came to the sensitive subject of individual personality disorders, it found that the evidence for “borderline personality disorder” was insufficient for it to be included. But a lobby of supporters did not allow this, and eventually two extra personality disorder groupings were included under the heading of “emotionally unstable personality disorder” (F60.3) – an “impulsive type” (F60.30), characterized by a “tendency to act unexpectedly” and to show “quarrelsome behaviour” and an “unstable and capricious mood”; and a “borderline type” (F60.31), characterized by uncertain self-image, unstable relationships, efforts to avoid abandonment, and recurrent self-harm.

We have yet to see much evidence that the impulsive type (F60.30) has been used in practice. On the contrary, the borderline type is by far the most commonly used personality disorder diagnosis, so much so that the original splitting of the “emotionally unstable personality disorder” into two groups has been forgotten entirely.

In the ICD-11 revision group, more than two decades later, the same conclusion was reached: borderline personality disorder was not considered to be a suitable diagnosis for inclusion and was ignored, as indeed were all other categories of personality disorder in the new dimensional system¹. But, as with the ICD-10, the borderline diagnosis was not to be spurned by others. There was general dissatisfaction with its omission², and a strong appeal for it to be included in some form. Thus, the “borderline pattern specifier” was added as a compromise³.

How do we explain that, after two revision groups decided to exclude this condition as unsatisfactory, borderline personality disorder continues to be supported as a diagnosis? The standard explanations are that it is useful in clinical practice, is widely used, and gives options for treatment, unlike other personality disorders. However, the same could be said, almost exactly, of the diagnosis of neurasthenia between 1870 and 1990 (it appeared apologetically in the ICD-10), which has now been recognized to be redundant, as it was vaguely defined, was so prevalent that it lacked discrimination, and became toxic through criticism and stigma.

These same concerns apply to borderline personality disorder. It is like a large bubble wrap over all personality disorders, easily recognized on the surface but obscuring the disorders that lie beneath. Personality abnormality is identifiable through traits that are persistent, exactly as normal personality traits. The features of borderline personality disorder are not traits, but symptoms and fluctuating behaviours⁴, and – like many symptomatic conditions – improve steadily over time⁵. When borderline symptoms are examined in factor analytic studies, they are scattered over a range of both personality and other mental disturbance, and have no specificity⁶.

All attempts to find a borderline trait have failed. While borderline symptoms appear coherent when examined in isolation, they disappear into a general personality disorder factor when modelled alongside other personality disorder symptoms⁷. Borderline personality disorder symptoms strongly align with all other personality disorder symptoms, and the borderline personality disorder diagnosis is better conceptualized as moderate to severe personality pathology in general⁶. Gunderson and Lyons-Ruth may have been on to something when they identified the core of borderline pathology as interpersonal hypersensitivity, a symptom-behaviour complex present in most personality disorders⁸.

An unsatisfactory diagnosis leads to imperfect treatment. Although it appears that there are many treatments available for borderline personality disorder, their value evaporates on analysis. While the treatments are complex, often time-consuming and well-constructed, they are no more effective than good psychiatric care, which now, in our current passion for three-letter acronyms, is called SCM (structured clinical management) or GPM (general psychiatric management). There is confusion over who should receive SCM and GPM and who needs the more complex interventions of dialectic behavioural therapy (DBT), mentalization-based therapy (MBT), transference-focused psychotherapy (TFT), cognitive behavioural therapy (CBT) and cognitive analytic therapy (CAT). Wheeling out stepped care as an answer sounds good but, because the diagnosis is so defective, nobody knows where stepped care is to begin.

An argument might be made that, while criticisms of the borderline personality disorder diagnosis are valid, the term is familiar to clinicians and could be seen as a synonym for moderate to severe personality pathology and lead to appropriate treatment with structured psychotherapy. The problem with this argument is that the term is a major source of stigma. Patients identified as having borderline personality disorder are seen as more difficult to manage even when their behaviour is the same as other patients without the label⁹. Access to treatment for other psychiatric disorders – such as attention-deficit/hyperactivity disorder, substance use disorder or mood disorders – as well as for physical disorders may also become more difficult. The label borderline personality disorder devalues all other symptoms, so that they can be more easily disregarded. This, in turn, increases the sense of alienation that many patients with personality problems already feel.

We argue that the solution is to drop the borderline personality disorder diagnosis and replace it with a more transparent system of describing personality pathology. Since borderline personality disorder diagnoses are highly correlated with overall moderate to severe personality disorder, assessing the level of severity of patient dysfunction is the first step. Many patients with moderate or severe personality disorder will have features now called “borderline”, such as emotional dysregulation, interpersonal hypersensitivity and impulsive behaviours, but not everyone. Some will have prominent social and emotional detachment, others perfectionism and stubbornness, or self-centeredness and a lack of empathy. These patients, with personality features described over many centuries, are largely ignored by treating personality disorders with a focus on so-called borderline features.

The new ICD-11 personality disorder classification allows this broader assessment. The dimensional classification of severity – which is divided into personality difficulty and mild, moderate and severe personality disorder – means that clinicians are encouraged to assess overall severity before focusing on specific symptoms and behaviours. The five domains (negative affectivity, detachment, dissociality, disinhibition and anankastia), similar to the Big Five in normal personality, allow a more nuanced description of these symptoms and behaviours, going beyond those encompassed within borderline personality disorder, particularly in the detachment and anankastia domains.

This should lead clinicians to consider the whole spectrum of personality pathology in their patients, rather than losing interest when the borderline personality disorder criteria have been ticked off. A sophisticated formulation would hopefully lead to a range of interventions rather than standard protocol-driven treatment given to everyone. It might also encourage research around treatment for those with non-borderline personality disorder symptoms and traits.

In conclusion, borderline personality disorder may best be seen as a transitional diagnosis which drew attention to patients suffering from moderate to severe personality disorders and encouraged structured psychotherapies to be tested. However, it has now emerged that the diagnosis is not related to specific personality traits, is overinclusive, and does not lead to specific treatments beyond structured clinical care. Its domineering presence in the field means that assessment and treatment of other personality pathology is discouraged, and the whole concept of personality dysfunction is stigmatized. It is time for borderline personality disorder to lie down and die.

在 20 世纪 80 年代末，ICD-10 人格障碍工作组几乎没有证据可以作为其决策的依据，因此可以理解的是，它追随了 DSM 的领导，其资金充足且受欢迎的第三版及后续版本。

当工作组谈到个人人格障碍这一敏感话题时，发现“边缘性人格障碍”的证据不足，无法将其纳入其中。但支持者游说团体不允许这样做，最终两个额外的人格障碍分组被纳入“情绪不稳定的人格障碍”（F60.3）标题下——一种“冲动型”（F60.30），其特征是“行为出乎意料的倾向”并表现出“争吵行为”和“不稳定且反复无常的情绪”；以及“边缘型”（F60.31），其特征是自我形象不确定、人际关系不稳定、努力避免被遗弃以及反复自残。

我们还没有看到太多证据表明脉冲型（F60.30）已在实践中使用。相反，边缘型人格障碍是迄今为止最常用的人格障碍诊断，以至于人们完全忘记了最初将“情绪不稳定的人格障碍”分为两类。

二十多年后，在 ICD-11 修订组中，得出了相同的结论：边缘性人格障碍不被认为是适合纳入的诊断，因此被忽略，就像新维度中的所有其他类别的人格障碍一样。系统¹ .但是，与 ICD-10 一样，其他人也不能拒绝这种边缘诊断。人们普遍对其遗漏²表示不满，并强烈呼吁以某种形式将其纳入其中。因此，作为折衷方案添加了“边界模式说明符” ³ 。

我们如何解释，在两个修订小组决定排除这种不令人满意的情况后，边缘性人格障碍继续被支持作为诊断？标准的解释是，与其他人格障碍不同，它在临床实践中有用，被广泛使用，并提供了治疗选择。然而，对于 1870 年至 1990 年间的神经衰弱诊断（在 ICD-10 中对此表示歉意）也可以这样说，几乎完全一样，这种诊断现在已被认为是多余的，因为其定义模糊，而且如此普遍，以至于它缺乏歧视，并因批评和污名而变得有毒。

这些同样的担忧也适用于边缘型人格障碍。它就像一个大气泡包裹着所有的人格障碍，很容易在表面上被识别出来，但却掩盖了隐藏在下面的障碍。人格异常可以通过持久的特征来识别，就像正常的人格特征一样。边缘性人格障碍的特征不是特征，而是症状和波动行为⁴ ，并且像许多症状一样，随着时间的推移稳步改善⁵ 。当在因素分析研究中检查边缘症状时，它们分散在一系列人格和其他精神障碍中，并且没有特异性⁶ 。

所有寻找边缘特征的尝试都失败了。虽然边缘症状在单独检查时显得连贯，但当与其他人格障碍症状一起建模时，它们就消失为一般人格障碍因素⁷ 。边缘性人格障碍症状与所有其他人格障碍症状密切相关，一般来说，边缘性人格障碍诊断最好被概念化为中度至重度人格病理学⁶ 。当冈德森和莱昂斯-露丝将边缘病理学的核心确定为人际超敏反应时，他们可能已经找到了一些东西，这是大多数人格障碍中存在的一种症状行为复合体⁸ 。

不令人满意的诊断会导致不完美的治疗。尽管似乎有许多治疗边缘性人格障碍的方法，但它们的价值在分析中就消失了。虽然治疗方法很复杂、通常耗时且结构完善，但它们并不比良好的精神科护理更有效，在我们当前对三个字母缩写词的热情中，这种护理被称为 SCM（结构化临床管理）或 GPM（通用）精神科管理）。对于谁应该接受 SCM 和 GPM，以及谁需要辩证行为治疗 (DBT)、基于心智化的治疗 (MBT)、移情聚焦心理治疗 (TFT)、认知行为治疗 (CBT) 和认知分析等更复杂的干预措施，存在一些困惑。治疗（CAT）。推出分级护理作为答案听起来不错，但由于诊断有缺陷，没有人知道分级护理从哪里开始。

可能有人会说，虽然对边缘性人格障碍诊断的批评是有效的，但该术语对临床医生来说很熟悉，可以被视为中度至重度人格病理的同义词，并导致结构化心理治疗的适当治疗。这一论点的问题在于，这个词是耻辱的主要来源。被确定为患有边缘性人格障碍的患者被认为更难以管理，即使他们的行为与其他没有标签的患者相同⁹ 。获得其他精神疾病（例如注意力缺陷/多动障碍、药物滥用障碍或情绪障碍）以及身体疾病的治疗也可能变得更加困难。边缘性人格障碍的标签贬低了所有其他症状，因此它们更容易被忽视。这反过来又增加了许多有人格问题的患者已经感受到的疏离感。

我们认为，解决方案是放弃边缘性人格障碍的诊断，代之以更透明的人格病理描述系统。由于边缘性人格障碍的诊断与总体中度至重度人格障碍高度相关，因此评估患者功能障碍的严重程度是第一步。许多患有中度或重度人格障碍的患者都会有现在被称为“边缘型”的特征，例如情绪失调、人际过敏和冲动行为，但不是每个人都如此。有些人会表现出明显的社会和情感超然，另一些人则完美主义和固执，或者以自我为中心，缺乏同理心。这些具有多个世纪以来描述的人格特征的患者，在治疗人格障碍时基本上被忽视了，而治疗人格障碍的重点是所谓的边缘特征。

新的 ICD-11 人格障碍分类允许进行更广泛的评估。严重程度的维度分类——分为人格困难和轻度、中度和重度人格障碍——意味着鼓励临床医生在关注特定症状和行为之前先评估总体严重程度。这五个领域（消极情感、疏离、不合群、去抑制和反常人格）与正常人格中的“大五”相似，可以对这些症状和行为进行更细致的描述，超出了边缘性人格障碍所包含的范围，特别是在疏离和人格障碍中。阿南卡斯蒂亚域。

这应该引导临床医生考虑患者的整个人格病理学，而不是在边缘人格障碍标准被勾选时失去兴趣。复杂的配方有望带来一系列干预措施，而不是为每个人提供标准的方案驱动的治疗。它还可能鼓励针对具有非边缘性人格障碍症状和特征的人的治疗研究。

总之，边缘性人格障碍最好被视为一种过渡性诊断，它引起了对患有中度至重度人格障碍的患者的关注，并鼓励对结构化心理治疗进行测试。然而，现在发现，诊断与特定的人格特征无关，过于包容，并且不会导致超出结构化临床护理的特定治疗。它在该领域的霸道存在意味着不鼓励对其他人格病理学的评估和治疗，并且人格功能障碍的整个概念受到侮辱。边缘型人格障碍是时候躺下死去了。